Previous Coronary Artery Bypass Grafting Research Articles

Patients reporting to be healthy and not needing to change lifestyle after percutaneous coronary intervention - a cause for action?

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): The Western Norway Health Authority, The Norwegian Nurses Association Background A substantial proportion of patients with coronary artery disease do not achieve risk factors control, and are subsequently readmitted to hospital. In addition to decreased longevity, this increases the burden to the healthcare system and already strained resources. Aim To determine lifestyle and clinical characteristics of patients reporting to be healthy and not needing to change their lifestyle after percutaneous coronary intervention (PCI). Methods CONCARDPCI is a prospective multicentre cohort study including 3417 patients after PCI at seven Norwegian and Danish university hospitals during 2017-2019. Socio-demographic characteristics were obtained by self-report during the index hospitalization for PCI, and self-report on perceived health and the need to do lifestyle changes were repeated after 12 months. Clinical data were collected from patients’ medical records and the Norwegian Registry on Invasive Cardiology. Descriptive statistics, as well as t-test and chi-square test, scrutinized the aim. Results At baseline, 18% reported to be healthy and not needing to change their lifestyle. This increased to 28% (p<0.001) at 12 months. Most patients were men (78%) with a mean age of 66 years (SD 11, range 20-96 years). A sizeable proportion had previous cardiovascular comorbidities, including history of myocardial infarction (21%), hypertension (52%) and hypercholesterolemia (47%). Further, 27 % were obese (BMI >=30), 17% were smoking, 26% had previous PCI, and 9% previous coronary artery bypass grafting (CABG). Patients reporting to be healthy and not needing to change their lifestyle were older (69 vs 65, p<0.001). At baseline, compared to the total study population, significantly fewer patients with history of: hypercholesterolemia 13% (p = 0.002), hypertension 12% (p = 0.001), previous PCI 11% (p<0.001), previous CABG 9% (p<0.001), obesity 6% (p<0.001) and smoking 4% (p<0.001) reported to be healthy and asserted not needing to change lifestyle. After 12 months, more patients with risk factors reported to be both healthy and not needing to change lifestyle: those having hypercholesterolemia 25% (p<0.001), hypertension 25% (p<0.001), obesity 17% (p<0.001) and smoking 11% (p<0.001), as well as those with history of previous PCI 19% (p<0.001) or CABG 18% (p<0.001). Although the proportion was less for those with history of risk factors than for the total study population at 12 months, the increase in this group was large and significant. Conclusion The proportion of patients reporting to be healthy and not needing to change their lifestyle increased significantly in the longer term. This applied especially to patients with risk factors such as hypercholesterolemia, hypertension, obesity and current smoking, as well as those with history of previous PCI or CABG. For patients to better understand the seriousness and implications of their disease, patient education and increased health literacy is important.

Outcomes of Transcatheter Aortic Valve Implant Among Patients With A Previous Coronary Artery Bypass Graft: A Nationwide Analysis

There is a paucity of data regarding the temporal trends and outcomes of transcatheter aortic valve implant (TAVI) among patients with a previous coronary artery bypass graft (CABG) surgery. We queried the Nationwide Readmissions Database (2016 to 2019) for hospitalized patients who underwent TAVI using the appropriate International Classification of Diseases, Tenth Revision procedural codes. A multivariable regression analysis was used to adjust for the patients' and hospitals' characteristics in comparing the study groups. The primary outcome was in-hospital mortality. The final analysis included 237,829 patients who underwent TAVI, of whom 42,671 (17.9%) had a previous CABG. During the study period, there was a decrease in the proportion of patients with previous CABG who underwent TAVI (21.0% in 2016 vs 15.5% in 2019, ptrend=0.01), although there was no change in their in-hospital mortality rate (1.08% in 2016 vs 1.25% in 2019, ptrend=0.43). Patients with a previous CABG were younger and less likely to be women than those without a previous CABG. TAVI among those with a previous CABG was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.79, 95% confidence interval [CI] 0.69 to 0.91), similar rate of ischemic stroke (aOR 0.81, 95% CI 0.71 to 0.93) and permanent pacemaker implant (aOR 1.00, 95% CI 0.93 to 1.05). Patients with a previous CABG had a lower all-cause 90-day readmission (odds ratio 0.95, 95% CI 0.94 to 1.06) but higher readmission for transient ischemic attack. Among those with a previous CABG, female gender and chronic kidney disease stage ≥3 were independently associated with a higher in-hospital mortality, whereas obesity was associated with a lower in-hospital mortality. In conclusion, there was a decrease in the proportion of patients with a previous CABG among those who underwent TAVI. TAVI among those with a previous CABG was not associated with increased in-hospital adverse events or 90-day all-cause readmissions.

Percutaneous Coronary Intervention in Men, Women, and Minorities With a Previous Coronary Artery Bypass Graft Surgery (from the Pooled PLATINUM Diversity and PROMUS Element Plus Registries)

There is limited data on new-generation stent outcomes in patients with previous coronary artery bypass graft (CABG) and the associated risk of gender and race/ethnicity is unclear. We investigated 1-year outcomes after platinum chromium everolimus-eluting stent implantation in a diverse population of men, women, and minorities with previous CABG pooled from the PLATINUM Diversity (NCT02240810) and PROMUS Element Plus (NCT01589978) registries. Our primary outcome was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR) at 1-year post percutaneous coronary intervention (PCI). Secondary end points included all-cause death, MI, TVR, target vessel failure, and stent thrombosis. A total of 4,175 patients were included in the analysis, including 1,858 women (44.5%), 1,057 minorities (25.3%), and 662 (15.9%) with previous CABG. Patients with previous CABG were older, included more men and White patients, and had more co-morbidities compared with patients without previous CABG. At 1 year, patients with previous CABG had a higher risk of MACE (12.6% vs 7.5%, hazard ratio 1.70, 95% confidence interval 1.32 to 2.19, p<0.001) and end points, including death/MI, TVR, and target vessel failure. After multivariate adjustment, no differences were observed in MACE (adjusted hazard ratio 1.11, 95% confidence interval 0.82 to 1.49, p=0.506) or any secondary end points. No interaction was observed between previous CABG and gender or minority status. In conclusion, in a contemporary PCI population, patients with previous CABG remain at high risk for PCI because of their elevated risk profile. Previous CABG status was however not independently associated with worse outcomes after adjustment, nor was any interaction observed with gender or race/ethnicity.

Long-term outcomes after lower extremity bypass in the actively smoking claudicant

ObjectiveSmoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is for elective general surgery procedures. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. MethodsWe queried the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 36 clinical variables (age, gender, race, ethnicity, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS). ResultsPropensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (HR, 0.93; 95% CI, 0.70-1.24; P = .61), LS (HR, 1.07; 95% CI, 0.63-1.82; P = .80), FR (HR, 0.9; 95% CI,0.71-1.21; P = .59), or AFS (HR, 0.93; 95% CI,0.71-1.22; P = .62). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI,0.94-1.97; P = .11) or FR (HR, 1.02; 95% CI,0.88-1.19; P = .76). However, we did find a significant increase in OS (HR, 1.37; 95% CI,1.15-1.64, P <.001) and AFS (HR, 1.38; 95% CI,1.18-1.62; P < .001) in FS compared with CS. ConclusionsClaudicants represent a unique nonemergent vascular patient population that may require LEB. Our study found that FS have better OS and AFS when compared with CS. Additionally, FS mimic nonsmokers at 5-year outcomes for OS, LS, FR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before elective LEB procedures in claudicants.

Clinical Outcomes and Associations With Radial to Femoral Crossover in ST-Elevation Myocardial Infarction

Radial access during primary percutaneous coronary intervention is associated with reduced mortality and major bleeding compared with femoral access and is the recommended access site. Nevertheless, failure to secure radial access may necessitate crossover to femoral access. This study aimed to identify the associations with crossover from radial to femoral access in all comers with ST-elevation myocardial infarction and to compare the clinical outcomes with those patients who did not require crossover. From 2016 to 2021, a total of 1,202 patients presented to our institute with ST-elevation myocardial infarction. Associations, clinical outcomes, and independent predictors of crossover from radial to femoral access were identified. From 1,202 patients, radial access was used in 1,138 patients (94.7%) and crossover to femoral access occurred in 64 patients (5.3%). Patients who required crossover to femoral access had higher rates of access site complications and longer length of stay in the hospital. Inpatient mortality was higher in the group requiring a crossover. This study identified 3 independent predictors of crossover from radial to femoral access in primary percutaneous coronary intervention: cardiogenic shock, cardiac arrest before arrival at the catheterization laboratory, and previous coronary artery bypass grafting. Biochemical infarct size and peak creatinine was also found to be higher in those requiring crossover. In conclusion, crossover in this study portended an increased rate of access site complications, greatly prolonged length of stay, and a significantly higher risk of death.

PCI or CABG for left main coronary artery disease: the SWEDEHEART registry.

An observational nationwide all-comers prospective register study to analyse outcomes after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease. All patients undergoing coronary angiography in Sweden are registered in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. Between 01/01/2005 and 12/31/2015, 11 137 patients with LMCA disease underwent CABG (n = 9364) or PCI (n = 1773). Patients with previous CABG, ST-elevation myocardial infarction (MI) or cardiac shock were excluded. Death, MI, stroke, and new revascularization during follow-up until 12/31/2015 were identified using national registries. Cox regression with inverse probability weighting (IPW) and an instrumental variable (IV), administrative region, were used. Patients undergoing PCI were older, had higher prevalence of comorbidity but lower prevalence of three-vessel disease. PCI patients had higher mortality than CABG patients after adjustments for known cofounders with IPW analysis (hazard ratio [HR] 2.0 [95% confidence interval (CI) 1.5-2.7]) and known/unknown confounders with IV analysis (HR 1.5 [95% CI 1.1-2.0]). PCI was associated with higher incidence of major adverse cardiovascular and cerebrovascular events (MACCE; death, MI, stroke, or new revascularization) than CABG, with IV analysis (HR 2.8 [95% CI 1.8-4.5]). There was a quantitative interaction for diabetic status regarding mortality (P = 0.014) translating into 3.6 years (95% CI 3.3-4.0) longer median survival time favouring CABG in patients with diabetes. In this non-randomized study, CABG in patients with LMCA disease was associated with lower mortality and fewer MACCE compared to PCI after multivariable adjustment for known and unknown confounders.

Can previous therapy with statin be considered a protective factor in acute coronary syndrome?

Abstract Funding Acknowledgements Type of funding sources: None. Background Statin therapy is nowadays a cornerstone in primary and secondary prevention of cardiovascular events. Purpose This retrospective observational study intends to characterise the influence of previous therapy with statins on clinical and electrocardiographic presentation of acute coronary syndrome (ACS) and on in-hospital morbidity and mortality. Methods We evaluated a population of 746 patients admitted in a Cardiac Care Intensive Unit diagnosed with ACS (D). We then considered two groups: patients with previous therapy with statins (D1) and patients without it (D2). We documented demographic factors, personal history, clinical and electrocardiographic presentation of ACS, coronary angiography and angioplasty. The following in-hospital complications were defined: heart failure (HF), cardiogenic shock, reinfarction, stroke, major bleeding and need for blood transfusion. In-hospital mortality was compared between both groups. Results D1 consisted of 37.5% of the population (N=280). These patients had a higher prevalence of hypertension (90.7% vs 65.4%, p &amp;lt;0.001), diabetes (45.0% vs 27.8%, p &amp;lt;0.001), dyslipidaemia (81.8% vs. 36.6%, p = 0.001), chronic renal failure (18.6% vs 7.6%, p = 0.001), stroke (10.7% vs. 4.5%, p = 0.003), previous myocardial infraction (MI) (45,0% vs 12,6%, p = 0.001) and previous coronary artery bypass graft (13.2% vs. 2.0%, p = 0.001). They also had more frequently smoking habits (37.4% vs 13.9%, p = 0.001). They were less frequently admitted with ST-elevation MI (24.6% vs 49.2%, p = 0.001) and more frequently with non-ST elevation MI (56.1% vs 40, 9%, p = 0.001) and unstable angina (10.7% vs 5.6%, p = 0.02). The rate of coronary angiography was similar, however patients receiving previous statin therapy underwent less angioplasty. During hospitalization, there were no differences in any of the complications considered, nor in in-hospital mortality between the 2 groups. Conclusions In patients with ACS, previous therapy with statins seems to influence the presentation of ACS but it does not affect in-hospital morbidity and mortality. An important percentage of patients with diabetes and of those with previous MI or stroke were not on statins therapy as recommended in the European guidelines.

Long-term Outcomes in the Smoking Claudicant After Elective Lower Extremity Bypass

Smoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is in general surgery. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. We queried the Vascular Quality Initiative VISION LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 25 clinical variables (age, gender, race, ethnicity, treatment setting, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass grafting, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from target lesion reintervention (FTR) and amputation-free survival (AFS). Propensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.70-1.24; P = .61), LS (HR, 1.08; 95% CI, 0.63-1.82; P = .80), FTR (HR, 0.95; 95% CI, 0.73-1.23; P = .69), or AFS (HR, 0.93; 95% CI, 0.71-1.2; P = .62) (Fig 1). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI, 0.94-1.97; P = .10) or FTR (HR, 1.02; 95% CI, 0.87-1.19; P = .85). However, we did find a significant increase in OS (HR, 1.37; 95% CI, 1.15-1.64; P < .001) and AFS (HR, 1.38; 95% CI, 1.18-1.62; P < .001) (Fig 2) in FS compared to CS. Claudicants represent a unique nonemergent vascular patient population who can require LEB. Our study found that former smokers have better overall survival and amputation free survival when compared to current smokers, while former smokers mimic never smokers at 5-year outcomes for OS, LS, FTR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before and after LEB and can even be considered a requirement prior to elective LEB procedures in claudicants.Fig 2Amputation-free survival (AFS) (5 years) for former smokers (FS) and current smokers (CS) after propensity score matching.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Myocardial perfusion imaging by 15O-H2O positron emission tomography predicts clinical revascularization procedures in symptomatic patients with previous coronary artery bypass graft.

We wanted to assess if 15O-H2O myocardial perfusion imaging (MPI) in a clinical setting can predict referral to coronary artery catheterization [coronary angiography (CAG)], execution of percutaneous coronary intervention (PCI), and post-PCI angina relief for patients with angina and previous coronary artery bypass graft (CABG). We analysed 172 symptomatic CABG patients referred for 15O-H2O positron emission tomography (PET) MPI at Aarhus University Hospital Department of Nuclear Medicine & PET Centre, of which five did not complete the scan. In total, 145 (87%) enrolled patients had an abnormal MPI. Of these, 86/145 (59%) underwent CAG within 3 months; however, no PET parameters predicted referral to CAG. During the CAG, 25/86 (29%) patients were revascularized by PCI. Relative flow reserve (RFR) (0.49 vs. 0.54 P = 0.03), vessel-specific myocardial blood flow (MBF) (1.53 vs. 1.88 mL/g/min, P < 0.01), and vessel-specific myocardial flow reserve (MFR) (1.73 vs. 2.13, P < 0.01) were significantly lower in patients revascularized by PCI. Receiver operating characteristic analysis of the vessel-specific parameters yielded optimal cutoffs of 1.36 mL/g/min (MBF) and 1.28 (MFR) to predict PCI. Angina relief was experienced by 18/24 (75%) of the patients who underwent PCI. Myocardial blood flow was an excellent predictor of angina relief on both a global [area under the curve (AUC) = 0.85, P < 0.01] and vessel-specific (AUC = 0.90, P < 0.01) level with optimal cutoff levels of 1.99 mL/g/min and 1.85 mL/g/min, respectively. For CABG patients, RFR, vessel-specific MBF, and vessel-specific MFR measured by 15O-H2O PET MPI predict whether subsequent CAG will result in PCI. Additionally, global and vessel-specific MBF values predict post-PCI angina relief.

Redo mitral surgery after coronary artery bypass grafts under hyperkalemic hypothermia using thoracotomy and axillary artery cannulation in a patient with functioning bilateral internal thoracic arteries and atheromatous aorta

BackgroundRedo mitral valve surgery using resternotomy after coronary artery bypass grafting (CABG) is challenging as previous CABG with patent internal thoracic artery (ITA) poses a risk of injury due to dense adhesion. It is paramount to have alternative method to minimize this risk.Case presentation: We report a case of redo mitral and tricuspid valve repair via right thoracotomy under hypothermia and systemic potassium administration with axillary artery cannulation in a patient after CABG with patent bilateral ITA grafts crossing over the sternum. Herein, critical dissection around the aorta and functioning ITA grafts was avoided by performing the procedure under systemic hypothermia via thoracotomy. Furthermore, considering the presence of atheroma in the aorta, the axillary artery was used as a perfusion route to prevent stroke events. Postoperative course was uneventful and echocardiography demonstrated preserved cardiac function.ConclusionPerforming axillary artery cannulation and right thoracotomy under hypothermic cardiac arrest with systemic hyperkalemia without clamping the patent bilateral ITAs and aorta allowed us to perform redo mitral valve surgery after CABG without major postoperative cardiac or cerebral complications.

Transannular rupture during transcatheter aortic valve replacement: management in a patient with prior cardiac surgery.

Annular rupture occurs in approximately 1% of transcatheter aortic valve replacementcases. Annular rupture often requires surgical management and is associated with high mortality. Repair of annular rupture in patients with previous coronary artery bypass grafting (CABG) is undercharacterized and poses a unique challenge given the increased difficulty and complexity from both an emergent and reoperative case. An 80-year-old male with previous CABG experienced annular rupture post-transcatheter aortic valve replacement requiring urgent surgical management. This case illustrates the successful repair of a rare and high-risk complication describing the approach utilized in correcting annular rupture in a patient with previous CABG.

Meta-analysis Comparing Long-Term Clinical Outcomes of Percutaneous Coronary Intervention versus no Intervention in Patients with Chronic Total Occlusion.

We performed a meta-analysis to evaluate the efficacy of CTO PCI. The study outcomes were the occurrence of all-cause mortality, myocardial infarction, repeat revascularization, stroke, or freedom from angina at the longest documented follow-up period. In five trials including 1790 patients, the mean age was 63 ± 10 years, 17% were female, with a median follow-up of 2.9 years. The procedural success rate ranged from 73% to 97% and the right coronary artery was the most involved artery (52%). There was no significant difference between CTO PCI and no intervention regarding all-cause mortality (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 0.49-2.47, P = 0.82), myocardial infarction (OR: 1.20, 95% CI: 0.81-1.77, P = 0.36), repeat revascularization (OR: 0.67, 95% CI: 0.40-1.14, P = 0.14), or stroke (OR: 0.60, 95% CI: 0.26-1.36, P = 0.22). In two trials including 686 patients, significantly more patients were free of angina at 1 year, defined as the Canadian Cardiovascular Society grading of angina pectoris Grade 0, in the CTO PCI group compared to the no intervention group (OR: 0.52, 95% CI: 0.35-0.76, P < 0.001). Meta-regression analyses based on various trial-level covariates (gender, diabetes, previous myocardial infarction, PCI or coronary artery bypass graft, SYNTAX or J-CTO scores, and CTO-related artery percentages) did not suggest any statistically significant relationships. CTO PCI appears to have a similar efficacy profile compared to no intervention at long-term follow-up, but with a significant improvement of angina favoring PCI-treated patients. Further adequately powered and long-term trials are required to identify the best management strategy for patients with coronary CTO.

In-hospital Outcomes of Patients With and Without Previous Coronary Artery Bypass Graft Surgery Who Present With a Non-ST-Segment Elevation Myocardial Infarction

The clinical course of patients with a previous coronary artery bypass graft surgery (CABG) presenting with non-ST-elevation myocardial infarction (NSTEMI) is not well defined. We aimed to compare the management and outcomes of patients with and without previous CABG who present with an NSTEMI. Patients hospitalized with an NSTEMI between 2002 and 2018 were identified from the National Inpatient Sample. The baseline characteristics and outcomes of patients with and without a previous CABG were compared. The outcomes included the rates of invasive procedures (defined as coronary angiography, percutaneous coronary intervention [PCI], or CABG), and its individual components, and in-hospital mortality. A total of 1,445,545 cases of NSTEMI were found, of which 133,691 (9.3%) had a previous CABG. Patients with a previous CABG were older (72.4 vs 68.6years, p <0.001), more likely men (68.8% vs 56.9%, p <0.001), and of White race (79.7% vs 74.8%, p <0.001). The previous CABG cohort had lower rates of invasive procedures (50.4% vs 65.6%, p <0.001), PCI (23.7% vs 32.0%, p <0.001), or CABG (1.2% vs 10.6%; p <0.001) in the unmatched analysis. The results were consistent in the propensity score-matched analysis with the previous CABG group less likely to receive any invasive procedures (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.47 to 0.49), including coronary angiography (OR 0.54, 95% CI 0.53 to 0.55), PCI (OR 0.66, 95% CI 0.64 to 0.67), or repeat CABG (OR 0.11, 95% CI 0.10 to 0.12). Moreover, the risk of in-hospital mortality was higher in the previous CABG group (OR 1.15, 95% CI 1.10 to 1.21). In the subset of patients who were revascularized in both groups, this excess mortality was no longer observed (OR 0.82, 95% CI 0.66 to 1.03). In conclusion, a previous CABG in patients who present with NSTEMI is associated with lower rates of invasive procedures and revascularization and higher in-hospital mortality than patients without a previous CABG.

Procedural Characteristics and Clinical Outcomes Associated with Chronic Total Occlusion Percutaneous Coronary Intervention in Patients with a History of Prior Coronary Artery Bypass Graft: A Meta-Analysis.

Owing to advances in procedural techniques and the training of interventional staff in catheterization labs, recent work has demonstrated the safety of percutaneous coronary intervention (PCI) as a treatment for patients suffering from chronic total occlusion (CTO). However, there has been little research focused on systematic comparisons of PCI outcomes in CTO patients that did or did not exhibit a history of previous coronary artery bypass grafting (CABG). Electronic databases were systematically searched for all studies comparing CTO-PCI outcomes for patients with and without a history of CABG, with event rates subsequently being compared via random-effects models with forest plots and odds ratios with 95% confidence intervals (CI), owing to the assumption of between-studies heterogeneity. In total, 8 observational studies enrolling 13,509 CTO patients were identified, including 3389 and 10,120 patients with and without a history of prior CABG, respectively. Patients were enrolled in these studies from 1999-2018. Pooled analyses indicated that CABG history was not linked to a lower proportion of radial access 24 (95% CI 0.52-1.03, p = 0.08), and a prior CABG history was linked to a greater contrast volume (95% CI 0.12-0.44, p 0.001), higher radiation dose (95% CI 0.27-0.40, p 0.001), longer fluoroscopy time (95% CI 0.42-0.61, p 0.001), longer procedural time (95% CI 0.38-0.64, p 0.001), a higher number of implanted stents (95% CI 0.41-0.60, p 0.001), longer total stent length (95% CI 0.21-0.60, p 0.001), higher technical failure rates (95% CI 1.46-1.85, p 0.001), and higher rates of procedural failure (95% CI 1.42-1.79, p 0.001). The in-hospital mortality (95% CI 1.50-4.03, p 0.001) and periprocedural mortality (95% CI 1.63-3.73, p 0.001) of patients with a history of CABG were also higher. While stroke incidence was comparable in both groups (95% CI 0.80-4.47, p = 0.15), periprocedural major adverse cardiovascular and cerebrovascular events (MACCE) rates were significantly higher among patients exhibiting a history of CABG (95% CI 1.66-2.94, p 0.001). These results suggest that CTO-PCI procedures may be more challenging and associated with lower rates of success in CABG patients relative to procedures performed in patients without any history of CABG. Moreover, in-hospital outcomes including MACCE and mortality were worse for patients that had undergone prior CABG.

Meta-Analysis on the Impact of Coronary Bypass Graft Markers on Angiographic Procedural Outcomes

Utilization of radio-opaque coronary artery bypass graft markers is known to decrease the amount of contrast dye required to complete the procedure. Thepractice of marking bypass grafts varies significantly among surgeons. Limited data exist comparing the outcomes of percutaneous coronary intervention with and without coronary artery bypass graft (CABG) markers. We sought to explore the impact of proximal radio-opaque markers placed during CABG in subsequent percutaneous coronary intervention procedural risks. In our understanding of the current literature, this is the first meta-analysis conducted to evaluate the association between procedural angiographic metrics and CABG radio-opaque markers.We performed a query of MEDLINE and Scopus databases through August 2022 to identify relevant studies evaluating procedural metrics among patients with previous CABG with and without radio-opaque markers who underwent angiography. The primary outcomes of interest were fluoroscopy time, amount of contrast, and duration of angiography.We identified a total of 4 studies with 2,046 patients with CABG (CABG with markers n=688, CABG without markers n=1,518).2-5 Total fluoroscopy time was significantly reduced among patients with CABG markers compared with those with no markers (odds ratio [OR] -3.63, p <0.0001).The duration of angiography (OR -36.39, p >0.10) was reduced, although the result was not statistically significant. However, the amount of contrast utilization was significantly reduced (OR -33.41, p <0.0001).In patients who underwent CABG with radio-opaque markers, angiographic procedural metrics were improved, including reduced fluoroscopic time and the amount of contrast agent required compared with no markers.

Clinical Outcome of Revascularization Deferral With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A 5-Year Follow-Up Substudy From the iFR-SWEDEHEART Trial.

Background Although physiology-based assessment of coronary artery stenosis using instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) are established methods of guiding coronary revascularization, its clinical outcome in long-term deferral needs further evaluation, especially with acute coronary syndrome as a clinical presentation. The aim was to evaluate the long-term clinical outcome of deferral of revascularization based on iFR or FFR. Methods and Results This is a substudy of the iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trial, where patients deferred from revascularization from each study arm were selected. Nine hundred eight patients deferred from coronary revascularization with iFR (n=473) and FFR (n=435) were followed for 5 years. The national quality registry, SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), was used for patient data collection and clinical follow-up. The end point was major adverse cardiac events and their individual components all-cause death, cardiovascular death, noncardiovascular death, nonfatal myocardial infarction, and unplanned revascularization. No significant difference was found in major adverse cardiac events (iFR 18.6% versus FFR 16.8%; adjusted hazard ratio, 1.08 [95% CI, 0.79-1.48]; P=0.63) or their individual components. Conclusions No differences in clinical outcomes after 5-year follow-up were noted when comparing iFR versus FFR as methods for deferral of coronary revascularization in patients presenting with stable angina pectoris and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166736.

Five-Year Survival and Complications of Thoracic Endovascular Aortic Repair (TEVAR): A Single Tertiary Center Registry for All-Comers Patients

IntroductionStudies on the mid and long-term outcomes of thoracic endovascular aortic repair (TEVAR) are scarce. This study aimed to investigate the long-term outcomes of TEVAR for all-comers patients with various types of thoracic aortic pathologies, predominantly thoracic aortic dissections and thoracic aortic aneurysms. MethodsBetween January 2005 and December 2015, 123 consecutive patients with thoracic aortic pathologies underwent TEVAR. The patients were divided into groups based on aortic pathologies (dissections or aneurysms) and the type of procedure (hybrid TEVAR or non-hybrid TEVAR). Mortality, complications, and reintervention rates were compared between these four groups. The Kaplan–Meier curve and the Cox regression analysis were employed to estimate survivals and factors associated with 5-year mortality. ResultsOne hundred twenty-three consecutive patients with various aortic pathologies undergoing TEVAR were evaluated. Hypertension (79.7 %) and smoking (39 %) were the most common comorbidities in the study population. The patients were followed up for a mean duration of 58.1 ± 7.1 months to evaluate the postprocedural surveillance. Most complications occurred in the dissection and hybrid groups; however, these differences were nonsignificant. The overall 5-year surveillance and reintervention rates were 65 % and 12.1 %, respectively. A significant difference existed in 5-year survival between the patients with aneurysmal and aortic dissection pathologies based on the log-rank test (P = 0.01). On the other hand, no significant differences were observed in 5-year survival between the patients who underwent hybrid and non-hybrid TEVAR. The Cox regression analysis confirmed that chronic kidney disease, previous coronary artery bypass grafting, age >65 years, platelet counts <150∗ 103/μL, aneurysmal aortic pathology, and ejection fraction ≤ 50 % were predictors of 5-year mortality. ConclusionsThe long-term outcomes of TEVAR for various aortic pathologies disclosed that this procedure was well-tolerated in a group of patients with high comorbid conditions. The five-year survival rate of TEVAR for thoracic aortic dissections was more favorable than that for thoracic aortic aneurysms, but there were no significant differences between hybrid and non-hybrid procedures regarding the mortality rate.

Post market surveillance registry (PIONEER) of the Yukon Choice PC-Elite Coronary Stent System for percutaneous coronary intervention in Indian acute coronary syndrome population

AimThe aim of this study was to assess the safety and efficacy profile of a newer generation biodegradable DES, the Yukon Choice PC Elite with a temperature controlling mechanism, in patients with acute coronary syndrome (ACS). MethodsThis prospective multi-center study (PIONEER Registry) was conducted in an Indian ACS population, therefore providing data in real world clinical practice. Patients with ACS underwent DES implantation in de novo native-vessel coronary lesions with the Yukon Choice PC Elite biodegradable polymer DES and were followed up for a year. ResultsA total 999 patients were evaluated. The majority of patients were male (79.2%). A total of 6.7% of the patients had a history of prior myocardial infarction (MI) and 2.7% of patients had a history of previous coronary artery bypass graft. The clinical presentations of the patients included: unstable angina pectoris (UA) (46.4%), ST-segment elevation MI (STEMI) (38.1%), and Non-ST-segment elevation MI (NSTEMI) (15.4%). Implantation of the device was successful in 99.9% of cases. The median stent length and stent size were 21.0 mm (Range: 8.0–40.0 mm) and 2.8 mm (Range 2.0–4.0 mm), respectively. Through to one-year clinical follow-up after percutaneous coronary intervention, all-cause death occurred in 4 of 999 patients (Crude Percentage: 0.4%). Cardiac death, MI, TLR, and stent thrombosis were occurred in 1 (0.1%), 8 (0.8%), 12 (1.2%) and 1 (0.1%) patients, respectively. ConclusionThe results of this post marketing surveillance registry suggest favorable safety and efficacy outcomes associated with the Yukon Choice PC Elite biodegradable DES in a real world Indian ACS population.

Utilidade do Nível de NT-Pro-BNP no Plasma à Internação em Predizer a Formação de Aneurisma do Ventrículo Esquerdo após Infarto Agudo do Miocárdio com Elevação do Segmento ST

BackgroundLeft ventricular aneurysm (LVA) is an important complication of acute myocardial infarction. In this study, we investigated the role of N- Terminal pro B type natriuretic peptide level to predict the LVA development after acute ST-segment elevation myocardial infarction (STEMI).MethodsWe prospectively enrolled 1519 consecutive patients with STEMI. Patients were divided into two groups according to LVA development within the six months after index myocardial infarction. Patients with or without LVAs were examined to determine if a significant relationship existed between the baseline N- Terminal pro B type natriuretic peptide values and clinical characteristics. A p-value < 0.05 was considered statistically significant.ResultsLVA was detected in 157 patients (10.3%). The baseline N- Terminal pro- B type natriuretic peptide level was significantly higher in patients who developed LVA after acute MI (523.5 ± 231.1 pg/mL vs. 192.3 ± 176.6 pg/mL, respectively, p < 0.001). Independent predictors of LVA formation after acute myocardial infarction was age > 65 y, smoking, Killip class > 2, previous coronary artery bypass graft, post-myocardial infarction heart failure, left ventricular ejection fraction < 50%, failure of reperfusion, no-reflow phenomenon, peak troponin I and CK-MB and NT-pro BNP > 400 pg/mL at admission.ConclusionsOur findings indicate that plasma N- Terminal pro B type natriuretic peptide level at admission among other variables provides valuable predictive information regarding the development of LVA after acute STEMI.

Validation of the OPEN-CLEAN Chronic Total Occlusion Percutaneous Coronary Intervention Perforation Score in a Multicenter Registry

Coronary artery perforation is one of the most common and feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We evaluated the utility of the recently presented OPEN-CLEAN (Coronary artery bypass graft, Length of occlusion, Ejection fraction, Age, calcificatioN) perforation score in an independent multicenter CTO PCI dataset. Of the 2,270 patients who underwent CTO PCI at 7 centers, 150 (6.6%) suffered coronary artery perforation. Patients with perforations were older (69 ± 10 vs 65 ± 10, p <0.001), more likely to be women (89% vs 82%, p=0.010), more likely to have history of previous coronary artery bypass graft (38% vs 20%, p <0.001), and unfavorable angiographic characteristics such as blunt stump (64% vs 42%, p <0.001), proximal cap ambiguity (51% vs 33%, p <0.001), and moderate-severe calcification (57% vs 43%, p=0.001). Technical success was lower in patients with perforations (69% vs 85%, p <0.001). The area under the receiver operating characteristic curve of the OPEN-CLEAN perforation risk model was 0.74 (95% confidence interval 0.68 to 0.79), with good calibration (Hosmer-Lemeshow p=0.72). We found that the CTO PCI perforation risk increased with higher OPEN-CLEAN scores: 3.5% (score 0 to 1), 3.1% (score 2), 5.3% (score 3), 7.1% (score 4), 11.5% (score 5), 19.8% (score 6 to 7). In conclusion, given its good performance and ease of preprocedural calculation, the OPEN-CLEAN perforation score appears to be useful for quantifying the perforation risk for patients who underwent CTO PCI.