Primary Coronary Artery Bypass Grafting Research Articles

Does the use of a free internal mammary artery graft on the left anterior descending artery compromise long-term survival?†

The aim of the study was to determine if there is a long-term outcomes disadvantage associated with using the internal mammary artery (IMA) as a free graft to the left anterior descending artery (LAD) during coronary artery bypass graft surgery. Between 1991 and 2014, 21 876 consecutive patients underwent isolated primary coronary artery bypass graft surgery at our institution. Among these, 238 underwent a free IMA (f-IMA) graft to bypass the LAD. Propensity score matching with bootstrap analysis was performed to produce a cohort of 222 f-IMA patients matched to 222 patients with in situ IMA grafting to the LAD. Early and long-term outcomes including survival, readmission for cardiovascular causes and repeat revascularization up to a maximum of 23 years post-coronary artery bypass graft surgery were compared. Provincial vital statistics and administrative hospital readmission data were used to analyse long-term outcomes. Operative mortality [3.2% f-IMA vs 1.9% in situ IMA; odds ratio = 1.79, 95% confidence interval (CI) = 0.91-3.52] and the majority of postoperative adverse events were not significantly different among matched patients. The risk of late death was not significantly different between the 2 matched groups (hazard ratio = 1.14, 95% CI = 0.92-1.41, P = 0.15). The risk of hospital readmission for cardiovascular reasons was significantly higher in the f-IMA group (54.5% vs 47.3%, odds ratio = 1.4; 95% CI = 1.10-1.72), although repeat revascularization (18.4% vs 13.5%; odds ratio = 1.53, 95% CI = 0.96-2.44) was not significantly different between the matched groups. Late survival and the need for repeat coronary revascularization were not influenced by using the IMA as a free graft to the LAD. However, there is a small but significant increase in the risk of hospital readmission for cardiac reasons.

D-dimer is associated with arterial and venous coronary artery bypass graft occlusion

ObjectiveIn this observational prospective study, we assessed the role of clinical variables and circulating biomarkers in graft occlusion at 18 months to identify a signature for graft occlusion. MethodsA total of 330 patients undergoing primary elective coronary artery bypass grafting were enrolled. Blood collection for biomarker assessment was performed before surgery and discharge. Patients were then scheduled to undergo coronary computed tomography angiography at 18 months follow-up, and 179 patients underwent coronary computed tomography angiography 18 ± 2 months postoperatively. ResultsThere were 46 of 503 (9.1%) occluded grafts; of these, 29 (63%) were venous and 17 (37%) were arterial grafts; overall, 43 of 179 patients (24%) had at least 1 occluded graft. Logistic mixed effects model assessing independent factors associated with graft occlusion identified that lower D-dimer levels at baseline (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.36-4.89; P = .00) and total protein content at discharge (OR, 1.09; 95% CI, 1.01-1.19; P = .028) were related to overall graft occlusion at follow-up, along with an arterial graft other than the left internal thoracic artery (OR, 2.92; 95% CI, 1.24-6.9; P = .078); moreover, a venous graft emerged was possibly associated with graft occlusion (OR, 1.51; 95% CI, 0.95-2.39; P = .078). By separately analyzing saphenous vein and arterial grafts, D-dimer levels (OR, 2.67; 95% CI, 1.15-6.2; P = .022 and OR, 2.5; 95% CI, 1.01-7.0; P = .05 for venous and arterial graft, respectively) were still associated with arterial and venous graft occlusion at follow-up. ConclusionsWe identified D-dimer as a biomarker associated with arterial and venous grafts occlusion. This may help stratify patients at risk of graft failure and identify new molecular targets to prevent this complication.

Coronary Artery Bypass Graft Surgery Using the Radial Artery, Right Internal Thoracic Artery, or Saphenous Vein as the Second Conduit

It is not clear whether radial artery (RA), right internal thoracic artery (RITA), or saphenous vein (SV) is the preferred second bypass graft during coronary artery bypass graft surgery using the left internal thoracic artery (LITA) in patients aged less or greater than 70 years. Late survival data were collected for 13,324 consecutive, isolated, primary coronary artery bypass graft surgery patients from three hospitals. Cox regression analysis was performed on all patients grouped by age. Adjusted Cox regression showed overall better RA versus SV survival (hazard ratio [HR] 0.82, p<0.001) and no difference in RITA versus SV survival (HR 0.95, p= 0.35). However, the survival benefit of RA versus SV was seen only in patients aged less than 70years (HR 0.77, p < 0.001); and RITA patients aged less than 70 years also had a survival benefit compared with SV (HR 0.86, p= 0.03). There was no difference in survival for RA versus RITA across all ages. For patients aged less than 70 years, the optimal grafting strategy is using either RA or RITA as the second preferred graft. In patients aged 70 years or more, RA and RITA grafting should be used selectively. Multiple arterial grafting using either RA or RITA should be more widely utilized during coronary artery bypass graft surgery for patients less than 70 years of age.

The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting

Study of objectiveTo compare the effects of oral tramadol+paracetamol combination on morphine consumption following coronary artery bypass grafting (CABG) in the patient-controlled analgesia (PCA) protocol. DesignA prospective, double-blind, randomized, clinical study. SettingSingle-institution, tertiary hospital. PatientsFifty cardiac surgical patients undergoing primary CABG surgery. InterventionsAfter surgery, the patients were allocated to 1 of 2 groups. Both groups received morphine according to the PCA protocol after arrival to the coronary intensive care unit (bolus 1 mg, lockout time 15 minutes). In addition to morphine administration 2 hours before operation and postoperative 2nd, 6th, 12th, 18th, 24th, 30th, 36th, 42th, and 48th hours, group T received tramadol+paracetamol (Zaldiar; 325 mg paracetamol, 37.5 mg tramadol) and group P received placebo. Sedation levels were measured with the Ramsay Sedation Scale, whereas pain was assessed with the Pain Intensity Score during mechanical ventilation and with the Numeric Rating Scale after extubation. If the Numeric Rating Scale score was ≥3 and Pain Intensity Score was ≥3, 0.05 mg/kg morphine was administered additionally. MeasurementsPreoperative patient characteristics, risk assessment, and intraoperative data were similar between the groups. Main resultsCumulative morphine consumption, number of PCA demand, and boluses were higher in group P (P<.01). The amount of total morphine (in mg) used as a rescue analgesia was also higher in group P (5.06±1.0), compared with group T (2.37±0.52; P<.001). The patients who received rescue doses of morphine were 8 (32%) in group T and 18 (72%) in group P (P<.001). Duration of mechanical ventilation in group P was longer than group T (P<.01). ConclusionTramadol+paracetamol combination along with PCA morphine improves analgesia and reduces morphine requirement up to 50% after CABG, compared with morphine PCA alone.

Bleeding-Related Complications and Readmission Rates Associated With Fibrin Sealant Use in Patients Undergoing Coronary Artery Bypass Graft Surgery in the United States

To compare the clinical and economic outcomes of EVICEL (Ethicon, Inc., Somerville, NJ) and TISSEEL (Baxter Healthcare Corporation, Westlake Village, CA) use in patients undergoing primary coronary artery bypass graft (CABG) surgery. Retrospective database analysis. Premier prospective hospital database (June 2009 through March 2014) covering approximately 20% of hospital discharges in the United States. Adults undergoing primary CABG surgery who received either EVICEL or TISSEEL on the day of surgery (index date). Two intervention groups were formed, EVICEL and TISSEEL. Clinical outcomes compared included postoperative bleeding complications (International Classification of Diseases, Ninth Revision, Clinical Modification code: 998.1) and number of blood transfusions received on the index day. Economic outcomes compared included hospital length of stay, hospital costs, and 30-day readmission rates. Propensity-score matching was used to control for patient and hospital characteristics. A total of 129,014 primary CABG surgery patients were identified; 986 patients (mean age: 64 years, 73% male) received EVICEL and 6,340 patients (mean age: 65 years, 75% male) received TISSEEL on the index day. After propensity-score matching, patients who received EVICEL compared with TISSEEL had significantly fewer postoperative bleeding complications (3.0% v 5.0%, p = 0.0197), index-day blood transfusion rates (19% v 34%, p<0.0001), readmission rates (18% v 32%, p<0.0001), and costs ($40,736 [standard deviation $19,465] v $46,005 [standard deviation $24,049], p<0.0001). Results from a sensitivity analysis using a generalized linear model to control for other hemostatic agent use also favored EVICEL over TISSEEL. Results from this real-world retrospective database analysis showed fewer bleeding complications and lower costs in patients undergoing primary CABG surgery who received EVICEL compared with TISSEEL.

QUALITY OF ACUTE MYOCARDIAL INFARCTION CARE IN CANADA: A 10-YEAR REVIEW OF 30-DAY HOSPITAL READMISSION

The Canadian Institute for Health Information has recently released new cardiac care quality indicators regarding 30-day readmission after primary percutaneous coronary intervention (PCI) and coronary artery by-pass grafting (CABG). The objectives of our study were to examine temporal trends and provincial variation in the 30-day hospital readmission after PCI and CABG among patients with acute myocardial infarction (AMI) in Canada.

Should Bilateral Internal Thoracic Artery Grafting Be Used in Patients With Diabetes Mellitus?

Bilateral internal thoracic artery (BITA) grafting in patients with diabetes mellitus is controversial because of a higher risk for sternal infection. The purpose of this study is to compare the outcome of BITA grafting to that of single ITA (SITA) grafting in patients with diabetes. Between 1996 and 2010, 964 diabetic patients with multivessel disease who underwent primary coronary artery bypass graft surgery with BITA were compared with 564 patients who underwent coronary artery bypass graft surgery with SITA and saphenous vein grafts. The SITA patients were older, more often female, more likely to have chronic obstructive pulmonary disease, ejection fraction 30% or less, insulin-dependent diabetes, recent myocardial infarction, renal insufficiency, peripheral vascular disease, and emergency operation. The BITA patients more often underwent coronary artery bypass graft surgery with three or more grafts. The two groups had similar operative mortality, 2.6% BITA versus 3.0% SITA, and sternal infection, 3.1% versus 3.9%, respectively. The mean follow-up was 12.2 ± 4.3 years. Unadjusted Kaplan-Meier 10-year survival of the BITA group was better than that of the SITA group (65.3% ± 3.1% versus 55.5% ± 4.5%, respectively; p= 0.004), After propensity score matching (490 well-matched pairs), Kaplan-Meier 10-year survival was not significantly different between the matched groups; however, the Cox-adjusted survival of the BITA patients was better (hazard ratio 0.729, 95% confidence interval: 0.551 to 0.964, p= 0.027). The findings of this large cohort study suggest that the long-term outcome of patients with diabetes and multivessel disease who undergo BITA grafting is better than that of diabetic patients who undergo coronary artery bypass graft surgery with SITA and saphenous vein grafts.

Estimated glucose disposal rate and long-term survival in type 2 diabetes after coronary artery bypass grafting.

We performed a nationwide population-based cohort study to investigate the association between estimated glucose disposal rate (eGDR) and long-term survival after coronary artery bypass grafting (CABG) in patients with type 2 diabetes. All patients who underwent primary CABG in Sweden from 2006 to 2013 were identified from the SWEDEHEART register and by record linkage to the National Diabetes Register; all patients with type 2 diabetes were included and formed the study population. Patients were followed until 2013 through national registers for major adverse cardiovascular events and death from any cause. eGDR was calculated using waist circumference, hemoglobin A1c, and presence or the absence of hypertension. The association between eGDR and death was estimated using multivariable Cox regression. A total of 3256 patients were included. During a mean follow-up of 3.1years (10,227 person-years), in total, 14% patients died: 17% (n=186) in the 1st tertile (lowest eGDR), 14% (n=145) in the 2nd tertile, and 13% (n=133) in the 3rd tertile (highest eGDR). There was a significant association between eGDR and increased risk of death: adjusted hazard ratio (95% confidence interval): 1.46 (1.12-1.90) for the 1st eGDR tertile compared to the 3rd and highest eGDR tertile. In conclusion, patients with type 2 diabetes who underwent CABG, a low eGDR, were associated with an increased risk of long-term all-cause mortality that was independent of other cardiovascular and metabolic risk factors. Insulin resistance measured by eGDR could be a useful risk marker in patients with type 2 diabetes and ischemic heart disease.

Multiple arterial grafts improve survival with coronary artery bypass graft surgery versus conventional coronary artery bypass grafting compared with percutaneous coronary interventions

ObjectiveTo compare long-term survival with multiple arterial coronary artery bypass grafting (CABG) (MultArt) versus percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). MethodsWe reviewed 12,615 patients with MVD with isolated primary CABG or PCI from 1993 to 2009. Patients with CABG (n = 6667) were grouped according to the number of arterial grafts into left internal thoracic artery (LITA)/saphenous vein (SV) (n = 5712) or MultArt (n = 955); patients with PCI (n = 5948) were grouped into balloon angioplasty (BA) (n = 1020), drug-eluting stent (DES) (n = 1686), and bare metal stent (BMS) (n = 3242). ResultsUnadjusted long-term survival was lower for CABG than PCI (15-year survival, 34% vs 46%; P < .001); however, in patients with MultArt, survival was greater than LITA/SV, BA, BMS (15-year survival, 65% vs 31%, 47%, 45%, respectively; P < .001), and DES (8-year survival, 87% vs 70%; P < .001). In matched analyses, 15-year survival of MultArt was higher than BA (66% vs 57%; P = .002), LITA/SV (64% vs 56%; P = .02), and BMS (5-year survival 94% vs 90%; P = .01), and similar to DES at 8 years. In multivariate analysis, compared with MultArt, LITA/SV had worse survival (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.09-1.52; P = .003). BMS (HR, 0.87; 95% CI, 0.80-0.94; P < .001) and DES (HR, 0.76; 95% CI, 0.66-0.88; P < .001) had improved survival versus LITA/SV but not versus MultArt (HR, 1.12; 95% CI, 0.94-1.34; P = .21, and HR, 0.98; 95% CI, 0.79-1.21; P = .83, respectively). Secondary analyses for treatment crossover indicated lower survival for LITA/SV versus MultArt and PCI. ConclusionsIn patients with MVD undergoing primary revascularization, MultArt increased survival benefit versus LITA/SV compared with PCI. Use of MultArt must increase.

A comparison of high-dose and low-dose tranexamic acid antifibrinolytic protocols for primary coronary artery bypass surgery.

Background and Aims:Tranexamic acid (TA) is used for prophylactic antifibrinolysis in coronary artery bypass surgeries to reduce bleeding. We evaluated the efficacy of two different doses of TA for prophylactic antifibrinolysis in patients undergoing primary coronary artery bypass grafting (CABG) surgery in this retrospective cohort study at a tertiary care referral centre.Methods:One-hundred eighty-four patients who underwent primary CABG with cardiopulmonary bypass (CPB) via sternotomy between January 2009 and June 2011 were evaluated. Pre-operative patient characteristics, intraoperative data, post-operative bleeding, transfusions, organ dysfunction and 30-day mortality were compared between high-dose TA (30 mg/kg loading dose followed by infusion of 15 mg/kg/h until the end of surgery along with 2 mg/kg priming dose in the bypass circuit) and low-dose TA (15 mg/kg loading dose followed by infusion of 6 mg/kg/h until the end of surgery along with 1 mg/kg priming dose in the bypass circuit) groups. Univariate comparative analysis of all categorical and continuous variables was performed between the two groups by appropriate statistical tests. Linear and logistic regression analyses were performed to control for the effect of confounding on the outcome variables.Results:Chest tube output, perioperative transfusion of blood products and incidence of re-exploration for bleeding did not differ significantly (P> 0.05) between groups. Post-operative complications and 30-day mortality were comparable between the groups. The presence of cardiogenic shock and increased pre-operative creatinine were found to be associated with increased chest tube output on the post-operative day 2 by multivariable linear regression model.Conclusions:Low-dose TA protocol is as effective as high-dose protocol for antifibrinolysis in patients undergoing primary CABG with CPB.

Abstract 17564: Long-term Risk of Stroke in Patients With Type 1 and Type 2 Diabetes Following Coronary Artery Bypass Grafting

Background: We performed a nationwide population-based cohort study to investigate the long-term risk of stroke after coronary artery bypass grafting (CABG) in patients with type 1 and type 2 diabetes. Hypothesis: Type 1 and type 2 diabetes is associated with an increased longterm risk of stroke after CABG. Methods and Results: All patients who underwent primary CABG in Sweden from 2000 through 2011 were included from the SWEDEHEART register. We excluded patients with prior stroke, and patients who had a stroke or died within 30 days of surgery. The National Diabetes Register was used to identify patients with type 1 and type 2 diabetes. Incident stroke (ischemic and hemorrhagic), and all-cause mortality was obtained by record linkage with the National Patient Register and the Cause of Death register. A total of 53 820 patients (type 1 diabetes (n=714), type 2 diabetes (n=10 054), no diabetes (n=43 052)) were included. During a mean follow-up of 7.4 years (398 337 person-years), in total, 8.0% (n=4 296) of the patients had a stroke: 7.3% (n=52) in patients with type 1 diabetes, 9.1% (n=915) in patients with type 2 diabetes, and 7.7% (n=3 329) in patients with no diabetes. The multivariable adjusted hazard ratio (95% confidence interval) for all stroke was 1.59 (1.20-2.11) in type 1 diabetes, and 1.32 (1.23-1.43) in type 2 diabetes compared to patients without diabetes. Figure 1 shows the age-adjusted cumulative incidence of stroke in relation to type 1 diabetes, type 2 diabetes and no diabetes. Conclusions: The long-term risk for stroke after CABG was higher in both patients with type 1 diabetes, and type 2 diabetes, compared to patients without diabetes.

Long-Term Risk of Stroke in Patients With Type 1 and Type 2 Diabetes Following Coronary Artery Bypass Grafting.

BackgroundWe performed a nationwide population‐based cohort study to investigate the long‐term risk of stroke after coronary artery bypass grafting in patients with type 1 and type 2 diabetes.Methods and ResultsAll patients who underwent primary coronary artery bypass grafting in Sweden from 2000 through 2011 were included from the SWEDEHEART register. We excluded patients with prior stroke, and patients who had a stroke or died within 30 days of surgery. The National Diabetes Register was used to identify patients with type 1 and type 2 diabetes. Incident stroke (ischemic and hemorrhagic), and all‐cause mortality was obtained by record linkage with the National Patient Register and the Cause of Death register. We used multivariable Cox regression to estimate the risk of stroke in relation to type of diabetes. A total of 53 820 patients (type 1 diabetes [n=714], type 2 diabetes [n=10 054], no diabetes [n=43 052]) were included. During a mean follow‐up of 7.4 years (398 337 person‐years), in total, 8.0% (n=4296) of the patients had a stroke: 7.3% (n=52) in patients with type 1 diabetes, 9.1% (n=915) in patients with type 2 diabetes, and 7.7% (n=3329) in patients with no diabetes. The multivariable adjusted hazard ratio (95% CI) for all stroke was 1.59 (1.20–2.11) in type 1 diabetes, and 1.32 (1.23–1.43) in type 2 diabetes.ConclusionsThe long‐term risk for stroke after coronary artery bypass grafting was increased in patients with type 1 and type 2 diabetes, compared to patients with no diabetes.

Cardiac reoperations in octogenarians: Do they really benefit?

According to the demographic development of our society, the numbers of octogenarians referred to cardiac surgery are continuously growing. Although the benefit of first-time cardiac procedures for these patients is well documented, the fate of octogenarians after redo-procedures, with special regard to long-term survival, functional status and quality of life, is poorly investigated. We retrospectively identified 84 consecutive patients aged ≥80 years, who underwent a cardiac reoperation at the department for Cardiothoracic Surgery in the Heart & Vessel Center Bad Bevensen between January 2007 and 2013. Demographic profiles as well as operative data were analyzed, and the patients were prospectively followed. Patient's functional status and quality of life were assessed with the Barthel Index, New York Heart Association class and the short form-12 questionnaire. The mean age of the study group (61 men, 23 women) was 81.9 ± 1.9 years. Most redo-procedures were carried out after primary coronary artery bypass grafting (65%), primary aortic valve replacement (21%) and primary mitral valve replacement (6%). The most frequent actual surgical procedures were combined coronary artery bypass grafting and aortic valve replacement (26%), isolated coronary artery bypass grafting (19%), and isolated aortic valve replacement (19%). The mean length of hospital stay was 17 ± 15 days. In-hospital mortality counted for 32.1%. During follow up (29 ± 20 months) a further 19.0% of the patients died. The Barthel Index of the survivors was 89 ± 17 and their mean New York Heart Association class was 2 ± 1. A total of 93% of the patients were living at home. Summary scores of physical and mental health of the short form-12 questionnaire equalled those of an age- and sex-matched normative population. Despite high perioperative mortality, results document a sustainable recovery of the survivors offering the prospect of a highly independent and satisfying life. Therefore, advanced age alone should not be a contraindication for redo cardiac interventions. Geriatr Gerontol Int 2016; 16: 1138-1144.

Postoperative Atrial Fibrillation Is Associated With High On-Aspirin Platelet Reactivity

Atrial fibrillation (AF) contributes to a prothrombotic state through platelet activation. It is unclear whether increased platelet aggregability in patients with AF is caused by the underlying cardiovascular condition rather than the arrhythmia per se. We investigated the effect of postoperative atrial fibrillation (POAF) on platelet reactivity after coronary artery bypass grafting (CABG). This study is a post hoc analysis from a randomized controlled trial (ClinicalTrials.gov: NCT01159639) based on patients undergoing elective primary CABG. Patients were dichotomized according to POAF. Postoperative platelet function testing with arachidonic acid as the platelet agonist (ASPI test) was used to define high on-aspirin platelet reactivity (HAPR). ΔASPI presented the difference between pre- and postoperative ASPI test values. To account for the isolated effect of POAF on platelet reactivity, a propensity score analysis was applied. Overall incidence of POAF was 23% (92 of 398 patients). HAPR was detected in 54% (214 of 398) of patients. HAPR was more prevalent among patients with POAF when compared with patients without POAF (64.1% versus 50.7%; odds ratio [OR], 1.74; 95% confidence interval [CI], 1.08-2.82; p = 0.023). The propensity score model produced a subcohort of patients that was well balanced for comorbidities. When compared with the matched group without POAF, the POAF group maintained its prevalence for HAPR (64.1% versus 45.7%; OR, 2.13; 95% CI, 1.18-3.85; p = 0.012) and had greater ΔASPI values (15.0 [IQR, 0.0-36.0] vs 8.0 [IQR, -5.5-19.5]; p = 0.030). The main finding of our study indicates there is added platelet activation in patients with POAF after CABG before and after controlling for pathologic conditions through propensity matching. The present study does not prove a causal association between POAF and HAPR.

Cell salvage during coronary artery bypass surgery and allogenic blood exposure.

Our primary aim was to assess the impact of intraoperative cell saver usage on patient exposure to allogenic blood transfusion during elective coronary artery bypass. The secondary endpoint was the impact of cell savage on the units of blood and blood products transfused perioperatively. A prospective observational cohort study with a historical cohort as a control group was performed in a single tertiary care center. One hundred and twenty-four patients undergoing primary on-pump coronary artery bypass grafting were included. Intraoperative cell salvage was performed in 60 patients (study group) but not in the control group (n = 64). Transfusion data, intensive care unit stay, hospital stay, and postoperative complications were evaluated in the cell saver and control groups. The number of patients exposed to allogenic red blood cell transfusion was significantly less in the study group (55% vs. 82.8%; p = 0.001) and the units per patient was also less in the study group (1.10 ± 1.7 vs. 2.25 ± 2.289 units; p = 0.002). However, there was no significant difference in terms of units of purified plasma fraction, platelets, or cryoprecipitate transfused. Intensive care unit stay, total hospital stay, number of reexplorations, complications, readmissions, and 28-day mortality were similar in both groups. Intraoperative cell salvage with a cell saver in patients undergoing primary elective coronary artery bypass decreases the proportion of patients exposed to allogenic red cell transfusions and the number of units of red blood cells transfused.

The relationship between vitamin D levels and saphenous vein graft patency.

A growing body of evidence supports an association between vitamin D and cardiovascular diseases. Coronary artery bypass grafting surgery is a treatment modality for suitable patients with coronary artery disease; however, patency rates of saphenous vein grafts (SVGs) are low. In this study we aimed to determine the association between vitamin D levels and the SVG disease. The study population included 180 patients who had undergone a primary coronary artery bypass grafting surgery with at least one SVG and later had a control angiography because of clinical indications. Patients were divided into two groups: 100 patients with SVG disease and 80 of them with patent SVG. The mean age of 180 patients was 57.4±8.8 years, and 64.4% of the study population were men. The total number of SVGs was 364, and the mean number of SVGs to each patient was 2.02±0.61. Vitamin D levels were higher in the patent SVG group than in the SVG disease group (36.2±10.7 and 21.1±10.4, respectively; P<0.001). C-reactive protein levels were significantly higher in the SVG disease group (8.3 vs. 6.5 mg/dl, P=0.001). In a multivariate regression analysis, current smoking, diabetes mellitus, target artery diameter less than 1.5 mm, bypass time duration, and vitamin D levels remained as independent factors associated with SVG disease. Lower vitamin D levels are associated with occlusion of SVGs in patients with coronary artery disease.

PP.01.10

Objective: Our country is in high risk cardiovascular region in Europe. The aim of the study was to evaluate healthy lifestyle and pharmacological therapy effect in hypertensive patients with coronary heart disease (CHD) according to European Guidelines on Cardiovascular Prevention. Design and method: We evaluated age, systolic blood pressure (SBP), diastolic blood pressure (DBP) heart rate (HR), total cholesterol (TC), smoking status and pharmacological therapy use in treated hypertensive patients after survived myocardial infarction or primary percutaneous coronary interventions (PCI) or coronary artery bypass grafting (CABG). We analyzed 105 CHD patients (77 men and 28 women) women living in community Stari Grad, Belgrade, during their control examinations in October-December 2014.year. All data tested by Student T test. Results: Mean age in men was 67 ± 9 and in women 70 ± 9 years (p = 0,1) Mean SBP in men was 137,17 ± 14 mm Hg and in women 134,68 ± 14 mm Hg (p = 0,5) Mean DBP in men was 79,81 ± 7 mm Hg and in women 79,44 ± 6 mm Hg (p = 0,8) Mean HR in men was 67,64 ± 9/sec and in women 75,10 ± 11/sec (p = 0,004) Mean TC was in men 5,0 mmol/L and in women 4,88 mmol/L (p = 0,8) Smoking status was present in 12 (16%) men and in 10 (36%) women. Beta blockers were used in 70 (91%) men and in 25 (89%) women ACE inhibitors were used in 68 (88%) men and in 23 (82%) women Calcium antagonists were used in 42 (55%) men and in 17 (61%) women Antithrombotic drugs were used in all patients Lipid lowering drugs were used in 60 (78%) men and in 22 (79%) women. Mean number drugs in men was 3,9 and in women 4,2 (p = 0,8) drug. Conclusions: Life style and pharmacological therapy made optimal mean blood pressure in hypertensive men and women with CHD. HR was optimal in hypertensive men with CHD Pharmacological therapy to improve prognosis was used in great percentage. Secondary prevention in hypertensive patients with CHD needs permanent implementation in these high risk regions in Europe.

Embedded Left Anterior Descending Artery During Coronary Bypass Operations: A 15-year Experience

Revascularisation of the left anterior descending coronary artery (LAD) is the most important part of coronary artery bypass grafting (CABG) operations. We analysed the results of CABG in patients with embedded LADs compared to age and gender-matched controls. Among 4,102 patients undergoing primary on-pump CABG from January, 1999, through April, 2014, 92 had embedded LADs. Direct dissection (n=19) or retrograde probe technique (n=73) was utilised to expose the LAD. Controls had epicardial courses of the LAD. A retrospective study was performed and follow-up information was obtained. Cross clamp and cardiopulmonary bypass times were longer (63.5 ± 8.5 vs. 46.6 ± 20, p<0.001; and 81.4 ± 21.4 vs. 60.1 ± 20.8, p<0.001, respectively) in the study group in which four patients had right ventricular injury (n = 3, direct dissection; n =1, retrograde probe). The groups did not differ in terms of associated comorbidities, number of grafts, reoperation rate for bleeding, duration of intensive care unit stay, and duration of hospital stay. There were no hospital deaths in either group. Kaplan-Meier analysis showed similar survival rates postoperatively. In patients with embedded LADs, surgical outcomes following on-pump CABG compare favourably with the age- and gender-matched controls.

Coronary Artery Bypass Grafting After Percutaneous Intervention Has Higher Early Mortality: A Meta-Analysis

We compared early adverse events and midterm survival between primary coronary artery bypass grafting (pCABG) and CABG in patients with percutaneous intervention (secondary CABG, sCABG) because data on this topic are very limited. A systematic review of published literature was done to obtain original studies fulfilling the search criteria. The end points studied were early mortality, stroke, renal failure, myocardial infarction, and the need for an intra-aortic balloon pump. A random-effect inverse variance weighted analysis was performed. The results are presented as risk ratios (RR) (95% confidence interval); p < 0.05 was considered statistically significant. Fourteen studies (84,983 pCABG patients and 14,775 sCABG patients) were included in the systematic review. Early mortality was lower with primary CABG (RR 1.54 [1.19-2]; p= 0.007). The incidence of myocardial infarction was also less with pCABG than with sCABG. (RR 1.46 [1.04-2.06]; p= 0.06). Patients undergoing pCABG were 14% (0% to 55%; p= 0.04). Less likely to need an intra-aortic balloon pump. Although renal failure was lower with pCABG (RR 1.254 [1.047-1.502]; p= 0.014), the stroke rates were comparable in both cohorts (p= 0.95). Renal failure was favorable in the primary CABG cohort. Early stroke was comparable between the two cohorts (p= 0.95). The pooled hazard ratios demonstrated comparable survival at the end of 3 years (p= 0.36). Patients undergoing CABG after prior percutaneous therapy have a higher incidence of myocardial infarction and mortality in the postoperative period. However, midterm survival is comparable in both cohorts.

Changes over time in risk profiles of patients who undergo coronary artery bypass graft surgery: the Veterans Affairs Surgical Quality Improvement Program (VASQIP).

Today's coronary artery bypass grafting (CABG) population appears to comprise sicker patients than in the past; however, little is known about the change in the risk profile. To evaluate the change with time in the risk profile of patients who undergo CABG. Retrospective review of records from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP); 65,097 patients who underwent isolated primary CABG from October 1, 1997, to April 30, 2011, were evaluated. Trends in risk profiles, surgical volume, and modern outcomes in the VA system. We determined the significance of changes in age and major comorbidities across time with simple linear regression analysis and evaluated the rates of perioperative mortality (30-day or in-hospital) and VASQIP predicted risk of mortality trends over time. From 1997 to 2011, there were increases in mean (SD) patient age (63.1 [9.4] vs 64.3 [7. 8] years; R² = 0.34; P = .02) and body mass index (28.3 [5.1] vs 30.1 [5.8]; R² = 0.95). There were also increases in the prevalence of diabetes mellitus (32.8% vs 41.3%; R² = 0.82), preoperative New York Heart Association (NYHA) class III or IV heart failure status (14.3% vs 34.2%; R² = 0.74), and left main coronary artery disease (26.0% vs 32.8%; R² = 0.82) (all P < .001). There was a decrease in the prevalence of advanced angina severity (Canadian Cardiovascular Society class III or IV) (R² = 0.95), previous myocardial infarction (R² = 0.82), and low ejection fraction (≤34%) (R² = 0.88) (all P < .05). There was no significant change in the prevalence of cerebrovascular and peripheral vascular disease, chronic obstructive pulmonary disease, or 3-vessel coronary artery disease. Perioperative mortality rates and the VASQIP predicted risk of mortality, respectively, decreased with time (3.2% and 3.1% vs 1.7% and 1.6%). From 2004 to 2011, there was a significant increase in the prevalence of previous percutaneous coronary intervention (18.6% to 29.2%; R² = 0.82; P = .002). Overall CABG volume decreased (5551 in 1998 vs 3857 in 2012; R² = 0.95; P < .001). From 1997 to 2011, there was a progressive increase in the prevalence of obesity, diabetes, left main coronary artery disease, and advanced NYHA heart failure class among VA patients undergoing CABG. The prevalence of previous myocardial infarction, low ejection fraction, and advanced angina decreased, perhaps because of earlier surgical referral, improvement in medical management, or a shift in patient selection for CABG. Operative mortality also decreased with time. These trends confirm the general perception of significant, ongoing improvement in the care of patients who undergo CABG in the VA, despite an older, sicker population.