Increasing But Variable Use of Surgical Treatment of Atrial Fibrillation: An Update from the STS Adult Cardiac Surgery Database.

The left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis is standard in coronary artery bypass grafting (CABG) owing to its long-term patency. However, in hemodialysis patients with an ipsilateral upper-limb arteriovenous fistula (AVF), in-situ LITA grafting may raise concern for coronary steal syndrome (CSS). We assessed whether AVF laterality influences outcomes after CABG with LITA-LAD in hemodialysis patients. We retrospectively reviewed hemodialysis patients who underwent isolated primary CABG with in-situ LITA-LAD between 2002 and 2020. Patients were classified by AVF side (ipsilateral vs. contralateral). The primary endpoint was all-cause mortality; secondary endpoints were cardiac death, major adverse cardiac events (MACEs), and in-hospital mortality. Propensity score matching (2 : 1), time-to-event analyses, and competing-risk analyses were performed. Of 206 patients (169 ipsilateral and 37 contralateral), 99 (66 ipsilateral and 33 contralateral) were matched, achieving covariate balance. All-cause mortality was similar in the overall and matched cohorts (log-rank P = 0.89 and P = 0.34), and AVF laterality was not associated with mortality (hazard ratio: 0.98, 95% confidence interval: 0.57-1.69, P = 0.94). Cardiac death, MACEs, and in-hospital mortality did not differ significantly; all four in-hospital deaths occurred in the ipsilateral group (three due to cardiac causes). In hemodialysis patients undergoing CABG with in-situ LITA-LAD, an ipsilateral AVF was not associated with worse survival or cardiovascular outcomes, supporting the safety of in-situ LITA grafting even when ipsilateral to an AVF. Future studies should identify CSS high-risk subgroups (e.g. subclavian artery stenosis, forearm vs. upper-arm AVF).

Long-term clinical outcomes and morphology of no-touch saphenous vein grafts.

ABSTRACTObjectivesProlonged cardiopulmonary bypass (CPB) time during coronary artery bypass grafting (CABG) is associated with poor outcomes, however, the association of other operating room (OR) times is less understood. We studied the impact of OR times on outcomes and resource utilization after CABG.MethodsPatients undergoing isolated primary CABG from a large multicentre regional collaborative were analysed. The impact of risk-adjusted total OR, surgery, non-surgery, CPB, and off-CPB times on morbidity, extubation time, ICU and hospital length of stay (LOS), cost, and mortality, was studied. Multivariable regressions were performed adjusting for STS predicted risk of morbidity or mortality, intraoperative blood transfusion, CPB time, cross-clamp time, presence of a cardiothoracic surgery fellowship program, and year of surgery. Our adjustment accounted for patient and intraoperative factors that contribute to complexity and intraoperative course of surgery. All models incorporated centre as a random effect to account for hospital-level variations.ResultsAmong 29 206 patients (mean age 64.8 years, 76% male), median OR, surgery, non-surgery, and CPB times were 308, 235, 72, and 141 minutes, respectively. Longer surgery times were significantly associated with complications, prolonged ventilation, longer ICU and hospital LOS, and mortality. Similarly, increasing non-surgery OR time was significantly associated with worse outcomes, including longer LOS and complications. Each additional 15 minutes in the OR was associated with increased odds of complications, mortality, and cost.ConclusionsLonger non-surgical OR times are associated with adverse outcomes and increased cost. Improving OR efficiency may contribute to better patient outcomes.

Risk-Adjusted Outcomes of Reoperative vs Primary Coronary Artery Bypass Grafting.

This study investigates the outcomes after very early chest drain removal following off-pump endoscopic coronary artery bypass grafting. A single-centre retrospective cohort study was conducted at our hospital. All patients undergoing a primary endoscopic coronary artery bypass grafting procedure between May 2021 and January 2025 were eligible. Both single- or multivessel endoscopic coronary artery bypass grafting procedures were analysed. Patients were excluded if they underwent a redo-operation, coronary unroofing procedure, or conversion to sternotomy. A total of 476 patients were included in the final analysis: 246 patients in the conventional drain removal protocol and 230 patients in the early drain removal protocol. Patients in the early drain removal group had significantly higher rates of preexisting comorbidities, preoperative antithrombotic therapy, and urgent procedures (52.6% vs. 36.2%, p < 0.001). The total drain time (5.1 vs. 22.4 h, p < 0.001) and the total drain volume (135 vs. 310 mL, p < 0.001) were both significantly lower in the early postoperative drain removal protocol. There were no significant differences between protocols in the incidence of cardiac tamponade in the first 30 postoperative days (1.3% vs. 0.4%, p = 0.569) and thoracentesis rates (8.7% vs. 5.3%, p = 0.199). Very early chest drain removal after endoscopic coronary artery bypass grafting is safe and does not increase postoperative complications for both single- and multivessel revascularisation. This approach enables early ambulation and may contribute to enhanced postoperative recovery.

Prognostic impact of prior percutaneous coronary intervention on patients undergoing coronary artery bypass grafting - A meta-analysis of reconstructed time-to-event data.

The influence of socioeconomic status on the decision to use bilateral internal mammary artery grafting in coronary artery bypass surgery

The effectiveness of bilateral internal mammary artery (BIMA) grafting during multivessel coronary artery bypass grafting (CABG) is uncertain in patients with mildly decreased renal function (glomerular filtration rate 60-89ml/min/1.73m2). We compared outcomes of bilateral versus single IMA (SIMA) grafting in this population. We analyzed 933 patients with mildly decreased renal function who underwent isolated primary CABG using BIMA (n = 454) or SIMA (n = 479) at our center. Patients receiving radial artery grafts or no IMA grafts were excluded. Inverse probability treatment weighting was used to create a well-balanced cohort. 6-year survival and the cumulative incidence of major adverse cardiac or cerebrovascular events (MACCE)-including death, stroke, myocardial infarction, revascularization, and rehospitalization-were assessed. The median age of the entire cohort was 68.0years (IQR 61.5-74.0). Median follow-up time was 4.63years (IQR 4.46-4.82). In well-balanced cohort, BIMA group had a higher number of total distal anastomoses (P < 0.001), with similar rate of complete revascularization (P = 0.101). BIMA group had significantly higher 6-year survival compared to SIMA group (91.9% [87.7-96.3%]; 85.9% [81.7-90.2%]; P = 0.046), which was reconfirmed on multivariable Cox regression analysis (Hazard ratio: 0.505 [0.268-0.953], P = 0.035). MACCE incidence was significantly lower with BIMA (23.5% vs. 40.5%, P < 0.001). Among patients with mildly decreased renal function, the BIMA group was associated with longer survival and lower major adverse cardiac or cerebrovascular events after multivessel CABG.

Background: Treatment for coronary heart diseases involve the use of coronary artery bypass grafting (CABG). However, the procedure is associated with certain complications including, systemic inflammation, postoperative atrial fibrillation, myocardial infarction, infection of the sternal wound, stroke, graft failure, and renal dysfunction. Objectives: To determine the early complications and per-operative parameters of patients who had CABG surgery. Methods: All patients who received CABG surgery at the hospital from January 2019 through December 2022 were included in the study population. Patients who were at least eighteen years old and had undergone primary CABG surgery met the inclusion criteria. Aortic cross-clamp time, the quantity and kind of grafts used, the length of cardiopulmonary bypass, and the use of the intra-aortic balloon pump (IABP) were among the operational factors that were evaluated. One of the main outcomes was postoperative complications, which included the rate of atrial fibrillation, myocardial infarction, stroke, wound infection, renal failure, and respiratory issues. Results: The study included 473 individuals who were having primary CABG surgery. The patients' average age was 63.2 ± 9.8 years. A total of 331 patients (70%) were men, and 142 patients (30%) were women. A total of 142 (30%) patients experienced postoperative complications. Atrial fibrillation accounted for the majority of complications, occurring in 56 patients (39%); wound infection followed in 38 patients (27%), respiratory problems in 19 (13%), myocardial infarction in 9 (6) %, stroke in 5 (4%), and renal failure in 15 patients (11%). Conclusion: The study's findings highlight the high incidence of wound infections, respiratory problems, and atrial fibrillation as postoperative consequences of CABG surgery. The findings highlight the necessity of careful postoperative observation and comorbidity treatment in order to enhance patient outcomes.

Abstract Background To ascertain the patency of bypass grafts during off pump Coronary Artery Bypass Surgery (CABG) cases using Transit time flowmetry (TTFM) in the intraoperative period. Methods A total of 240 grafts in 80 patients who underwent isolated primary elective off pump Coronary artery bypass grafting surgery were assessed by using Transit time flowmetry probe. The variables analyzed include Mean graft flow (MGF), Pulsatility Index (PI), Diastolic flow fraction (DF) and Backward flow (BF). Results 233 grafts of the total 240 grafts were found satisfactory as per TTFM values. 7 (2.9%) grafts were found to be unsatisfactory out of which 6 required surgical correction. Post surgical correction the TTFM values were satisfactory. Conclusion TTFM is logistically simple method of ascertaining the patency of CABG grafts intraoperatively. Sensitivity and specificity of the TTFM assessment increases if it combined with Epicardial High Frequency Ultrasound.

Bilateral internal mammary arteries (BIMAs) as the most advanced surgical option for coronary artery bypass grafting (CABG) are usually recommended for younger patients without traditional risk factors. This study compares outcomes in propensity score-matched patients aged over 70 years who received BIMAs versus those who received a single internal mammary artery (SIMA). From 2013 to 2024, 8123 patients underwent primary CABG for multivessel coronary artery disease at our institution. BIMA grafting was performed in 1233 patients (15.17%), with in situ BIMA grafting in 290 patients (3.57%). For in situ BIMA group, the right internal mammary artery was used to revascularize the right coronary artery, while the left internal mammary artery was utilized for the left anterior descending artery. BIMA patients aged over 70 years (n = 79) were compared with SIMA patients (n = 79) using propensity score matching. Primary outcome was all-cause mortality at 30 days and 8 years. Secondary outcomes included length of hospital stay, incidence of postoperative major adverse cardiovascular and cerebrovascular events, sternal wound infection and the need for subsequent percutaneous revascularization. There was no difference in immediate postoperative primary and secondary outcomes. Mean follow-up was 8.3 ± 1.0 years with an 8-year freedom from death of 67.08% ± 1.1% in the BIMA group versus 58.22% ± 0.9% in the SIMA group (P < 0.05). BIMAs as in situ grafts can be successfully used in CABG for patients aged 70 years and older. Consequently, the refined techniques for constructing internal mammary artery grafts used in this study challenge traditionally accepted limitations regarding the use of BIMAs.

Patients having Stanford type A acute dissection soon after cardiac surgery have a high risk of rupture and death. The presentation, management, and outcome of primary dissection of the ascending aorta (Stanford type A or De Bakey type I or II) are well described. However, patients with Stanford type A acute aortic dissection soon (3-4 weeks) after primary cardiac surgery have distinctly different presentation, management, and postoperative outcome. In this report, we describe the clinical and surgical findings of a patient with early Stanford type A acute aortic dissection four weeks after primary coronary artery bypass grafting.

Background: Recent studies showed that sodium-glucose cotransporter 2 inhibitors (SGLT2i) significantly reduce the risk of atrial fibrillation (AF) and the recurrence of AF after catheter ablation in diabetic patients. However, there is no evidence of a relationship between SGLT2i use and the incidence of postoperative atrial fibrillation (POAF), a common complication after coronary artery bypass grafting (CABG). Additionally, the protective mechanisms of SGLT2i on cardiomyocytes suggest a possible association with reduced postoperative myocardial injury. Methods: SGLT2i use was defined as taking SGLT2i at the time of admission and discontinuing it at least 3 days before surgery. Adult diabetic patients without a history of AF undergoing primary CABG (±valve surgery) between October 2023 and December 2024 were included from a large prospective cohort. Patients with acute coronary syndromes or emergency surgery were excluded. Patients in the SGLT2i group were matched by propensity score with the control group (no SGLT2i use) at a 1:3 ratio. Generalized estimating equations were utilized for repeated measures data. Primary outcomes were the incidence of POAF and the level of high-sensitivity troponin I (hs-cTnI) within 5 days post-surgery. Secondary outcomes included in-hospital death, stroke, perioperative myocardial infarction (MI), acute kidney injury stage 2/3, reoperation, ICU stay duration, postoperative NT-proBNP levels, and blood inflammatory biomarkers. Diabetic ketoacidosis (DKA) was also monitored. Results: The cohort included 10,106 subjects, with 1,407 (13.9%) in the SGLT2i group. A total of 1,001 patients in the SGLT2i group and 3,003 in the control group were analyzed, with well-matched baseline characteristics after propensity scoring. No DKA events were found in either group. After adjusting for multiple confounding factors, the incidence of POAF was significantly lower in the SGLT2i group (19.6% vs. 25.7%, odds ratio: 0.686, 95% confidence interval: 0.592 - 0.794, P &lt; 0.001). In the SGLT2i group, hs-cTnI levels within 5 days postoperatively decreased by an average of 0.36 ng/ml (95% CI: -0.707 to -0.012, P = 0.013). No significant differences were observed in postoperative NT-proBNP, inflammatory biomarkers, or ICU stay. No differences in other perioperative clinical outcomes were observed. Conclusion: SGLT2 inhibitors can reduce the incidence of POAF and levels of hs-cTnI following CABG, without an increased risk of other perioperative adverse events

For diabetic patients undergoing coronary artery bypass grafting (CABG), there is still a debate about whether an off-pump or on-pump approach is advantageous. A retrospective review of 1269 consecutive diabetic patients undergoing isolated, primary CABG surgery from January 1, 2013 to December 31, 2015 was conducted. Among them, 614 received non-cardiopulmonary bypass treatment during their operation (off-pump group), and 655 received cardiopulmonary bypass treatment (on-pump group). The hospitalization outcomes were compared by multiple logistic regression models with patient characteristics and operative variables as independent variables. Kaplan-Meier curves and Cox proportional-hazard regression models for mid-term (2-year) and long-term (5-year) clinical survival analyses were used to determine the effect on survival after CABG surgery. In order to further verify the reliability of the results, propensity-score matching (PSM) was also performed between the two groups. Five-year all-cause death rates were 4.23% off-pump vs. 5.95% on-pump (p = 0.044), and off-pump was associated with reduced postoperative stroke and atrial fibrillation. These findings suggest that off-pump procedures may have benefits for diabetic patients in CABG.

Redo coronary artery bypass grafting (CABG) remains technically challenging with significant procedural risk but may be the best option for patients in whom repeat revascularization is indicated. This review summarizes the latest data regarding risk of redo CABG, who should receive this surgery, and how to achieve best outcomes. Over the past two decades, the risk of performing redo CABG has declined and is approaching that of primary CABG in the hands of experienced surgeons. Nonetheless, patients for whom redo CABG is indicated tend to be older and have more complex medical comorbidities. Preoperative imaging is paramount in guiding sternal re-entry and mediastinal dissection, and in how to best employ rescue strategies when needed. Patients with complex, progressive coronary disease with unprotected left anterior descending (LAD) coronary artery disease and prior coronary bypass may benefit from the durable, complete revascularization that redo CABG can offer with internal thoracic artery bypass to the LAD and, when possible, arterial inflow to other important coronary targets. Preoperative imaging, careful planning, meticulous surgical technique, myocardial protection, and an experienced surgical team are critical for optimal outcomes.

ABSTRACT Background: Implementation of blood conservation protocol may increase the efficiency of blood utilization and optimize the maximum surgical blood ordering schedule (MSBOS) in our institution. The primary objectives of this study are to evaluate the efficient utilization of a fixed blood request of 4 units of packed red blood cells (PRBCs) and to establish an effective MSBOS on primary isolated elective coronary artery bypass graft (CABG). Methodology: This was a retrospective, analytical, observational, cohort type of study conducted through chart review of CABG patients from January 2018 to December 2019. Indices used to evaluate blood utilization efficiency were crossmatch to transfusion (C/T) ratio, transfusion probability (T%), and transfusion index (TI). MSBOS was computed based on the data gathered. Results: A total of 77 patients were included in this study. Blood transfusion based on C/T ratio was associated with body surface area &lt;1.75 m2 (P = 0.006) and involvement of distal grafts &gt;3 vessels (P = 0.042). Overall, C/T ratio was 2.44, T% was 70.1%, and TI was 1.69. Unutilized blood was measured at 59%. The computed MSBOS for elective CABG was at 2 units (2.53). Conclusion: There is efficient PRBC utilization in primary elective CABG when the blood indices were used. Evidence-based MSBOS is established and the previous 4 units PRBC can be reduced to 2 units to promote C/T ratio &lt;2 as evidence of an optimal blood utilization.

ObjectiveThe purpose of this investigation is to develop a novel nomogram for predicting major bleeding following off-pump coronary artery bypass grafting (CABG).MethodsBetween January 2012 and December 2022, 541 patients who underwent off-pump isolated primary CABG were included in a retrospective analysis. The primary outcome measure after off-pump CABG was major bleeding. Based on the outcomes of a multivariate analysis, nomograms were constructed. Using receiver operating characteristic analysis and calibration, the predictive accuracy of the nomograms was assessed. Using decision curve analysis (DCA), the clinical benefit of the nomograms was determined.ResultsWe categorized 399 and 142 patients in the “no major bleeding group” and “major bleeding group”, respectively. Age (odds ratio (OR) 1.038; 95% confidence interval (CI) 1.009–1.068; p = 0.009), body mass index (OR 0.913; 95% CI 0.849–0.982; p = 0.014), hemoglobin (OR 0.958; 95% CI 0.945–0.971; p < 0.001), sodium (OR 0.873; 95% CI 0.807–0.945; p = 0.001), blood urea nitrogen (OR 1.198; 95% CI 1.073–1.338; p = 0.001), and operation time (OR 1.012; 95% CI 1.008–1.017; p < 0.001) were independent predictors for major bleeding after off-pump CABG. The model based on independent predictors exhibited excellent discrimination and calibration, with good agreement between actual and nomogram-estimated probabilities of generalization. DCA demonstrated that nomogram-assisted decisions have a greater positive benefit than treating all patients or none.ConclusionsThe plotted nomogram accurately predicted major bleeding outcomes following off-pump CABG and may therefore contribute to clinical decision-making, patient treatment, and consultation services.

Background. Surgical mobilization of the internal mammary artery (IMA) can induce graft vasospasm, which is commonly managed by wrapping the IMA in a vasodilator‐soaked swab before grafting. However, the choice of the most effective topical vasodilator remains the subject of continued investigation. We carried out a prospective randomized controlled trial to compare the effect of topically applied milrinone, nitroglycerin, and normal saline on IMA free flow. Methods. Forty‐six consecutive patients undergoing elective primary coronary artery bypass grafting were enrolled. After the left IMA was harvested, free flow was measured under controlled hemodynamic conditions before any intervention (flow 1) and at a mean of 12.5 minutes after the topical application of one of three agents (milrinone, nitroglycerin, or normal saline) on the IMA (flow 2). Results. All agents induced a significant increase in IMA flow, and flow 2 was significantly higher in the nitroglycerin and milrinone groups compared to the normal saline group, even while controlling for flow 1 as a centered continuous variable. Nevertheless, there was no statistically significant difference in flow 2 between the nitroglycerin and milrinone groups. Conclusions. Topically applied milrinone and nitroglycerin can increase blood flow of the IMA significantly in the early period after surgical mobilization. IMA blood flow was greater after the topical application of milrinone compared to nitroglycerin, but this has failed to reach statistical significance in the present study setting. This trial is registered with NCT06301880.

Introduction: Women undergoing coronary artery bypass grafting (CABG) have higher mortality compared with men, yet its drivers are unclear. Hypothesis: The association of female sex with the risk of operative mortality after CABG may be mediated by intraoperative anemia. Aim: To investigate the relationship between sex, intraoperative anemia, and operative mortality. Methods: Retrospective cohort study of 1,434,225 isolated primary CABG patients (344,357 women) from the Adult Cardiac Surgery Database of the Society of Thoracic Surgeons (2011-2022). The primary outcome was operative mortality. The attributable risk (AR, quantifying the risk-adjusted strength of the association of female sex with CABG outcomes) was calculated. Causal mediation analysis adjusted for 42 baseline risk factors was used to derive the total effect of female sex on mortality risk and the proportion of that effect mediated by intraoperative anemia (nadir hematocrit). Spline regression evaluated the relationship of operative mortality and nadir intraoperative hematocrit. Results: Women had lower median preoperative hematocrit (36.9%, interquartile range [IQR] 33.3-40.0 vs 41.0% [37.4-44.0], standardized mean difference [SMD] 74.0%) and nadir intraoperative hematocrit (22.0% [20.0-25.0] vs 27.0% [24.0-30.0], SMD 97.0%) compared with men. Women had higher operative mortality than men (2.8% vs 1.7%, p&lt;0.001, adjusted odds ratio 1.36, 95% confidence interval [CI] 1.30-1.41). The AR of female sex for operative mortality was 1.21 (95% CI 1.17-1.24). After adjusting for nadir intraoperative hematocrit, the AR was reduced by 43% (1.12, 95% CI 1.09-1.16). Intraoperative anemia mediated 38.5% of the increased mortality risk associated with female sex (95% CI 32.3-44.7%). Spline regression showed a stronger association between operative mortality and nadir intraoperative hematocrit at hematocrit values below 22.0% (p&lt;0.001). Conclusions: The association of female sex with increased CABG operative mortality is mediated to a large extent by intraoperative anemia. Avoiding nadir intraoperative hematocrit values below 22.0% may reduce sex differences in CABG operative mortality.