Primary Coronary Artery Bypass Grafting Research Articles

Nomogram for predicting major bleeding after off-pump coronary artery bypass grafting

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.

Abstract 12145: Intraoperative Anemia Mediates Sex Disparity in Operative Mortality After Coronary Artery Bypass Grafting

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.

Practice makes perfect? Institutional coronary artery bypass case volumes and outcomes.

Older studies of coronary artery bypass grafting (CABG) institutional case volumes and outcomes reported conflicting results. We explored this association in the rapidly changing contemporary practice of American surgeons using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. The 2018-2019 isolated primary CABG experience in the STS Adult Cardiac Surgery Database was analysed (241902 patients; 1014 hospitals; 2718 surgeons). Generalized Estimating Equations were used to estimate coefficients between CABG institutional case volumes and outcomes. The observed-to-expected ratios based on STS risk models were used to assess risk-adjusted operative mortality (OM), mortality/major morbidity (MM) and deep sternal wound infections (DSWI) as a function of institutional case volumes. The mean (standard deviation) OM, MM and DSWI rates were 2.1% (2.7), 11.1% (9.2) and 0.6% (0.5), respectively. The mean (standard deviation) institutional case volumes per study period was 239 (192); 23% and 9% of institutions performed <100 and >500 cases/study period, respectively. There was a weak negative correlation between expected mortality (R2 -0.0014), OM (R2 -0.0272), MM (R2 -0.1213) and DSWI (R2 -0.003) and institutional case volumes. CABG outcomes generally improve with increasing institutional case volumes. Given the large number of CABG cases performed nationally, even the documented weak correlation has the potential to appreciably decrease OM, MM and DSWI if cases are performed at higher volume institutions. Studies focusing on additional hospital and surgeon factors are warranted to further define quality improvement opportunities.

Propensity score-matched comparison of total arterial off- and on-pump coronary artery bypass with complete revascularization

Little is known regarding the long-term (> 10 years) outcomes and risk factors of total arterial coronary artery bypass grafting (CABG). This study evaluated the long-term outcomes and risk factors for all-cause mortality and major adverse cardiac and cerebrovascular events (MACCEs) following total arterial on-pump CABG (ONCAB) or off-pump CABG (OPCAB) with complete revascularization. This retrospective cohort analysis enrolled patients with stable angina who underwent total arterial CABG with complete revascularization in our institute between July 2000 and June 2019. The endpoints were all-cause mortality and MACCE incidence, including a comparison between OPCAB and ONCAB. Long-term (10-year) outcomes were analyzed using propensity score-matched pairs, and risk factors were evaluated using univariate and multivariate analyses. Overall, 401 patients who underwent primary total arterial CABG were classified into the OPCAB (n = 269) and ONCAB (n = 132) groups. Using propensity score matching (PSM), 88 patients who underwent OPCAB were matched with 88 patients who underwent ONCAB. The mean follow-up period was 7.9 ± 6.3 years. No significant difference in all-cause mortality (hazard ratio, 1.04; 95% confidence interval, 0.53–2.04; p = 0.9138) and MACCE incidence (hazard ratio, 1.06; 95% confidence interval, 0.68–1.65; p = 0.7901) was observed between the two groups. Renal failure requiring dialysis was a significant risk factor for mortality (p < 0.0001) and MACCEs (p = 0.0003). Long-term outcomes of total arterial OPCAB and ONCAB with complete revascularization showed similar findings using PSM. Renal failure requiring dialysis was a significant risk factor for mortality and morbidity.Journal standard instruction requires an unstructured abstract; hence the headings provided in abstract were deleted. Kindly check and confirm.Thank you for your kindness.Clinical registration number 5598, Tokyo Women’s Medical University Hospital.

Body Mass Index Effect on Long-term Survival after Coronary Artery Bypass Surgery: A Competing-Risks Analysis.

To investigate the presence of an obesity paradox on the long-term mortality of patients undergoing primary isolated coronary artery bypass surgery and to uncover whether any discrepancy found could be attributable to cardiovascular or noncardiovascular causes. Retrospective analysis of 5242 consecutive patients with body mass index (BMI) over 18.5 kg/m2 undergoing primary isolated coronary artery bypass surgery, performed from 2000 to 2015, in a Portuguese level III Hospital. The primary endpoint was long-term all-cause mortality. Secondary outcomes were long-term cause-specific mortality (cardiovascular and noncardiovascular). We fitted overall, and cause-specific hazard models, with BMI forced both as a categorical (using World Health Organization predefined cutoffs) and as a continuous variable. Follow-up was 99.7% complete. The median follow-up time was 12.79 years (interquartile range, 9.51 to 16.61). The cumulative incidence functions failed to uncover any difference in 15-year all-cause (log-rank test, p = 0.400), cardiovascular (Gray's test, p = 0.996), and noncardiovascular mortality (Gray's test, p = 0.305) between BMI categories. Likewise, extensive multivariable-adjusted Cox regression and cause-specific hazards models failed to demonstrate in-between category differences, with BMI forced as a categorical variable. On the other hand, using BMI as a continuous variable, the model identified the optimal BMI as between 25.8 and 30.3 kg/m2 (nadir around 28.9 kg/m2), albeit this was dependent on the definition of the reference value. In this longitudinal, population-level analysis of patients undergoing isolated primary coronary artery bypass grafting, we could not attest to any protective effect of obesity on long-term survival.

Fibrinogen is an independent preoperative predictor of hospital length of stay among patients undergoing coronary artery bypass grafting

ObjectiveThis study aims to examine the impact of preoperative fibrinogen concentration on the short-term outcomes and hospital length of stay (LOS) of patients undergoing Coronary Artery Bypass Grafting (CABG).MethodsBetween January 2010 and June 2022, a retrospective analysis comprised 633 patients who sequentially received isolated, primary CABG. These patients were categorized into normal fibrinogen group (fibrinogen < 3.5 g/L) and high fibrinogen group (fibrinogen ≥ 3.5 g/L) according to preoperative fibrinogen concentration. The primary outcome was LOS. To correct for confounding and investigate the effect of preoperative fibrinogen concentration on the short-term outcomes and LOS, we employed propensity score matching (PSM). The correlation between fibriongen concentration and LOS in subgroups was examined using subgroup analysis.ResultsWe categorized 344 and 289 patients in the “normal fibrinogen group” and “high fibrinogen group”, respectively. After PSM, compared to the normal fibrinogen group, the high fibrinogen group had a longer LOS [12.00 (9.00–15.00) vs. 13.00 (10.00–16.00), P = 0.028] and higher incidence of postoperative renal impairment [49 (22.1%) vs. 72 (32.4%), P = 0.014]. Cardiopulmonary bypass (CPB) or non-CPB CABG patients showed similar correlations between various fibrinogen concentrations and LOS, according to subgroup analyses.ConclusionsFibrinogen is an independent preoperative predictor of both the LOS and the postoperative renal impairment that occurs after CABG. Patients with high preoperative fibrinogen concentration had a higher incidence of postoperative renal impairment and a longer LOS, emphasizing the significance of preoperative fibrinogen management.

Sex differences in frailty manifestations in patients with coronary artery disease

Aim. To analyze the differences in detection rate of prefrailty and frailty syndrome (FS) in male and female patients with multivessel coronary artery disease (CAD) undergoing elective coronary artery bypass grafting (CABG).Material and methods. The study included 387 patients admitted for elective primary CABG. Screening for prefrailty and FS in patients before surgery was performed using the questionnaire "Age is not a drawback".Results. In the age group of 45 to 59 years, 25% of females and only 6% of males had signs of FS, while 25% of women and 34% of men did not present with signs of frailty and prefrailty. Half of middle-aged women and 60% of middle-aged men had prefrailty. Between the ages of 60 and 74, only 14% of women and 24% of men were not frail. Elderly women are more likely than elderly men to present with signs of FS (p=0,040). The symptoms of prefrailty in elderly patients were detected at equal rate in men and women (59% and 60%, respectively). All senile-aged patients presented with the signs of prefrailty or FS.Conclusion. Patients with multivessel CAD present with manifestation of frailty in senile, elderly, and middle age. At the same time, middle-aged and elderly women with the higher rates of comorbid disorders require special attention.

Acute coronary syndrome in a young patient with ECG presentation of acute inferior myocardial infarction and acute thrombosis of left main stem coronary artery

Introduction. The left main stem (MS) coronary artery (CA) (MSCA) thrombosis is a rare but potentially lethal manifestation of acute coronary syndrome. The standard approach in treating such patients is the primary percutaneous coronary intervention (pPCI) or CA bypass graft surgery. In some cases, depending on the morphological appearance of the thrombus, findings and flow rates assessed on coronary angiography (CAn), clinical conditions, and cardiologist?s experiences, another possible method of treatment can be the conservative approach using antithrombotic therapy. Case report. A 37-year-old male was admitted to the emergency room with symptoms of an acute myocardial infarction with an ST elevation in diaphragmal localization. Using an emergency CAn, we have visualized a thrombus at the ostial and proximal part of the left MSCA, with no complete obstruction of the blood flow. Initially, dual antithrombotic therapy (ticagrelor and acetylsalicylic acid) was applied, and in the further procedure, it was decided to introduce glycoprotein IIb/IIIa platelet receptor inhibitor (tirofiban) as an intracoronary bolus (0.3 ?g/kg) and later as a continuous infusion (0.1 ?g/kg/min). Four days later, a control CAn and intravascular echocardiography were performed, and it was decided to continue the treatment using conservative therapy without a pPCI procedure. The patient was discharged in good condition with no signs of illness on the eighth day after hospital admission for home recovery, with planned frequent follow-ups in the future. Conclusion. In the case of non-obstructive thrombotic masses without significant atherosclerotic stenotic lesions, conservative treatment modality with the use of aggressive antithrombotic therapy may be considered.

Single-blind, randomized study comparing clinical equivalence of trulene and prolene polypropylene sutures in elective primary coronary artery bypass graft surgery

BackgroundCoronary artery bypass graft surgery (CABG) is one of the principle therapies for coronary artery disease, as it improves survival rate and quality of life (QoL). Polypropylene suture is commonly used in vascular and cardiac surgeries for anastomosis due to its long-term tensile strength and minimal tissue trauma. This study compared the clinical equivalence of Trulene® (Healthium Medtech Limited) and Prolene® (Ethicon-Johnson & Johnson) polypropylene sutures regarding incidence of myocardial infarction, stroke, renal failure and cardiac death (MACCE) occurring up to 26 weeks’ period post-CABG surgery.MethodsThis multicenter, prospective, two-arm, parallel-group, randomized (1:1), single-blind study (n = 89) was conducted between August 2020 and September 2021. The primary endpoint, post-surgery cumulative incidence of MACCE was evaluated. In addition, anastomotic revision, surgical site infection (SSI), operative time, length of post-operative hospital stay, repeat revascularization, intraoperative suture handling characteristics, time taken to return to work and resume normal day to day activities, subject satisfaction score and QoL, and other adverse events were also recorded.ResultsA total of 80 (89.89%) males and 9 (10.11%) females participated in the study. No incidence of MACCE was recorded in any of the study participants. Non-significant difference was observed in anastomotic revision, SSI, operative time, post-operative hospital stay, revascularization, return to work and normal day-to-day activities, subject satisfaction score and QoL, and intraoperative handling parameters (except ease of passage) between the treatment groups, Trulene® and Prolene®. Compared to screening visit, proportion of subjects with ‘no problems’ for each QoL dimension and the mean visual analogue scale increased with each subsequent follow-up visit.ConclusionTrulene® polypropylene suture is clinically equivalent to Prolene® polypropylene suture and is safe and effective for anastomosis construction in CABG surgery during a routine clinical procedure.Trial registration CTRI Registration No.: CTRI/2020/05/025157 (Registered on: 13/05/2020).

Timing of Blood Transfusions and 30-Day Patient Outcomes After Coronary Artery Bypass Graft Surgery

Packed red blood cell transfusion during coronary artery bypass graft surgery is known to be associated with adverse outcomes. However, the association of the timing between transfusions in relation to discharge and 30-day postoperative outcomes has not been studied. The study authors investigated the impact of transfusion timing on 30-day surgical outcomes. A retrospective review. At a single tertiary-care academic hospital. A total of 2,481 adult patients underwent primary coronary artery bypass graft surgery between January 2014 and December 2020. The relationship between the timing of packed red blood cell transfusion (intraoperative, postoperative, or both) and 30-day postoperative outcome variables was calculated as an odds ratio. The influence of timing of transfusion on adjusted probability of postoperative complications was plotted against the lowest intraoperative hematocrit. The median age of the population was 67 years (60.0-74.0), body mass index was 28.5 (25.6-32.3) kg/m2, and 497 (20.0%) were female. A total of 1,588 (36%) patients received packed red blood cell transfusions; 182 (7.3%) received intraoperative transfusions, 489 (19.7%) received postoperative transfusions, and 222 (9.0%) received both (intraoperative and postoperative transfusions). Postoperative transfusion was associated with significantly higher odds of readmission (1.83 [1.32-2.54], p=0.002) and heart failure (1.64 [1.2-2.23], p=0.008) compared to patients with no transfusions; whereas intraoperative transfusions were not. The authors' data suggested that the postoperative timing of transfusion in patients undergoing coronary artery bypass graft surgery may be associated with an increased incidence of 30-day heart failure and readmission. Prospective research is needed to conclusively confirm these findings.

The Pragmatic Role of COVID-19 on the Thrombus Grade of Patients with Contemporary ST-Segment-Elevation Myocardial Infarction.

Limited data exist on the clinical outcomes of patients with coronavirus disease 2019 (COVID-19) presenting with ST-segment-elevation myocardial infarction (STEMI). This multicenter study, conducted in 6 centers in Iran, aimed to compare baseline clinical and procedural data between a case group, comprising STEMI patients with COVID-19, and a control group, comprising STEMI patients before the COVID-19 pandemic, and to determine in-hospital infarct-related artery thrombus grades and major adverse cardio-cerebrovascular events (MACCEs), defined as a composite of deaths from any cause (cardiovascular and noncardiovascular), nonfatal strokes, and stent thrombosis. No significant differences were observed between the 2 groups regarding baseline characteristics. Primary percutaneous coronary intervention (PPCI) was performed in 72.9% of the cases and 98.5% of the controls (P=0.043), and primary coronary artery bypass grafting was performed in 6.2% of the cases and 1.4% of the controls (P=0.048). Successful PPCI procedures (final TIMI flow grade III) were significantly fewer in the case group (66.5% vs 93.5%; P=0.001). The baseline thrombus grade before wire crossing was not statistically significantly different between the 2 groups. The summation of thrombus grades IV and V was 75% in the case group and 82% in the control group (P=0.432). The rate of MACCEs was 14.5% and 2.1% in the case and control groups, respectively (P=0.002). In our study, the thrombus grade had no significant differences between the case and control groups; however, the in-hospital rates of the no-reflow phenomenon, periprocedural MI, mechanical complications, and MACCEs were statistically significantly higher in the case group.

Can C-reactive protein predict coagulation in off pump coronary artery bypass grafting? A cohort study

BackgroundPrevious study found that C-reactive protein (CRP) can predict bleeding after on-pump CABG. To evaluate whether preoperative C-reactive protein (CRP) can be a novel marker of postoperative bleeding in patients having off-pump coronary artery bypass grafting (CABG).MethodsThis is a retrospective cohort study. Multiple variable regression analyses were performed. 537 patients undergoing off-pump isolated primary CABG at Fuwai Hospital from September 2017 to July 2018 were recorded. The primary endpoint was bleeding volume within 24 h after surgery.ResultsData of 537 patients undergoing off-pump isolated primary CABG at Fuwai Hospital were recorded. The correlations between bleeding volume within 24 h after surgery and preoperative data were analyzed with univariate and multivariate linear regression. Much more preoperative CRP concentration (B = −0.089, P < 0.05) was associated with less postoperative bleeding volume and fibrinogen (B = 0.594, p < 0.001).ConclusionsPreoperative CRP concentration is independently correlated with the postoperative volume of bleeding within 24 h. CRP may become a novel coagulation index in coronary artery atherosclerotic disease.

Preclinical multi-target strategies for myocardial ischemia-reperfusion injury.

Despite promising breakthroughs in diagnosing and treating acute coronary syndromes, cardiovascular disease’s high global mortality rate remains indisputable. Nearly half of these patients died of ischemic heart disease. Primary percutaneous coronary intervention (PCI) and coronary artery bypass grafting can rapidly restore interrupted blood flow and become the most effective method for salvaging viable myocardium. However, restoring blood flow could increase the risk of other complications and myocardial cell death attributed to myocardial ischemia-reperfusion injury (IRI). How to reduce the damage of blood reperfusion to ischemic myocardium has become an urgent problem to be solved. In preclinical experiments, many treatments have substantial cardioprotective effects against myocardial IRI. However, the transition from these cardioprotective therapies to clinically beneficial therapies for patients with acute myocardial infarction remains elusive. The reasons for the failure of the clinical translation may be multi-faceted, and three points are summarized here: (1) Our understanding of the complex pathophysiological mechanisms of myocardial IRI is far from enough, and the classification of specific therapeutic targets is not rigorous, and not clear enough; (2) Most of the clinical patients have comorbidities, and single cardioprotective strategies including ischemia regulation strategies cannot exert their due cardioprotective effects under conditions of hyperglycemia, hypertension, hyperlipidemia, and aging; (3) Most preclinical experimental results are based on adult, healthy animal models. However, most clinical patients had comorbidities and received multiple drug treatments before reperfusion therapy. In 2019, COST Action proposed a multi-target drug combination initiative for prospective myocardial IRI; the optimal cardioprotective strategy may be a combination of additive or synergistic multi-target therapy, which we support. By establishing more reasonable preclinical models, screening multi-target drug combinations more in line with clinical practice will benefit the translation of clinical treatment strategies.

Coronary Artery Bypass Grafting in Patients with Chronic Kidney Disease: Chronic Kidney Disease Has an Independent Adverse Effect on the Long-Term Outcome of Coronary Artery Bypass Grafting.

We examined short- and long-term outcomes of coronary artery bypass grafting (CABG) in patients with ischemic heart disease and the effect of renal function on these outcomes. We included 2783 patients who underwent primary elective CABG at a single institution between 2002 and 2020 (age: 67.6 ± 10.2 years; male: 2281 male). They were stratified based on their preoperative estimated glomerular filtration rate and underwent off-pump CABG (completion rate, 98.1%); 57.6% cases used bilateral internal thoracic arteries (BITA). In-hospital mortality rate was 1.0%. Logistic regression analysis revealed that low left ventricular function (<40%), but not chronic kidney disease (CKD) severity, was an independent predictive risk factor for postoperative hospital mortality. Significant differences existed in respiratory complications, infections, and hospitalization duration according to CKD severity. Deep sternal wound infection rate was 0.5%. The mean follow-up period was 7.1 (0–18.5) years. Estimated 10-year survival rates were negatively correlated with CKD severity; in the Cox hazard model, severe CKD was an independent predictor of long-term survival. We examined the relationship between preoperative and intraoperative factors and their effects on long-term survival using propensity score matching by dividing the renal function severity into G1–2 and G3–5. Renal function severity, age, and operative time were independent risk factors. No prognostic improvement was observed with BITA grafts; graft patency was superior in the right internal thoracic artery (52/52; 100%) than in the great saphenous vein (48/59; 81.4%) in G5. Post-CABG in-hospital mortality was unrelated to renal function, but CKD severity strongly influenced long-term survival. Operation time was an important predictor of long-term prognosis in patients with impaired renal function. Treatment plans, including graft and anastomosis-site selections, should be designed to shorten the operation time. In conclusion, using the right internal thoracic artery in CABG is more beneficial in patients with CKD and cardiovascular comorbidities.

Hyperglycemia and Physical Impairment in Frail Hypertensive Older Adults.

BackgroundFrailty is a multidimensional condition typical of elders. Frail older adults have a high risk of functional decline, hospitalization, and mortality. Hypertension is one of the most common comorbidities in elders. Hyperglycemia (HG) is frequently observed in frail older adults, and represents an independent predictor of worst outcomes, with or without diabetes mellitus (DM). We aimed at investigating the impact of HG on physical impairment in frailty.MethodsWe studied consecutive older adults with frailty and hypertension at the ASL (local health unit of the Italian Ministry of Health) of Avellino, Italy, from March 2021 to September 2021. Exclusion criteria were: age <65 years, no frailty, no hypertension, left ventricular ejection fraction <25%, previous myocardial infarction, previous primary percutaneous coronary intervention and/or coronary artery bypass grafting. Blood glucose, Hb1Ac, and creatinine were measured in all patients. Physical frailty was assessed applying the Fried Criteria; we performed a 5-meter gait speed (5mGS) test in all patients.Results149 frail hypertensive older adults were enrolled in the study, of which 82 had normoglycemia (NG), and 67 had HG. We observed a significantly slower 5mGS in the HG group compared to the NG group (0.52 ± 0.1 vs. 0.69 ± 0.06; p<0.001). Moreover, we found a strong and significant correlation between 5mGS and glycemia (r: 0.833; p<0.001). A multivariable linear regression analysis using 5mGS as a dependent variable revealed a significant independent association with glycemia (p<0.001) after adjusting for likely confounders.ConclusionsHG drives physical impairment in frail hypertensive older adults independently of DM.

Total arterial coronary artery bypass grafting in patients with preoperative anemia.

Blood transfusions after coronary artery bypass grafting (CABG) has been associated to adverse outcomes, especially in anemic patients. However, little is known about the influence of the modality of revascularization. Total arterial revascularization (TAR) was shown to reduce postoperative transfusion when compared to saphenous vein-based (SV)-CABG (LIMA plus one/more SV grafts). We, therefore, aimed to investigate the impact of TAR-CABG versus SV-CABG on blood products use and perioperative outcomes in patients with preoperative anemia, normally at higher risk for postoperative transfusions. From a cohort of 936 patients with mild preoperative anemia undergoing primary elective on-pump CABG, 166 matched pairs of patients undergoing either TAR- or SV-CABG were obtained. Anemia was defined as hemoglobin level<13 g/dl for men and <12 g/dl for women. The primary endpoint was the evaluation of red packed cells (RPC) use over the entire hospital stay. TAR patients showed significantly reduced RPC usage compared with SV (mean difference 0.45 units). TAR patients had a reduced intubation time (mean difference 7.6 h) and were discharged 1.24 days earlier than SV patients. Pneumonia and acute kidney injury were doubled among SV patients. Adjusted regression showed that TAR technique is a predictor of reduced RPC unit use regardless of age and EuroSCORE II (odds ratio: 0.63, p < .01). Patients with preoperative anemia might benefit from TAR regardless of age or calculated operative risk. TAR-CABG was associated to reduced postoperative use of blood products and postoperative length of stay in comparison with SV-CABG in this subset of patients.

Early and mid-term results in patients undergoing primary CABG in comparison with patients with PCI prior to CABG

Aim: We evaluated the impact of prior percutaneous coronary intervention (PCI) on early and mid-term results in patients undergoing coronary artery bypass grafting (CABG). Methods: Between 2015 and 2020, 938 consecutive patients (mean age 67.4 ± 9.11 years) underwent CABG with prior PCI (n = 121) or primary CABG (n = 817). The mean follow-up was 37 ± 25 (median 36) months. Kaplan-Meier estimates were used to assess survival rates, while Logistic and Cox model analysis regressions assessed the risk of prior PCI and other variables. Results: Six-year survival including in-hospital mortality was 79% ± 6% in CABG with prior-PCI patients vs.88% ± 2% in primary CABG (P = 0.002). As compared with primary CABG, in prior-PCI patients, clinical presentation (acute coronary syndrome, reduced left ventricular ejection fraction, and previous myocardial infarction, P ≤ 0.01, for all comparisons) was worse, comorbidity increased (Euroscore-2, severe chronic renal dysfunction, P &lt; 0.01), and in-hospital mortality was higher (6.6% or 8 patients vs. 1.6% or 13 patients, P &lt; 0.001). Prior PCI was found to be an independent predictor of mortality (HR = 4.23; P = 0.01). Six-year freedom from late all-cause death and cardiac death were 84% ± 6% vs. 90% ± 2% (P = 0.2) and 96% ± 2% vs. 96% ± 1% (P = 0.5), respectively. Independent predictors of all-cause death were advanced age at the operation (P &lt; 0.0001), reduced left ventricular ejection fraction (P = 0.01), severe chronic renal dysfunction (P = 0.02), prior PCI (P = 0.03), and Euroscore-2 (P = 0.05). Prior PCI did not negatively affect late cardiac death (P = 0.5). Conclusion: Patients undergoing CABG after prior PCI have worse perioperative outcomes. Mid-term reduced survival in the prior-PCI patients is mainly due to the concomitant presence of worse clinical presentation and increased comorbidity. Freedom from cardiac death is comparable and satisfactory in both cohorts, highlighting the positive protective effect of CABG over time.

Impact of Diabetes on the Patients Undergoing Coronary Artery Bypass Grafting

: This study was designed to evaluate the impact of diabetes on functional capacity, level of physical activity, quality of life, dependency level and mortality risk in patients undergoing primary coronary artery bypass grafting. A total of 30 patients undergoing CABG procedure were assessed pre and postoperatively for their functional capacity by New York Heart Association classification and six-minute walk test, physical activity by Duke activity status index, dependency level by functional independency measurement, mortality risk by Society of thoracic surgeons, EuroSCORE II and CASUS and, quality of life preoperatively by Nottingham Health Profile questionnaire. Patients with a history of ≥10 years of diabetes were compared to the non-diabetics group. On analysis it was observed, that the diabetic group are older (68.67+7.52 years), hypertensive (87%), less obese, and have lesser ejection fraction than the non-diabetics. There was no significant difference between the group’s functional capacity, quality of life and mortality risk, but the diabetic group showed a significantly higher postoperative risk to stroke (p=0.042) and longer hospital stay (p=0.006). Dependency level, functional capacity and total ICU stay was reported to be more affected in the diabetics. Both the groups showed an improved dyspnea and angina after the surgery. The dependency level in diabetics (p=0.00) and non-diabetics (p=0.003) was also observed to decrease significantly with the surgery. The study concluded that diabetes has an impact on the functional capacity, physical activity, angina, dependency level, and total hospital stay in the individuals following bypass surgery.

Prospective randomized study comparing outcome of myocardial protection with Del-Nido Cardioplegia versus Saint Thomas Cardioplegia in adult cardiac surgical patients.

Objectives:To compare the effectiveness of Del-Nido cardioplegia as myocardial protective agent with Saint Thomas cardioplegia in adult cardiac surgical patients.Methods:This prospective randomized study was conducted in cardiac surgery department of Bahawal Victoria hospital Bahawalpur, from October 2020 to March 2021. Eighty adult patients who underwent primary Isolated coronary artery bypass grafting (CABG) or isolated Valve surgery requiring cardiopulmonary bypass were randomly divided into Del Nido (DN, n=40) and Saint Thomas (ST, n=40) groups. Data regarding operative and post-operative variables such as cardiopulmonary bypass (CPB) and aortic cross clamp (AXC) times, inotropic requirements, resumption of sinus rhythm, need for electrical defibrillation, post-operative CKMB, blood requirement and ICU stay were noted.Results:CPB and AXC times were statistically insignificantly different. Resumption of Sinus rhythm was seen significantly in more patients of DN group (95%) than in ST group (72.5%) [p-value 0.05]. Less patients of DN group (5%) were candidates of electrical defibrillation than ST group (17.5%) [p-value <0.001). Post- operative CKMB values were significantly lower in DN group as compared to ST group (30.5±22.6 IU vs 50.5±50.28 IU, p value.008). Blood transfusion was significantly lower in DN group; 50% versus 80% in ST group (p-value 0.005). Ventilation time was significantly less in DN group than ST group (165.95±48.09 minutes versus 165.95±48.09 minutes respectively, p-value 0.03). While ICU stay was also less in DN group; 5.2±0.8 days versus 6.05±1.6 days in ST group (p-value 0.003).Conclusion:Del-Nido cardioplegia is a reliable and better myocardial protective agent than Saint Thomas cardioplegia in adult cardiac surgical procedures.

Does the previous stenting affects the outcome of coronary artery bypass grafting in patients with multivessel disease

BackgroundDuring the past decade, the number of percutaneous coronary interventions (PCI) performed before coronary artery bypass grafting (CABG) has risen significantly. Patients with more serious coronary pathology are referred for CABG, which can affect the postoperative outcome.Patients and methodsOutcomes of 60 CABG patients, who were recruited in a prospective comparative study, were compared. Group A (n = 30) underwent primary CABG and group B (n = 30), had prior PCI before CABG.ResultsTotal morbidity was substantially higher in the second group than in the first, with six patients in group A (nonstent group) and 19 patients in group B being affected (stent group). Inotropes and intraaortic balloon pump were used more in the previous PCI community than in group A. Group B had a longer ICU stay (50.45 ± 33.49 h in group A vs. 79.56 ± 60.44 h in group B).ConclusionPrevious PCI can have a detrimental effect on the morbidity outcome of the subsequent CABG. However, postoperative mortality has not been affected significantly. Thus, percutaneous coronary revascularization should be carefully weighed against the increased risk of CABG afterward. The guidelines for intervention should be strictly followed, particularly in patients with complex coronary lesions who are more likely to be referred for CABG.