Progression Of Native Coronary Disease Research Articles

Revascularization after Minimally Invasive Coronary Artery Bypass Grafting in 566 Patients: Is It a Problem?

Minimally invasive coronary artery bypass grafting (MICS CABG) allows visualization and revascularization of all myocardial territories through a small anterolateral thoracotomy, with or without cardiopulmonary bypass. It is increasing in popularity as a safe and effective alternative to sternotomy CABG. In this study, we examine the correlates and long-term outcomes of repeat revascularization (RR) in MICS CABG patients. We prospectively followed all patients on annual or semi-annual basis who had undergone MICS CABG surgery over a 17-year period at a single institution. Cumulative incidence of RR was calculated accounting for competing risk of mortality. Kaplan-Meier curves were compared with log-rank test for survival and freedom from cardiac death at 12-years for both groups. Multivariable Cox proportional hazard models were performed to identify variables associated with RR and its impact on long-term survival. Clinical follow-up was complete for 100% of patients (N=566) at a mean of 7.0±4.4 years. Forty-nine (8.7%) patients required RR after their MICS CABG, for a cumulative incidence at 12 years of 14.8 ± 2.5%. The most common indication was progression of native coronary disease in 23 (46.9% of RR) patients. Perioperative transfusion was the only variable associated with RR (HR 5.0; 95%CI: 2.4, 10.3). Comparing patients who had RR versus those who did not, there was no significant difference in late survival (92.1±4.5% vs. 80.3±3.0%; P=0.18). Among 566 patients who underwent MICS CABG over a 17-year period, RR was an infrequent event affecting 8.7% of patients, with no negative impact on long-term survival.

Consideration of Native Coronary Disease Progression in the Decision to Perform Hybrid Coronary Revascularization

Consideration of Native Coronary Disease Progression in the Decision to Perform Hybrid Coronary Revascularization

Randomised comparison of titanium-nitride-oxide coated stents with bare metal stents: five year follow-up of the TiNOX trial

Revascularisation with Titanium-Nitride-Oxide (TiNOX) coated stents is safe and effective in patients with de novo native coronary artery lesions. In the TiNOX trial there was a reduction in restenosis and major adverse cardiac events as compared with stainless steel stents of otherwise identical design. The purpose of the present study was to evaluate the long-term outcome of these patients over five years.In 2003, 92 patients with de novo lesions were randomly assigned to treatment with TiNOX coated stents (n=45) or stainless steel stents (n=47; control). Baseline characteristics were similar in both groups. Follow-up at six months and five years was obtained in 87 patients. Five patients were lost to follow-up due to emigration or change in home address. At six months and five years, significantly less major adverse cardiac events (MACE) occurred in the TiNOX group (7% vs. 27%, [p=0.02] respectively and 16% vs. 39%, [p=0.03]), largely driven by a reduced need for target-lesion revascularisation. No stent thrombosis occurred in the TiNOX group vs. one in the control group. Patients in the TiNOX-group had lower all-cause mortality and less myocardial infarction, but the difference was not statistically significant.Five-year follow-up after implantation of titanium-nitride-oxide coated stents is favourable with a low rate of MACE and no stent thrombosis compared to bare metal stents of identical design. The need for revascularisation at five years was 9% in the TiNOX and 25% in the control group with little progression of native coronary disease.

Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the Bypass Angioplasty Revascularization Investigation (BARI)

After myocardial infarction (MI) treated with percutaneous coronary intervention (PCI), guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and an ADP receptor inhibitor (ADPri) for at least 1 year. However, whether real-world Canadian practice patterns reflect this recommendation is unknown.We studied 2175 MI patients treated with PCI and discharged from 26 Canadian hospitals between 12/2011 and 05/2013 in the Canadian Observational Antiplatelet sTudy (COAPT). Hierarchical Cox proportional hazard regression modeling was used to determine baseline demographic and clinical factors associated with duration of ADPri therapy post-discharge.At index-hospitalization discharge, 1597 (73%) patients were treated with clopidogrel, 220 (10%) with prasugrel, and 358 (17%) with ticagrelor. ADPri was discontinued prior to 1 year in 474 (21.8%) patients; discontinuation rates were lowest for patients discharged on prasugrel (17.7%), compared with clopidogrel (22.5%) or ticagrelor (21.0%), (log rank test, p = 0.03). In addition to regional variability, factors associated with shorter ADPri duration included older age, low body weight, Killip III/IV heart failure, atrial fibrillation, ticagrelor on discharge, and bare metal stent use, while longer ADPri duration was associated with history of prior MI.One in five PCI-treated MI patients did not complete Canadian guideline-recommended 1-year course of ADPri treatment. Premature ADPri discontinuation was most strongly associated with factors that increase the risk of bleeding. Further study is required to assess the clinical implications of premature ADPri discontinuation on patient outcomes.

Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the bypass angioplasty revascularization investigation (BARI)

Coronary angiograms obtained five years following revascularization were examined to assess the extent of compromise in myocardial perfusion due to failure of revascularization versus progression of native disease. The Bypass Angioplasty Revascularization Investigation (BARI) randomized revascularization candidates between bypass surgery and angioplasty. Entry and five-year angiograms from 407 of 519 (78%) patients at four centers were analyzed. Analysis of the distribution of coronary vessels and stenoses provided a measure of myocardial jeopardy that correlates with presence of angina. The extent to which initial benefits of revascularization were undone by failed revascularization versus native disease progression was assessed. Myocardial jeopardy fell following initial revascularization, from 60% to 17% for percutaneous coronary intervention (PCI)-treated patients compared with 60% to 7% for coronary artery bypass graft (CABG) surgery patients (p < 0.001), rebounding at five years to 25% for PCI and 20% for surgery patients (p = 0.01). Correspondingly, angina prevalence was higher at five years in PCI-treated patients than in surgery-treated patients (28% vs. 18%; p = 0.03). However, myocardial jeopardy at five years, and not initial treatment (PCI vs. surgery), was independently associated with late angina. Increased myocardial jeopardy from entry to five-year angiogram occurred in 42% of PCI-treated patients and 51% of CABG-treated patients (p = 0.06). Among the increases in myocardial jeopardy, two-thirds occurred in previously untreated arteries. Native coronary disease progression occurred more often than failed revascularization in both PCI- and CABG-treated patients as a cause of jeopardized myocardium and angina recurrence. These results support intensive postrevascularization risk-factor modification.

Risk Assessment by Myocardial Perfusion Imaging for Coronary Revascularization, Medical Therapy, and Noncardiac Surgery

Stress myocardial perfusion imaging (MPI) has become an important tool in risk stratification of patients with known coronary artery disease. A normal myocardial perfusion scan has a high negative predictive value and is associated with low annual mortality rate (< 1%). Patients with extensive ischemia (> 20% of the left ventricle), defects in more than 1 coronary vascular territory, transient or persistent left ventricular cavity dilation, and ejection fraction less than 45% have a high annual mortality rate (> 3%). Those patients should undergo coronary revascularization whenever feasible, as the cardiac event rate increases in proportion to the magnitude of the jeopardized myocardium. Stress MPI can be used to demonstrate ischemia in patients with symptoms early after coronary artery bypass surgery (< 5 years) or in those without symptoms late (>/= 5 years) after coronary artery bypass surgery. With respect to patients who underwent percutaneous interventions, stress MPI can help detect in-stent restenosis early after the intervention (3-6 months) or assess the progression of native coronary disease afterward. Since preliminary data suggest that a reduction in the perfusion defect size may translate to a reduction of coronary events, stress MPI can help assess the efficacy of medical management of coronary disease. Finally, stress MPI is indicated for perioperative cardiac risk stratification for noncardiac surgery in patients with intermediate risk predictors (mild angina, prior myocardial infarction or heart failure symptoms, diabetes mellitus, renal insufficiency) and poor functional capacity or in those who undergo high-risk surgery with significant implications in further preoperative management.

Coronary artery bypass grafting after primary isolated aortic valve surgery

tic valve disease, but survival is strongly related to the presence of coronary artery disease.1,2 In the past decade several less-invasive techniques have emerged in aortic valve surgery. These approaches are associated with reduced sternotomyrelated morbidity, but some may cause injury to one or both internal thoracic arteries (ITAs). The latter could be detrimental to the patient who needs coronary artery bypass grafting (CABG) at an older age, since the ITAs no longer can be used. However, little is known about the need for CABG after primary isolated aortic valve surgery. The goal of the present study was to assess the need for CABG after primary isolated aortic valve surgery and to identify possible predictors of future CABG at the time of the primary operation. Methods. We analyzed data of 1598 patients who had primary isolated aortic valve surgery between 1962 and 1997, excluding those with previous cardiac operations or concomitant procedures during the aortic valve operation that required a median sternotomy. The patient data from 2 centers, the Dijkzigt University Hospital in Rotterdam, The Netherlands (n = 1004), and Cedars-Sinai Medical Center in Los Angeles, California (n = 594), were combined to increase sample size and statistical power and to represent patients from different health care systems. The probability of long-term survival and of receiving a CABG operation were estimated by the method of Kaplan and Meier. In addition, the cumulative actual incidence of CABG was estimated, adjusting for the competing risk of death.3 Results. Preoperative and postoperative variables are displayed in Table I. Total follow-up was 11,102 patient-years. Survival was 97% at 1 month, 94% at 1 year, 85% at 5 years, 66% at 10 years (95% confidence interval [CI] 62%-69%), and 39% at 20 years (95% CI 33%-44%). Only 14 patients required CABG during follow-up. The median time to CABG was 8.8 years; median follow-up in those without CABG was 7.2 years. The actuarial probability of receiving a CABG

Early and long term results of re-operation for coronary artery disease.

To define the incidence, possible causes, operative procedure, and early and medium term results of patients undergoing reoperation for coronary artery disease. A retrospective analysis of patients undergoing reoperation in one hospital during a 10 year period. A regional cardiothoracic centre. 115 patients had reoperation for recurrent angina, 1-17 years (mean (SD) 7.4 (3.9)) after primary revascularisation. They received 279 grafts (2.4 grafts per patient); 58% of the grafts were anasatomosed to previously grafted vessels. The internal mammary artery was used in 87% of patients who required grafts to the left anterior descending coronary artery. Reoperation accounted for 8.3% of the total number of patients who underwent coronary bypass grafting. Graft failure alone or in combination with other factors was judged to be the cause of recurrence of symptoms in 87%. 42% of patients had two or more coronary risk factors. The early mortality was 5.2% and the actuarial survival at five and 10 years was 90.4% and 88.4% respectively. 85% of the survivors had initial complete relief of angina and 14% had partial improvement. Freedom from recurrent symptoms at five and 10 years was 66.6% and 34.6% respectively. Vein graft failure either alone or in combination with progression of native coronary disease is the main cause for symptomatic deterioration after bypass grafting. Reoperation can be performed with slightly increased risk and can give good early and medium term results.

Usefulness of percutaneous transluminal coronary angioplasty in alleviating silent myocardial ischemia in patients with absent or minimal painful myocardial ischemia

To examine the role of percutaneous transluminal coronary angioplasty (PTCA) in patients with silent ischemia, 50 consecutive patients (mean age 54 years, 88% men) with 1-vessel disease and absent or minimal symptoms who underwent PTCA were identified. Nineteen patients (38%) were asymptomatic and 31 patients (62%) had minimal angina (at most 1 episode/month, and with marked exertion only). Exercise-induced ischemia was present in 45 of 49 patients (92%) tested. The remaining 5 patients had a critical stenosis in a vessel supplying a large myocardial territory. A total of 75 lesions were dilated, 71 successfully (95%). There were no procedural deaths or infarctions. The single complication was an urgent bypass operation. After PTCA, only 3 of 46 patients exercised (7%) had inducible ischemia (p < 0.0005 vs before PTCA). At a mean follow-up of 36 months, 46 of 49 patients alive (94%) were asymptomatic (p < 0.0005 vs before PTCA). The 3-year actuarial survival and infarct-free survival were 98 and 96%, respectively. However, 5 patients (10%) crossed over to bypass surgery and 14 patients (28%) underwent repeat PTCA. Progression of native coronary disease was present in 9 of these patients (47%). As in symptomatic patients, elective PTCA can be performed safely and with a high success rate in patients with silent ischemia, and can markedly reduce the incidence of exercise-induced ischemia. With this approach, >90% of the patients were asymptomatic at the 3-year follow-up; however, 34% required a further revascularization procedure for restenosis or progression of native disease or both. A prospective randomized trial is needed to firmly establish the role of PTCA in the treatment of silent ischemia.