Rate Of Complete Revascularization Research Articles

Clinical Outcomes and Left Ventricular Functional Remodeling after Extracorporeal Membrane Oxygenation Assisted Percutaneous Coronary Intervention in Patients with Ischemic Cardiomyopathy: A Single-Center Retrospective Observational Study of 76 Cases.

Ischemic cardiomyopathy (ICM) is a common condition that leads to left ventricular (LV) functional remodeling and poor prognosis. Extracorporeal membrane oxygenation (ECMO) can provide temporary circulatory support and facilitate percutaneous coronary intervention (PCI) in patients with ICM and hemodynamic instability. However, the impact of ECMO-assisted PCI on LV functional remodeling and clinical outcomes in ICM patients is unclear. We retrospectively analyzed 76 patients with ICM who underwent ECMO-assisted PCI at our institution between January 2013 and December 2022. We assessed the changes in LV functional remodeling using echocardiography at baseline and 12 months after the procedure. We also evaluated the incidence of major adverse cardiac and cerebrovascular events (MACCEs) and ECMO-related complications during hospitalization and at one-year follow-up. The mean baseline left ventricular ejection fraction (LVEF) was 29.98 ± 2.65%. The rate of complete revascularization was 58%. The median duration of ECMO support was 38.99 hours. The most common ECMO-related complications were bleeding (8%) and lower extremity ischemia (5%). The one-year mortality rate was 30%. The overall freedom from MACCEs at 12 months was 59% (95% confidence interval (CI): 49-71%). LVEF increased significantly after the procedure from baseline to 6 months, yet decreased slightly at 12 months, although it was still higher than the baseline value. Wall motion score index (WMSI), end-diastolic volume index (EDVI), and end-systolic volume index (ESVI) decreased significantly from baseline to 12 months, indicating an improvement in LV function and a reduction in LV size. In a high-volume tertiary center with extensive experience in advanced heart failure therapies and a dedicated ECMO team, ECMO-assisted PCI demonstrated feasibility and safety in patients with ischemic cardiomyopathy. However, the rate of complete revascularization was modest at 58%. Despite the high-risk profile of the patients, ECMO-assisted PCI was associated with a significant improvement in LV functional remodeling and a favorable 12-month survival rate. Further prospective studies are needed to confirm these findings and to identify the optimal patient and device selection criteria for ECMO-assisted PCI.

Outcomes of Patients with Normal LDL-Cholesterol at Admission for Acute Coronary Syndromes: Lower Is Not Always Better.

There are few prospective data on the prognostic value of normal admission low-density lipoprotein cholesterol (LDL-C) in statin-naïve patients with acute coronary syndromes (ACS) who are treated with a preemptive invasive strategy. We aimed to analyze the proportion of patients with normal LDL-C at admission for ACS in our practice, and their characteristics and clinical outcomes in comparison to patients with high admission LDL-C. Two institutions' prospective registries of patients with confirmed ACS from Jan 2017 to Jan 2023 were used to identify 1579 statin-naïve patients with no history of prior coronary artery disease (CAD), and with available LDL-C admission results, relevant clinical and procedural data, and short- and long-term follow-up data. Normal LDL-C at admission was defined as lower than 2.6 mmol/L. All demographic, clinical, procedural, and follow-up data were compared between patients with normal LDL-C and patients with a high LDL-C level (≥2.6 mmol/L) at admission. There were 242 (15%) patients with normal LDL-C at admission. In comparison to patients with high LDL-cholesterol at admission, they were significantly older (median 67 vs. 62 years) with worse renal function, had significantly more cases of diabetes mellitus (DM) (26% vs. 17%), peripheral artery disease (PAD) (14% vs. 9%), chronic obstructive pulmonary disease (COPD) (8% vs. 2%), and psychological disorders requiring medical attention (19% vs. 10%). There were no significant differences in clinical type of ACS. Complexity of CAD estimated by coronary angiography was similar between the two groups (median Syntax score 12 for both groups). There were no significant differences in rates of complete revascularization (67% vs. 72%). Patients with normal LDL-C had significantly lower left ventricular ejection fraction (LVEF) at discharge (median LVEF 52% vs. 55%). Patients with normal LDL-C at admission had both significantly higher in-hospital mortality (5% vs. 2%, RR 2.07, 95% CI 1.08-3.96) and overall mortality during a median follow-up of 43 months (27% vs. 14%, RR 1.86, 95% CI 1.45-2.37). After adjusting for age, renal function, presence of diabetes mellitus, PAD, COPD, psychological disorders, BMI, and LVEF at discharge in a multivariate Cox regression analysis, normal LDL-C at admission remained significantly and independently associated with higher long-term mortality during follow-up (RR 1.48, 95% CI 1.05-2.09). A spontaneously normal LDL-C level at admission for ACS in statin-naïve patients was not rare and it was an independent risk factor for both substantially higher in-hospital mortality and mortality during long-term follow-up. Patients with normal LDL-C and otherwise high total cardiovascular risk scores should be detected early and treated with optimal medical therapy. However, additional research is needed to reveal all the missing pieces in their survival puzzle after ACS-beyond coronary anatomy, PCI optimization, numerical LDL-C levels, and statin therapy.

Impact of the Timing of Mechanical Circulatory Support on the Outcomes in Myocardial Infarction-Related Cardiogenic Shock: Subanalysis of the PREPARE CS Registry.

(1) Background: Mechanical circulatory support (MCS) in myocardial infarction-associated cardiogenic shock is subject to debate. This analysis aims to elucidate the impact of MCS's timing on patient outcomes, based on data from the PREPARE CS registry. (2) Methods: The PREPARE CS prospective registry includes patients who experienced cardiogenic shock (SCAI classes C-E) and were subsequently referred for cardiac catheterization. Our present analysis included a subset of this registry, in whom MCS was used and who underwent coronary intervention due to myocardial infarction. Patients were categorized into an Upfront group and a Procedural group, depending on the timing of MCS's introduction in relation to their PCI. The endpoint was in-hospital mortality. (3) Results: In total, 71 patients were included. MCS was begun prior to PCI in 33 (46%) patients (Upfront), whereas 38 (54%) received MCS during or after the initiation of PCI (Procedural). The groups' baseline characteristics and hemodynamic parameters were comparable. The Upfront group had a higher utilization of the Impella® device compared to extracorporeal membrane oxygenation (67% vs. 33%), while the Procedural group exhibited a balanced use of both (50% vs. 50%). Most patients suffered from multi-vessel disease in both groups (82% vs. 84%, respectively; p = 0.99), and most patients required a complex PCI procedure; the latter was more prevalent in the Upfront group (94% vs. 71%, respectively; p = 0.02). Their rates of complete revascularization were comparable (52% vs. 34%, respectively; p = 0.16). Procedural CPR was significantly more frequent in the Procedural group (45% vs. 79%, p < 0.05); however, in-hospital mortality was similar (61% vs. 79%, respectively; p = 0.12). (4) Conclusions: The upfront implantation of MCS in myocardial infarction-associated CS did not provide an in-hospital survival benefit.

Choice of revascularization strategy for ischemic cardiomyopathy due to multivessel coronary disease

ObjectiveLimited comparative data guide the decision between coronary artery bypass grafting and percutaneous coronary intervention for multivessel revascularization in ischemic cardiomyopathy. The study objective was to compare the long-term outcomes of coronary artery bypass grafting and percutaneous coronary intervention for ischemic cardiomyopathy. MethodsClinical registries from the New Jersey Department of Health linked to administrative databases were used to compare all-cause mortality, repeat revascularization, heart failure readmissions, myocardial infarction, and stroke using Cox proportional hazards and propensity matching with competing risk analysis in 5988 patients with ejection fraction 35% or less who underwent coronary artery bypass grafting (3673, 61.3%) or percutaneous coronary intervention (2315, 38.6%) for multivessel coronary disease between 2007 and 2018. Median follow-up time was 5.2 years (range, 0-13 years); the last follow-up date was December 31, 2020. ResultsAfter controlling for completeness of revascularization, at 13 years, mortality was 57% (95% CI, 51-63) after percutaneous coronary intervention and 60% (95% CI, 53-66) after coronary artery bypass grafting (hazard ratio [HR], 1.10; 95% CI, 0.93-1.31; P = .28); risk of repeat revascularization was 18% for percutaneous coronary intervention versus 14% for coronary artery bypass grafting (HR, 1.62; 95% CI, 1.17-2.25; P = .003); risk of readmission for heart failure was 16% after percutaneous coronary intervention and coronary artery bypass grafting (HR, 1.13,95% CI, 0.84-1.51, weighted P = .10); risk of myocardial infarction was 10% versus 6%, respectively (HR, 1.91; 95% CI, 1.18-3.09; P = .007); and stroke risk was 3% versus 4%, respectively (HR, 0.79; 95% CI, 0.41-1.53; P = .52). Rate of complete revascularization was lower after percutaneous coronary intervention than after coronary artery bypass grafting and associated with higher mortality after percutaneous coronary intervention (HR, 1.35; 95% CI, 1.20-1.52; P < .001). ConclusionsCoronary bypass was associated with similar mortality, stroke, and heart failure readmissions, and reduced repeat revascularization compared with percutaneous coronary intervention in patients with ischemic cardiomyopathy if similar rates of complete revascularization were achieved. These findings support consensus recommendations for coronary artery bypass grafting and medical therapy in patients with multivessel coronary disease and left ventricular dysfunction.

Benefits of immediate complete revascularization in patients with acute coronary syndromes.

Acute coronary syndrome is one of the leading causes of death worldwide. Up to 60% of patients present with additional significant non-culprit lesions. Complete revascularization (CR) of all (culprit and non-culprit) lesions is recommended and recent randomized trials showed the benefit of performing complete multivessel percutaneous coronary intervention in a single setting. Immediate CR is associated with a reduced risk of repeat myocardial infarction and unplanned ischemia driven revascularization. Furthermore, immediate CR resulted in less implanted stents, total contrast use and a shorter duration of hospitalization while maintaining a similar success rate of complete revascularization. Further studies need to evaluate the role of coronary physiology and intravascular imaging for enhanced understanding of the pathophysiology of early events in non-culprit lesions.

De novo Biological Coronary Artery Bypass in a Rat Model: Case Report and the Concept of Hybrid Cardiovascular Regeneration

Background: Peripheral blood mononuclear cell-derived progenitor cells (regeneration associated cells: RACs) have been reported to migrate to tissues with inflammation to expedite anti-inflammatory and pro-regeneration actions, but cell sources, administration, timing, dosage, and combined procedures after myocardial ischemia and/or infarction (MI) still remain to be elucidated in preclinical studies. Materials and Methods: Rats with induced MI were treated with intravenous infusion of 5-day culture-primed autologous RACs or control cell transfusion, followed by weekly echocardiography until 4 weeks after MI, at which time pressure-volume relationship (PVR) analyses and histological studies were performed. Results: While most rats treated with autologous RACs infusion after MI developed vascular regeneration from surrounding pericardial tissues and significant functional improvements, one rat developed a de novo coronary artery bypass (φ&lt; 0.3 mm) mimicking surgical bypass grafting (CABG), echocardiography revealed recovered left ventricular (LV) motion, and PVR analyses showed restored LV function as well as histological changes suggesting revascularization and myocardial regeneration. Conclusion: Development of isolated bypass-like structure by RAC therapy after MI led us to consider further surgical as well as biological modifications to expedite biological coronary revascularization and myocardial regeneration. A combination with vascular approaches to provide arterial inflow may increase the rate of complete revascularization and regeneration of cardiomyocytes as hybrid procedure, as they complement each other, to realize cardiovascular regeneration.

On- vs. Off-Pump CABG in Heart Failure Patients with Reduced Ejection Fraction (HFrEF): A Multicenter Analysis.

This study aimed to compare postoperative outcomes and 30-day mortality in patients with reduced ejection fraction (<40%) who underwent isolated coronary artery bypass grafting (CABG) with (ONCAB) and without (OPCAB) the use of cardiopulmonary bypass. data from four university hospitals in Germany, spanning from January 2017 to December 2021, were retrospectively analyzed. A total of 551 patients were included in the study, and various demographic, intraoperative, and postoperative data were compared. demographic parameters did not exhibit any differences. However, the OPCAB group displayed notably higher rates of preoperative renal insufficiency, urgent surgeries, and elevated EuroScore II and STS score. During surgery, the ONCAB group showed a significantly higher rate of complete revascularization, whereas the OPCAB group required fewer intraoperative transfusions. No disparities were observed in 30-day/in-hospital mortality for the entire cohort and the matched population between the two groups. Subsequent to surgery, the OPCAB group demonstrated significantly shorter mechanical ventilation times, reduced stays in the intensive care unit, and lower occurrences of ECLS therapy, acute kidney injury, delirium, and sepsis. the study's findings indicate that OPCAB surgery presents a safe and viable alternative, yielding improved postoperative outcomes in this specific patient population compared to ONCAB surgery. Despite comparable 30-day/in-hospital mortality rates, OPCAB patients enjoyed advantages such as decreased mechanical ventilation durations, shorter ICU stays, and reduced incidences of ECLS therapy, acute kidney injury, delirium, and sepsis. These results underscore the potential benefits of employing OPCAB as a treatment approach for patients with coronary heart disease and reduced ejection fraction.

Impact of SGLT2-inhibitors on contrast-induced acute kidney injury in diabetic patients with acute myocardial infarction: data from SGLT2-I AMI PROTECT Registry

Abstract Background Diabetes patients presenting with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) have an increased risk of contrast induced-acute kidney injury (CI-AKI). It has been shown that SGLT2-I have a nephroprotective effect. Purpose To analyze the association between SGLT2-I treatment and the development of contrast-induced acute kidney injury (CI-AKI) in diabetic patients with AMI (both ST- and non-ST segment elevation myocardial infarction - STEMI and NSTEMI) treated with PCI. Methods In this multicenter international registry, all consecutive diabetic AMI patients undergoing PCI between 2018 and 2021 were enrolled. Based on the admission anti-diabetic therapy, they were divided into SGLT-I users versus non-SGLT2-I users. All patients had estimated glomerular filtration rate (eGFR) of &amp;gt;30 mL/min/1.73 m2. No patient discontinued SGLT2-I during hospitalization. Serum creatinine was collected at admission and within 72 h post-PCI. CI-AKI was defined as absolute (≥0.5 mg/dl) or relative increase (≥25%) in serum creatinine at 48-72 h after PCI compared to baseline serum creatinine values. Results The study population consisted of 646 AMI patients: 111 SGLT2-I users and 535 non-SGLT-I users. The mean age of the overall study population was 70 [61-79] years, and more than 77% were males. The mean T2DM duration was similar for both groups. SGLT2-I patients were younger and with better renal function at admission compared to non-SGLT2-I users (p&amp;lt;0.018 for both). Gender, cardiovascular risk factors, glucose-metabolic control, and comorbidities were similar in the two groups. The rate of STEMI and the main angiographic characteristics were similar between the two study groups, except for the higher number of stents implanted in the SGLT2-I group (p=0.041). Vascular access and contrast dosage did not differ between the 2 cohorts. A similar rate of complete revascularization, staged procedure and complex PCI was observed between the study groups. After PCI, the overall rate of CI-AKI was 76 (11.8%). SGLT2-I users exhibit a lower rate of CI-AKI compared to non-SGLT-I ones (5.4% vs 13.1%, p=0.02), with significantly lower creatinine values both after PCI (p=0.016) and at discharge (p=0.046). At multivariate analysis, after adjusting for all confounding factors, the use of SGLT2-I was identified as independent predictor of reduced rate of CI-AKI (OR 0.374; 95% CI 0.142-0.987, p=0.040). During a median follow-up of 24±13 months, patients with CI-AKI showed a higher incidence of MACE compared to patients without (44.7% vs 25.8%, p=0.001). Conclusion In diabetic patients with AMI, the use of SGLT2-I was associated with a lower risk of CI-AKI during index hospitalization, providing new insights into the cardioprotective effects of SGLT2-I in the setting of AMI.

Angina en pacientes con estenosis aórtica grave sometidos a implante percutáneo de la válvula aórtica

Introduction and objectivesTo evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. MethodsA total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database. ResultsA total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up. ConclusionsMore than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

Angina in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Introduction and objectivesTo evaluate the prevalence, clinical characteristics, and outcomes of patients with angina undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. MethodsA total of 1687 consecutive patients with severe aortic stenosis undergoing TAVR at our center were included and classified according to patient-reported angina symptoms prior to the TAVR procedure. Baseline, procedural and follow-up data were collected in a dedicated database. ResultsA total of 497 patients (29%) had angina prior to the TAVR procedure. Patients with angina at baseline showed a worse New York Heart Association (NYHA) functional class (NYHA class> II: 69% vs 63%; P=.017), a higher rate of coronary artery disease (74% vs 56%; P <.001), and a lower rate of complete revascularization (70% vs 79%; P <.001). Angina at baseline had no impact on all-cause mortality (HR, 1.02; 95%CI, 0.71-1.48; P=.898) and cardiovascular mortality (HR, 1.2; 95%CI, 0.69-2.11; P=.517) at 1 year. However, persistent angina at 30 days post-TAVR was associated with increased all-cause mortality (HR, 4.86; 95%CI, 1.71-13.8; P=.003) and cardiovascular mortality (HR, 20.7; 95%CI, 3.50-122.6; P=.001) at 1-year follow-up. ConclusionsMore than one-fourth of patients with severe aortic stenosis undergoing TAVR had angina prior to the procedure. Angina at baseline did not appear to be a sign of a more advanced valvular disease and had no prognostic impact; however, persistent angina at 30 days post-TAVR was associated with worse clinical outcomes.

On‐pump beating‐heart coronary artery bypass grafting: Single Center Experience and Literature Review

Purpose: In this retrospective, observational, non-randomized study, we present the results of our department in on‐pump beating‐heart coronary artery bypass grafting and we review the relevant medical literature. Methods: All data related to patients who underwent on‐pump beating‐heart coronary artery bypass grafting at our center for three consecutive years were collected. These patients were classified into two groups: isolated bypass grafts or combined with aortic valve replacement. All data related to preoperative characteristics, procedural characteristics, and clinical outcomes are presented separately for the two groups. Results: During the study period, 175 patients underwent on‐pump beating‐heart bypass grafting alone and 32 combined with aortic valve replacement. Despite higher than average Euroscore in both groups, mortality, and morbidity were satisfactory while the rate of complete revascularization was higher than previously reported for classic off-pump surgery. Conclusion: On‐pump beating heart coronary artery bypass grafting offers an excellent alternative in the surgical treatment of coronary artery disease. Patient selection is very important, and in the hands of skilled surgeons, it may prevent intraoperative complications and offer the appropriate revascularization, especially for high-risk patients.

Right ventricular-arterial uncoupling as an independent prognostic factor in acute heart failure with preserved ejection fraction accompanied with coronary artery disease.

Right ventricular (RV)-arterial uncoupling is a powerful independent predictor of prognosis in heart failure with preserved ejection fraction (HFpEF). Coronary artery disease (CAD) can contribute to the pathophysiological characteristics of HFpEF. This study aimed to evaluate the prognostic value of RV-arterial uncoupling in acute HFpEF patients with CAD. This prospective study included 250 consecutive acute HFpEF patients with CAD. Patients were divided into RV-arterial uncoupling and coupling groups by the optimal cutoff value, based on a receiver operating characteristic curve of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP). The primary endpoint was a composite of all-cause death, recurrent ischemic events, and HF hospitalizations. TAPSE/PASP ≤0.43 provided good accuracy in identifying patients with RV-arterial uncoupling (area under the curve, 0.731; sensitivity, 61.4%; and specificity, 76.6%). Of the 250 patients, 150 and 100 patients could be grouped into the RV-arterial coupling (TAPSE/PASP >0.43) and uncoupling (TAPSE/PASP ≤0.43) groups, respectively. Revascularization strategies were slightly different between groups; the RV-arterial uncoupling group had a lower rate of complete revascularization (37.0% [37/100] vs . 52.7% [79/150], P <0.001) and a higher rate of no revascularization (18.0% [18/100] vs . 4.7% [7/150], P <0.001) compared to the RV-arterial coupling group. The cohort with TAPSE/PASP ≤0.43 had a significantly worse prognosis than the cohort with TAPSE/PASP >0.43. Multivariate Cox analysis showed TAPSE/PASP ≤0.43 as an independent associated factor for the primary endpoint, all-cause death, and recurrent HF hospitalization (hazard ratios [HR]: 2.21, 95% confidence interval [CI]: 1.44-3.39, P <0.001; HR: 3.32, 95% CI: 1.30-8.47, P = 0.012; and HR: 1.93, 95% CI: 1.10-3.37, P = 0.021, respectively), but not for recurrent ischemic events (HR: 1.48, 95% CI: 0.75-2.90, P = 0.257). RV-arterial uncoupling, based on TAPSE/PASP, is independently associated with adverse outcomes in acute HFpEF patients with CAD.

Effect of Asymptomatic Hyperuricemia on Mortality of Elderly Patients After Elective Percutaneous Coronary Intervention.

PurposeThe purpose of this study is to investigate the effect of asymptomatic hyperuricemia on mortality of elderly patients with coronary artery disease (CAD) after elective percutaneous coronary intervention (PCI).MethodsOne thousand two hundred ninety-six patients with coronary heart disease ≥65 years old who had increased uric acid records and without gout history underwent elective PCI from January 2015 to January 2016 were enrolled. The hyperuricemia is defined as serum uric acid level >420 μ mol/l (7 mg/dl) for males and >357 μ mol/l (6 mg/dl) for females. Patients were divided into hyperuricemia group and non-hyperuricemia group. After an average of 519 days follow-up, the differences in mortality between the two groups were compared.ResultsThere were 236 patients in hyperuricemia group and 1060 patients in non-hyperuricemia group. In hyperuricemia group, BMI was higher (P = 0.036); the proportions of patients with hypertension (P < 0.001) and myocardial infarction history (P = 0.046) were higher; white blood cells (P = 0.015) and triglyceride levels were higher (P < 0.001); and estimated glomerular filtration rate (P < 0.001) and high-density lipoprotein cholesterol level were lower (P = 0.007). In addition, in hyperuricemia group, during hospitalization, the ratios of patients treated with diuretics (P < 0.001) and the number of PCI lesions were higher (P = 0.030), and the complete revascularization rate was lower (P = 0.017). The mortality rate (2.2 vs. 7.6%, P < 0.001) of hyperuricemia group was significantly higher than that of non-hyperuricemia group. Multivariate Cox regression analysis showed that after adjusting for other factors, hyperuricemia was an independent risk factor for increased mortality after PCI (HR 2.786, 95% CI 1.233–6.297, P = 0.014).ConclusionAsymptomatic hyperuricemia is an independent risk factor for increased mortality of elderly patients with coronary heart disease undergoing elective PCI.

Frontline thrombectomy strategy and outcome in acute basilar artery occlusion

BackgroundNovel thrombectomy strategies emanate expeditiously day-by-day counting on access system, clot retriever device, proximity to and integration with the thrombus, and microcatheter disengagement. Nonetheless, the relationship between native thrombectomy strategies...

Bilateral internal thoracic artery use in two-vessel disease does not increase the perioperative risk—A propensity score matched analysis

BackgroundBilateral internal thoracic arteries (BITA) are uncommonly used in the every-day practice due to safety concerns and technical challenges with Y-grafts. We hypothesized that in-situ BITA use during coronary artery by-pass grafting (CABG) for two vessel disease is equally safe to standard strategy with left internal thoracic artery-left anterior descending artery revascularization and venous graft to other target vessels.MethodsA propensity score matched analysis was used to compare elective on-pump CABG patients who received in-situ BITA (BITA-group), versus left internal thoracic artery graft to the left anterior descending artery plus vein (SITA-group). Primary end points were 30-days all-cause-mortality, major adverse cardiac events and incidents and deep sternal wound infections.ResultsA total of 50 matched pairs (c-statistics 0.769) were selected from patients operated on between January 2015 and April 2020 using BITA (n = 50) and SITA (n = 2170). There were no inter-group differences in demographics and basic clinical characteristics. The total operation time was longer in the BITA-group (4.0 vs 3.6 hours; p = 0.004). The rate of complete revascularization was similar, as was median aortic cross-clamp time, median extracorporeal circulation time, rate of re-explorations for bleeding, deep sternal wound infections or length of stay. One patient died in BITA group, 3 days after surgery, from a non-cardiac cause. After 36 months, the survival rate was 98% for BITA-group and 96% for controls (log-rank, p = 0.577).ConclusionsIn-situ use of BITA during coronary revascularization for two-vessel disease is as safe and effective, as use of single ITA and vein graft. In-situ strategy abolishes allows to avoid the technically demanding composite graft configuration.

Revascularization Strategies for Multivessel Coronary Artery Disease in the Elderly Population

Prospective trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary disease (MVCAD) have included mostly younger patients. We compared treatment strategies in the elderly population. We performed a propensity-score-matched comparison of patients ≥75 y who underwent isolated CABG or PCI for MVCAD between 2011 and 2018, excluding those with prior cardiac surgery and/or significant left main disease. The primary outcome was 5-year Kaplan Meier survival, and secondary outcomes included readmissions and major adverse cardiovascular and cerebrovascular events (MACCE). Propensity-matching yielded 536 patients (266 PCI and 266 CABG). Rates of complete revascularization of all stenotic lesions were higher in the CABG arm (86.8% versus 21.8%; P < 0.001). Thirty-d mortality was similar between cohorts, though PCI recipients had shorter hospital stay and greater likelihood of discharge to home. Unadjusted one- (89.1% versus 88.4%) and 5-year (73.8% versus 60.1%) survival were both higher in patients who underwent CABG (P=0.0332). Patients undergoing CABG had reduced, but nonsignificant cumulative incidence of all-cause hospital readmission and MACCE at 5 y. Subgroup analysis of patients 80 y or older revealed similar late survival benefit with CABG when compared to PCI. Among patients undergoing CABG, there did not appear to be any 5-year benefits from multi-arterial grafting. Despite longer hospitalization and higher rate of nonhome discharge, CABG was associated with improved late survival over PCI in the elderly population. Cardiac surgeons should be included in the multidisciplinary evaluation of older patients with MVCAD.

Off-pump versus on-pump coronary artery bypass grafting: a propensity score-matching analysis of safety and long-term results

Abstract Background The role and the indications for using off-pump coronary artery bypass surgery (OPCAB), instead of the traditional on-pump (ONCAB), is still to be addressed. Aim To describe our centre experience and to compare 15-years survival and early safety outcomes between OPCAB and ONCAB. Methods Single-centre retrospective cohort including 9-years of isolated first CABG (2005–2013). Multi-vessel disease with at least 2 surgical grafts patients were considered and the first 50 surgeries of each surgeon with each technique were excluded to account for the learning curve effect. Emergent surgeries and on-pump beating heart procedures were also excluded. A propensity-score matching (PSM) analysis was performed to balance groups and both survival and early outcomes comparison was done within the matched cohort using Kaplan-Meier or Cox stratified and paired tests, respectively. The median follow-up was 9 years, maximum 15 years. Results From 3012 multi-vessel patients with at least 2 surgical grafts, 2503 were included at the main analysis: 1487 ONCAB and 1016 OPCAB. ONCAB patients presented more frequently 3-vessels disease and left ventricular dysfunction, but received similar number of grafts than OPCAB, who in turn, received more frequently multiple arterial grafts. The surgical completeness of revascularization (CR) was similar, but hybrid procedures were more frequent in OPCAB raising CR rate in this group. After PSM (646 pairs), both groups were similar regarding pre and peri-operative characteristics. The long-term survival was similar (HR stratified by pair: 1.02 (0.81–1.30), but OPCAB evidenced benefits at early term results including bleeding, postoperative atrial fibrillation and stroke incidence. Conclusion At our centre, OPCAB performed by experienced surgeons provides rates of complete revascularization and long-term survival similar to ONCAB. In-hospital results favoured OPCAB. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Universidade do Porto/FMUP; Social European Fund; FCT-Fundação para a Ciência e a Tecnologia

Coronary endarterectomy in coronary artery disease: Factors affecting graft patency and survival.

Coronary endarterectomy aims to improve completeness of revascularization in patients with occluded coronary vessels. The benefits of coronary endarterectomy remain uncertain. The aim of this study was to evaluate short-term surgical outcomes and factors affecting graft patency post-coronary endarterectomy. Between 2009 and 2019, 81 consecutive patients who had coronary endarterectomy done were evaluated for their perioperative and early results. A total of 36 patients with follow-up coronary studies were included in patency analysis. Mortality rates, major adverse cardiac and cerebrovascular events, and graft patency were outcomes of interest. Survival and risk factor analysis were performed with Kaplan-Meier and logistic regression analysis. The average age of the cohort was 61.9 ± 9.29 years. Complete revascularization rate was 95.4% post-coronary endarterectomy. The 30-day and 1-year mortality was 2.5 and 6.2%, respectively. One-year major adverse cardiac and cerebrovascular events rate was 11.1%. Periprocedural myocardial infarction rate was 7.4%. Three patients required repeat revascularization within a mean follow-up duration of 49.6 ± 36.5 months. Overall graft patency was 89.2% at 20.2 months and graft patency post-coronary endarterectomy was 85.4%. Arterial grafts showed 100% patency. Vein grafts to endarterectomized obtuse marginal branch had patency rates of 33.3%. Multiple endarterectomies were associated with worse one-year major adverse cardiac and cerebrovascular events (OR: 28.6 ± 1.16; P = 0.003). Coronary endarterectomy facilitates completeness of revascularization and does not increase early mortality. Graft patency post-coronary endarterectomy on obtuse marginal artery was suboptimal. Judicious use of coronary endarterectomy should be practiced to balance the need of completeness of revascularization against the risk of myocardial infarction.

Graft patency and completeness of revascularization in minimally invasive multivessel coronary artery bypass surgery.

Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency. Clinical variables during hospitalization and follow-up were collected and analyzed. All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2-5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3 of 186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491 of 510) (98.3% [171 of 174] for left internal thoracic artery grafts and 95.2% [318 of 334] for saphenous vein grafts). The rate of complete revascularization was 99.5% (185 of 186). Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for selected patients with multivessel disease.

Off-pump coronary artery bypass surgery lacks a longitudinal survival advantage in patients with left ventricular dysfunction.

This study evaluates the longitudinal impacts of off-pump coronary artery bypass (OPCAB) surgery in patients with reduced left ventricular ejection fraction (LVEF). Adults with LVEF ≤ 30% undergoing coronary artery bypass grafting between 2011 and 2020 were included. Patients were stratified based on the utilization of cardiopulmonary bypass into OPCAB or on-pump coronary artery bypass (ONCAB) groups. Primary outcomes included survival and hospital readmissions. Secondary outcomes evaluated postoperative morbidities. Multivariable regression evaluated risk-adjusted mortality and readmission. Propensity score matching was utilized to reduce bias. A total of 660 low LVEF patients were included, of which 28.5% (n = 188) were OPCAB and 71.5% (n = 472) were ONCAB. The rates of complete revascularization were similar between the groups (80.3% vs 82.0%; P = .67). Early survival between the unmatched groups was similar at 1-year follow-up (86.2% vs 87.9%; P = .53); however, at 5 years OPCABs had significantly worse survival compared with ONCABs (71.5% vs 64.2%; P = .02). These findings persisted in the matched cohort where survival at 1 year was comparable (86.8% vs 85.7%; P = .80), but 5-year survival was better for ONCABs (64.1% vs 69.9%; P = .03). The rates of readmission were similar between the unmatched and matched groups at all time intervals, including readmissions for cardiac-related and heart failure-related events (all, P > .05). In contemporary patients with reduced LVEF, survival after OPCAB was similar at 1 year but lower at 5-year follow-up compared with ONCAB, despite similar rates of complete revascularization. These findings suggest that there may be other factors influencing longitudinal mortality in the low LVEF cohort, beyond the use of cardiopulmonary bypass.