Redo Coronary Artery Bypass Grafting Research Articles

Abstract 4146142: Constrictive Pericarditis Due to Sarcoidosis: Role of Multimodality Imaging in a Patient with a Metal Jacket Full of Calcification

Clinical Presentation: A 62-year-old male with a complex medical history, including pulmonary sarcoidosis, diabetes, constrictive pericarditis post partial pericardial stripping, cirrhosis, and congestive heart failure, presented with signs and symptoms of volume overload. Despite increasing diuretics and previous paracentesis, his condition continued to deteriorate. There were raising concerns for constrictive pericarditis due to cardiac sarcoidos. Echocardiography (TEE) showed pericardial thickening and calcification adjacent to the left ventricle and dilated IVC 2.4 cm (TTE). Cardiac magnetic resonance imaging (CMR) demonstrated conical deformity of the ventricles, thickened pericardium with signal void suggestive of calcification. Computed Tomography (CT) showed significant near circumferential pericardial calcifications. Subsequent catheterization confirmed constriction and identified a right coronary artery lesion. Following this, the patient underwent a redo pericardiectomy and coronary artery bypass grafting, at the Cleveland Clinic. However, his post-operative course was marked by complex challenges, including multi-organ dysfunction, the need for tracheostomy, feeding tube, renal replacement therapy, and recurrent ascites. Despite intensive care, his condition did not improve, leading to a transition to comfort care and eventually the patient passed away in December 2023. Discussion: This case highlights the intricate management of a patient with a myriad of underlying health issues. While multimodality imaging is pivotal in ensuring accurate preoperative diagnosis and guiding surgical interventions, it is important to acknowledge that challenges may persist in the postoperative phase. This case study underscores the vital role of multimodality imaging, irrespective of post-surgical outcomes, in facilitating precise diagnosis and delivering optimal patient care. The subsequent referral to the Cleveland Clinic for redo surgery, followed by a challenging and ultimately palliative care journey, shows the complexity of her clinical course and the importance of multimodality imaging and comprehensive care strategies.

Long-term survival after coronary artery bypass grafting comparing bilateral versus single internal mammary artery in a women cohort

Abstract Introduction Although neutral results from the ART randomized controlled trial, observational studies have been supporting better survival after bilateral internal mammary artery (BIMA) vs single internal mammary artery (SIMA) coronary artery bypass grafting (CABG). However, for some specific subgroups, like women patients, more doubts remain about BIMA benefits. Aim To compare long-term survival and early results in women after SIMA vs BIMA. Methods Longitudinal, retrospective, single-center study including consecutive women with at least 2 left-coronary system (LCS) vessel disease who underwent primary isolated CABG with at least 1 internal mammary artery (IMA) conduit and a minimum of 2 conduits targeting the LCS, between 2004-2014. Emergent or salvage surgeries, on-pump beating-heart, BIMA in which 1 IMA targeted the right coronary artery territory were excluded. The primary outcome was all-causes mortality (checked on February 2023). Time-to-event outcomes were studied using Kaplan-Meier Curves, Log-Rank test and multivariable Cox Regression. Median follow-up was 11 years, maximum of 19 years. Results From 539 women selected for this study, BIMA CABG was performed in 30%. SIMA patient’s were older (mean age 68.95±8.39 vs 62.75±9.82 years, p<0.001), but the prevalence of cardiovascular risk factors were similar between groups (arterial hypertension, p=0.693; dyslipidemia, p=0.111; diabetes mellitus, p=0.462 and obesity, p=0.109). Peripheral artery disease (p=0.707), left ventricular dysfunction (p=0.727), cerebrovascular disease (p=0.730), active smoking habits (p=0.05) and chronic obstrutive pulmonary disease (p=0.537) were also similar. Severe chronic kidney disease (27% vs 14%, p<0.001) and Canadian Coronary Society - grade IV (74% vs 63%, p=0.011) were more frequent in SIMA group. In the univariable survival analysis, SIMA had worse survival results than BIMA (Log Rank test p<0.01). At 5-, 10- and 15- years of follow-up, cumulative survival for SIMA vs BIMA were 88% vs 90%, 68% vs 75%, 42% vs 58%, respectively. However, the multivariable Cox regression showed that BIMA was not associated with long-term survival (HR [95%CI]: 1.09 [0.75-1.59], p=0.6). Most of post-operative outcomes were similar between groups, with the exception of atrial fibrilation (25% vs 16%, p=0.031) and time to discharge (median days [min-max]: 7 [4-128] vs 7 [4-59]) that were higher in SIMA. No differences were found in immediate reexploration of thorax (sternal infection – 0.3% SIMA vs 1.2% BIMA, p=0.219; bleeding- 1.6% SIMA vs 0.6% BIMA, p=0.681). Redo CABG occurred in 1 SIMA and 1 BIMA women, at 41 and 84 months of follow-up, respectively. Conclusion In this study, revascularization with BIMA seems to be safe in women and provides similar results than SIMA. More studies in women are needed to establish the better approach for this specific subgroup.

Multiarterial grafting in redo coronary artery bypass grafting: Type of arterial conduit and patient sex determine benefit

ObjectiveTo evaluate whether multiarterial grafting provides an incremental benefit above single arterial grafting in isolated redo coronary artery bypass grafting (CABG). MethodsFrom January 1980 to July 2020, 6559 adults underwent a total of 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity score–matched with those undergoing single arterial grafting with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. The median follow-up was 10 years, with 25% of patients followed for >17 years. Multivariable multiphase hazard models and nonparametric random survival forest models for survival were used to identify patients for whom multiarterial grafting was most beneficial. ResultsAmong propensity score–matched patients, postoperative complications in multiarterial versus single arterial grafting included any reoperation (50 [2.5%] vs 65 [3.2%]); renal failure (73 [3.6%] vs 55 [2.7%]), stroke (44 [2.2%] vs 38 [1.9%]), and deep sternal infection (36 [1.8%] vs 25 [1.2%]). In-hospital mortality was 1.7% (n = 35) in multiarterial grafting versus 2.8% (n = 56) in single arterial grafting (P = .03). Comparing multiarterial to single arterial grafting, overall survival was 95% versus 94% at 1 year, 92% versus 88% at 3 years, 87% versus 82% at 5 years, 49% versus 42% at 15 years, and 31% versus 25% at 20 years. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P < .0001). ConclusionsRedo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used.

Redo coronary artery bypass grafting: when and how.

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

Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association.

Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.

B-3 | Cardiovascular Outcomes of Redo-Coronary Artery Bypass Graft Versus Percutaneous Coronary Intervention of Index Bypass Grafts Among Acute Coronary Syndrome: Regression Matched National Cohort Study

B-3 | Cardiovascular Outcomes of Redo-Coronary Artery Bypass Graft Versus Percutaneous Coronary Intervention of Index Bypass Grafts Among Acute Coronary Syndrome: Regression Matched National Cohort Study

B-4 | Cardiovascular Outcomes of Redo-Coronary Artery Bypass Graft Versus Percutaneous Coronary Intervention of Index Bypass Grafts Among Non ST Elevation Myocardial Infarction (NSTEMI) Patients: Regression Matched National Cohort Study of United States

B-4 | Cardiovascular Outcomes of Redo-Coronary Artery Bypass Graft Versus Percutaneous Coronary Intervention of Index Bypass Grafts Among Non ST Elevation Myocardial Infarction (NSTEMI) Patients: Regression Matched National Cohort Study of United States

Outcomes After Early Postoperative Myocardial Infarction Due to Graft Failure in Patients Undergoing Coronary Artery Bypass Grafting.

Early graft failure (EGF) after coronary artery bypass grafting (CABG) occurs in up to 12% of grafts, but is often clinically unapparent. EGF may result in perioperative myocardial infarction with consequently increased mortality. The aim of the present study was to analyze the incidence of clinically apparent EGF in patients undergoing CABG and the influence on mortality. We analyzed outcomes of consecutive patients undergoing CABG from January 2015 to December 2018 with respect to postoperative emergency coronary angiography (CAG) due to suspected EGF and 30-day mortality. Patients with CAG-documented EGF were matched to patients without EGF to examine predictors of mortality. The analysis included 5638 patients undergoing CABG. Eighty-six patients (1.5%) underwent emergency CAG due to suspected EGF. Clinically apparent EGF was observed in 61 of these patients (70.9%), whereas 14 (16.3%) had a culprit lesion in a native coronary artery. The majority of patients (n = 45; 52.3%) were treated with percutaneous coronary intervention and 31 (36%) underwent re-do CABG. The remaining patients were treated conservatively. The 30-day mortality rate of suspected EGF patients undergoing CAG was 22.4% (n = 19), which was higher than the mortality rate of 2.8% overall (P<.001); this remained higher after matching the EGF patients with the control group (11 [20.4%] vs 2 [4.0%]; P=.02). Emergency CAG after CABG is rare and is primarily carried out in patients with EGF. The 30-day mortality rate of these patients is high, and EGF is an independent predictor of mortality. Perioperative CAG with subsequent treatment is mandatory in these patients.

15-year outcomes of the JOCRI study (JOCRIED study): a randomised comparison of off-pump and on-pump multiple arterial coronary revascularisation.

The Japanese Off-Pump Coronary Revascularization Investigation (JOCRI) study reported a non-significant difference in early outcomes and graft patency between off-pump coronary artery bypass grafting and on-pump coronary artery bypass grafting in 2005. The JOCRIED study aimed to review the long-term outcomes of the JOCRI study participants. The JOCRIED study enrolled 123 of the JOCRI study participants completing the clinical follow-up between August 2018 and August 2020; 61 patients in the off-pump group and 62 patients in the on-pump group. The follow-up period was 13.8 ± 2.8years. The groups were compared regarding mortality, the incidence of major adverse cardiac and cerebrovascular events and repeat revascularisation. The 15-year cumulative survival rate (off-pump vs on-pump, respectively; 77.7% vs 75.3%; p = 0.85), major adverse events-free survival rate (62.5% vs 55.6%; p = 0.27) and repeat revascularisation-free rate (84.8% vs 78.0%; p = 0.16) were not significantly different between the two groups. Revascularisation was the most common major adverse events in the JOCRIED participants. Although percutaneous coronary intervention was performed in 8 patients (13%) in the off-pump group and in 14 patients (23%) in the on-pump group (p = 0.23), no patients underwent redo coronary artery bypass grafting. Off-pump coronary artery bypass grafting provides comparable 15-year outcomes to on-pump coronary artery bypass grafting.

Redo Coronary Artery Bypass Grafting in the era of Advanced PCI.

Objective To review the evidence behind the role and relevance of redo coronary artery bypass grafting (CABG) in the current practice of percutaneous coronary intervention (PCI).Methods A comprehensive electronic literature search was performed to identify articles that discuss the practice of PCI and redo CABG in patients that require coronary revascularization. All relevant studies are summarized in narrative manner to reflect current indications and preference.Results The advancement in utilization of PCI has reduced the rate of redo CABG in patients with previous CABG that requires revascularization of an already treated coronary disease or a new onset of coronary artery stenosis. Redo CABG is associated with satisfactory perioperative outcomes but higher mortality at immediate postoperative period when compared to PCI.Conclusion Redo CABG patients are less likely to develop comorbidities associated with revascularisation, but the operative mortality is higher and long-term survival rates are similar in comparison to PCI. There is a need for further research into the role of redo CABG in the current advanced practice of PCI.

Immediate results of minimally invasive redo off-pump coronary artery bypass grafting

Coronary heart disease (CHD) ranks first among the causes of death from cardiac events. Patients who have previously undergone surgical treatment – coronary artery bypass grafting (CABG) – are not immune from the return of angina due to the progression of atherosclerosis in the native coronary arteries or degenerative changes in the shunts. Therefore, the issue of redo surgery in this group of patients is debatable.The aim of the research is to show that the use of alternative sternotomy approaches and the rejection of artificial blood circulation (ABC) are considered as possible measures to improve the results of redo CABGs.Materials and methods. In the Cardiac Surgery Unit No. 1 of the Irkutsk Regional Clinical Hospital from 2003 to 2020, 6773 off-pump CABG surgeries were performed. Of these, 6338 (93.6 %) surgeries were performed using median sternotomy and 435 (6.4 %) surgeries were performed using minitoracotomy or subxyphoid access. Of the 6338 CABG surgeries performed using sternotomy, 58 (0.9 %) were performed repeatedly. All redo surgeries during the period under review were performed by minithoracotomy or subxyphoid access. The indication for redo surgery was the return of angina of III or IV functional class, which did not respond to optimal drug therapy. When performing 54 redo surgeries, the access was leftsided mini-thoracotomy. In 3 patients, CABG was performed by subxyphoid access and in 1 patient – from right-sided mini-thoracotomy.Results. 58 redo CABG surgeries were performed. There was no damage to the access of the heart or functioning shunts. Complications were noted in 5 (8.6 %) patients. In 1 case, a second operation was required due to bleeding from the intercostal artery. In other cases, there were rhythm disturbances, or the need for inotropic support.Conclusion. Performing redo off-pump CABG surgeries using mini-accesses reduces the risk of damage to the heart and functioning shunts, eliminates manipulations on the ascending aorta, and avoids difficulties with cardioplegic protection of the myocardium with a functioning mammarocoronary graft.

Comparing one-year outcomes of invasive versus medical management of patients with prior coronary artery bypass graft surgery presenting with non-ST elevation myocardial infarction

Abstract Background Early percutaneous coronary intervention (PCI) has a Class 1A recommendation for patients with non-ST elevation myocardial infarction (NSTEMI). However, the benefits of this invasive approach in patients with previous coronary artery bypass graft (CABG) surgery are uncertain, as these patients have previously been excluded from pivotal trials. Purpose We hypothesised that routine invasive management in patients with previous CABG presenting with NSTEMI, but otherwise medically stable, carried similar prognostic outcomes to patients who were medically managed. Methods This single centre retrospective observational study screened patients with prior CABG presenting with NSTEMI between January 2015 and December 2019. Patients either underwent coronary angiography with or without PCI at their physician's discretion or received standard acute coronary syndrome (ACS) medical therapy. Follow up time was 365 days from admission date, and clinical, demographic, procedural and outcome data were collected. The primary endpoint was major adverse cardiac events (MACE), a composite of all-cause mortality and rehospitalisation for unstable angina, myocardial infarction, or heart failure. Results The study included 267 patients (mean ±SD age: 72±10 years, 82% male), of whom 80.1% (N=214) underwent cardiac catheterisation, and 19.9% (N=53) only received standard ACS medical therapy. Amongst the invasive group, 65.4% (N=140) received PCI. No one was referred for re-do CABG. At 1-year follow up, the primary composite outcome occurred in 18 (13%) patients in the PCI group, 13 (18%) in those managed conservatively following angiography, and in 27 (51%) patients receiving medical therapy only. Cox regression modelling showed no significant difference in the 1-year primary endpoint amongst those having an angiogram who received PCI versus those treated medically after invasive assessment (HR: 0.75 [95% CI: 0.38–1.48; P=0.412]). Previous revascularisation with PCI (HR: 1.90 [CI, 1.11–3.24; P=0.018]) and chronic kidney disease (CKD) (HR: 2.60 [CI, 1.56–4.34; P&amp;lt;0.001]) at any stage, were the most important predictors of poor outcomes in CABG patients with NSTEMI irrespective of management strategy. Conclusion Patients with previous CABG who are admitted with NSTEMI who were not considered suitable for invasive angiography experienced significantly higher rates of MACE at 1-year follow up. The presence of CKD or previous PCI were key indicators of poor outcomes irrespective of management strategy. Outcomes amongst those deemed fit enough for invasive angiography were similar irrespective of treatment, suggesting that additional non-invasive testing may help further define which patients would benefit from an invasive strategy. Funding Acknowledgement Type of funding sources: None.

A narrative review of redo coronary artery bypass grafting

A narrative review of redo coronary artery bypass grafting

MANAGEMENT OF EARLY GRAFT FAILURE POST CORONARY ARTERY BYPASS GRAFTING: A CASE REPORT

Background: Early postoperative graft failure after coronary artery bypass grafting (CABG) is still a significant problem that results in high morbidity and mortality. It is associated with early graft thrombosis, anastomotic stenosis, bypass kinks, overstretching or tension, significant spasm, and incomplete revascularization. Case Report: 67 years-old male with Coronary Artery Disease involving three vessels (CAD 3VD) underwent CABG surgery. Direct post-operation electrocardiograph (ECG) shown changes in ST segments (elevation on anterior leads and depression on inferior leads) with a significant increase of cardiac markers level. Post-operative coronary angiography revealed an occluded left internal mammary artery (LIMA) graft and native left anterior descending artery (LAD) blockage. Patients’ hemodynamics was not stable, and was urgently underwent an off-pump redo CABG. Intraoperatively we found thrombus at LIMA and saphenous vein graft (SVG) – right coronary artery (RCA) grafts that were caused by atheroma and dissection on anastomotic side. Discussion: The diagnosis of myocardial infarction (MI) remains a clinical challenge since patients are unable to express classic clinical symptoms. Routine ECG combined with cardiac biomarkers are beneficial in diagnosing MI post CABG, and percutaneous coronary angiography (PTCA) is useful in detecting the patency of the grafts. Although percutaneous coronary intervention (PCI) is preferable in the case of anastomosis problem with stable hemodynamic, redo CABG shows more benefit in salvaging infarcted myocardium in patients with unstable hemodynamic. Conclusion: Redo CABG surgery with new or additional grafting may save myocardium and preserve its function in perioperative infarct caused by graft failure.

Mid-Term Outcomes and Angiographic Patency of Redo Coronary Artery Bypass Grafting: A Comparison between Off-Pump and On-Pump Surgery

BackgroundWe evaluated the mid-term outcomes and angiographic patency of redo coronary artery bypass grafting (CABG).MethodsOf 2,851 patients who underwent isolated CABG at Seoul National University Hospital from 2000 to 2017, 88 underwent redo CABG. Patients’ mean age at redo CABG was 66.0±8.0 years. The mean interval between the first-time and redo CABG was 113.0±62.4 months. The mean follow-up duration was 86 months. Early and mid-term clinical outcomes were evaluated. Angiographic patency rates were evaluated early (1–2 days), 1 year, and 5 years after surgery. Comparative analyses between on-pump and off-pump CABG were also performed.ResultsThe culprits for reoperation were previous grafts (65.6%), native coronary vessels (17.8%), and both (16.7%). Off-pump CABG was performed in 75 cases (85.2%), and the mean number of distal anastomoses was 1.8±0.8. The saphenous vein (39.7%) was used most frequently, followed by the right internal thoracic artery (28.4%), right gastroepiploic artery (21.3%), left internal thoracic artery (7.8%), and radial artery (2.8%). Operative mortality was 1.1%. The overall survival, cumulative incidence of cardiac death, and cumulative incidence of major adverse cardiac events were 71.3%,12.0%, and 23.3% at 5 years after surgery, respectively. The overall angiographic patency rates were 95.7%, 90.1%, and 92.2% on early, 1-year, and 5-year angiograms, respectively. The angiographic patency rates of saphenous vein grafts were 93.1%, 85.6%, and 91.3% on early, 1-year, and 5-year angiograms, respectively. No significant differences in clinical outcomes or angiographic patency rates were observed between the on-pump (n=13) versus off-pump (n=75) groups. Multivariable analysis revealed that age (hazard ratio [HR], 1.07; p=0.005) and chronic kidney disease (HR, 3.85; p=0.001) were risk factors for all-cause mortality.ConclusionRedo CABG could mostly be performed using the off-pump technique and did not show increased operative mortality and morbidities.

Mid-Term Outcomes and Angiographic Patency of Redo Coronary Artery Bypass Grafting: A Comparison between Off-Pump and On-Pump Surgery

Mid-Term Outcomes and Angiographic Patency of Redo Coronary Artery Bypass Grafting: A Comparison between Off-Pump and On-Pump Surgery

Analysis of direct results of reoperative coronary artery bypass surgery

Aim. To compare the immediate results of treatment of patients after redo coronary artery bypass grafting (reCABG) off pump and with cardiopulmonary bypass.Methods. The retrospective study included 138 patients who underwent isolated reCABG for recurrence of angina pectoris in the period of 2013 to 2019 at the Almazov Research Centre. The operation was performed with cardiopulmonary bypass using isothermal blood cardioplegia in 74 cases (group A). Sixty-four operations were performed without cardiopulmonary bypass (group B). The primary endpoint was a major adverse cardiovascular event (e.g. myocardial infarction, acute cerebrovascular accident, cardiovascular death) during hospitalisation. Secondary endpoints were cardiovascular failure, respiratory failure, renal failure, and wound healing complications during hospitalisation.Results. Redo CABG with cardiopulmonary bypass compared with CABG off pump was more often complicated by cardiovascular failure (39.2% versus 20.3%, p = 0.043), respiratory failure (7.8% versus 2.7%, p = 0.047), and postpericardiotomy syndrome (13.5% versus 0%, p = 0.047). The revascularisation index was higher in the group of reCABG off pump (2.9) compared to the group of reCABG with cardiopulmonary bypass (2.4). In the early postoperative period there was a decrease in the duration of inpatient treatment and stay in the intensive care unit, the duration of surgery, as well as a lower incidence of postoperative complications in group B.Conclusion. Redo CABG showed satisfactory results in the early postoperative period. Performing reCABG off pump was advantageous and was associated with a decrease in the incidence of postoperative complications. Received 23 June 2020. Revised 9 September 2020. Accepted 10 September 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributions Conception and design: I.K. Ismail-zade, V.K. GrebennikData collection and analysis: I.K. Ismail-zade, D.G. Zavarzina, N.R. AbutalimovaDrafting the article: I.K. Ismail-zade, I.Yu. Ivanov, G.I. IshmukhametovCritical revision of the article: V.K. Grebennik, M.l. GordeevFinal approval of the version to be published: M.L. Gordeev, V.K. Grebennik, I.K. Ismail-zade, G.I. Ishmukhametov, I.Yu. Ivanov, N.R. Abutalimova, D.G. Zavarzina

Periprocedural and In-Hospital Outcomes Among Percutaneous Coronary Intervention in Saphenous Vein Graft: A Retrospective Observational Study at a Tertiary Care Hospital in South Asian Country.

BackgroundSaphenous vein graft (SVG) may occlude either early or several months to years after coronary artery bypass graft (CABG) surgery. Doing re-do CABG surgery is associated with higher complication and mortality rate as compared to percutaneous coronary intervention (PCI) in SVG. However, PCI of SVG is associated with more periprocedural and in-hospital complications as compared to PCI of native coronary arteries. Due to the scarcity of local data in this regard, this study was designed to estimate the periprocedural and in-hospital outcomes among PCI in SVG.ObjectivesWe aim to study the periprocedural and in-hospital outcomes among patients who underwent PCI in SVG.MethodsIt is a retrospective observational study. We reviewed hospital record files of 167 consecutive patients, admitted to Aga Khan University Hospital, Karachi, from January 2010 to December 2019, who underwent PCI in SVG.ResultsOut of 167 patients, 145 (86.8%) were male with a mean age of 72.26 (±8.46) years. Hypertension was the most common comorbid condition. Majority of 141(84.4%) patients presented within 6-10 years since the last CABG done. Seventy-eight (46.7%) patients presented with non-ST elevation myocardial infarction (NSTEMI). Patients who presented with acute coronary syndrome (ACS), 51 (36.9%), and 21 (15.2%) had congestive heart failure and cardiogenic shock on presentation respectively. Coronary angiography was performed in the majority of 155 (92.8%) patients through the femoral artery. The body of the SVG was the most common site affected by the disease. In 88 (52.7%) patients stents were deployed in SVG to obtuse marginal (OM). Drug-eluting stents (DES) were used in 124 (74.3%) patients. 22 (13.2%) of patients developed periprocedural complications, predominantly slow flow and 7 (4.2)% patients had in-hospital complications.ConclusionsPCI of SVG is associated with a high procedural success rate and acceptable risk for periprocedural and in-hospital complications. PCI of SVG may be considered as a safe and efficacious option for the percutaneous intervention of SVG lesions.

Aortic Valve Leaflet Disruption: A Severe Complication of Impella 5.5

A 73-year-old male with a history of severe coronary artery disease and prior coronary artery bypass grafting (CABG) presented with chest pain and elevated troponins. His workup revealed an ejection fraction of 15%, severe native coronary disease, as well as stenosis of his bypass grafts. He underwent a high-risk redo CABG with an Impella 5.5® (Abiomed, Danvers, MA) placement. The device was removed on postoperative day eight, at which time he went into cardiogenic shock from aortic valve leaflet injury. Given that he had no calcium deposits around the aortic valve annulus and severe aortic insufficiency, a multidisciplinary heart team decided he would be best served by a surgical aortic valve replacement. He was taken back to the operating room for a surgical aortic valve and intra-aortic balloon pump. His postoperative course was complicated by pneumonia, sepsis, and renal failure requiring continuous renal replacement therapy. He was discharged to a rehabilitation facility after 42 days. The following case encompasses the high morbidity risk of acute aortic valve insufficiency after Impella placement, never before documented in an Impella 5.5.

Off-pump versus on-pump redo coronary artery bypass grafting: a systematic review and meta-analysis.

Redo coronary artery bypass grafting (redo CABG) is associated with increased mortality and morbidity. The aim of this study was to systematically evaluate the evidence comparing the outcomes of off-pump with on-pump redo CABG. Studies were systematically searched and identified using PubMed, EMBASE, the Cochrane Library, and the International Clinical Trials Registry Platform (ICTRP) by two researchers independently. The primary outcome was 30-day mortality, and the secondary outcomes were in-hospital mortality, post-operative complications, completeness of revascularization, blood transfusion rate, duration of mechanical ventilation, intensive care unit and hospital stays. The 21 studies including 4,889 patients were enrolled in our meta-analysis. Compared with on-pump, the off-pump technique was associated with significantly reduced 30-day mortality (odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.26-0.72, p = 0.001). Moreover, a notably decreased in-hospital mortality (OR = 0.55, 95% CI = 0.39-0.76, p = 0.0004) and incidence of post-operative new-onset atrial fibrillation, myocardial infarction, acute kidney injury, low cardiac output state, blood transfusion rate (OR = 0.46, 95% CI = 0.35-0.60, p < 0.00001; OR = 0.54, 95% CI = 0.38-0.78, p = 0.0007; OR = 0.51, 95% CI = 0.37-0.70, p < 0.0001; OR = 0.31, 95% CI = 0.20-0.47, p < 0.00001; OR = 0.29, 95% CI = 0.14-0.61, p = 0.001) and significantly shortened duration of mechanical ventilation, intensive care unit and hospital stays (mean difference [MD] = -8.21 h, 95% CI = -11.74 to -4.68, p < 0.00001; MD = -0.77 d, 95% CI = -0.81 to -0.73, p < 0.00001; MD = -2.24 d, 95% CI = -3.17 to -1.32, p < 0.00001) could be observed when comparing the outcomes of off-pump with on-pump redo CABG. There was nonsignificant difference between off-pump and on-pump redo CABG in completeness of revascularization. In patients undergoing redo CABG surgery, the off-pump technique was associated with decreased mortality, less post-operative complications when compared to on-pump.