Standard Coronary Artery Bypass Grafting Research Articles

Bilateral versus single internal thoracic coronary artery bypass grafting: the ART RCT

Background There is debate whether the use of more arterial grafts during coronary artery bypass graft surgery provides advantages to the standard operation using the left internal thoracic artery plus vein grafts. We review data from the Arterial Revascularisation Trial to determine whether there is support for the multiple arterial graft hypothesis. Methods Patients undergoing coronary artery bypass graft for clinical reasons and who provided written informed consent were randomised to standard coronary artery bypass graft using the single internal thoracic artery or use of bilateral internal thoracic arteries. Additional vein grafts could be used. The primary outcome was all-cause mortality at 10 years and exploratory analyses were carried out to test the multiple arterial graft hypothesis. Results A total of 3102 patients were enrolled (1548 bilateral internal thoracic artery and 1554 single internal thoracic artery). Follow-up to 10 years for vital status was 98% complete. In the bilateral group, 14% of patients received a single internal thoracic artery only and use of radial artery grafts occurred in about 20% of patients in both groups. Aspirin was used in 81% of the patients, beta-blockers in 74%, statins in 90% and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 73%. At 10 years, death rates were 20.3% and 21.2% in the bilateral internal thoracic artery and single internal thoracic artery groups, respectively (hazard ratio 0.96, 95% confidence intervals 0.82 to 1.12; p = 0.62) and composite of all-cause mortality, myocardial infarction or stroke 24.9% and 27.3%, respectively (hazard ratio 0.90, 95% confidence interval 0.79 to 1.03; p = 0.12). Exploratory analyses using the ‘as-treated’ approach indicate that outcomes were better in patients who received multiple arterial grafts (adding the right internal thoracic and/or radial arteries) compared with a single arterial graft. This effect appeared to be greater in patients with diabetes and those aged 70 years or less. Use of total arterial grafting without vein grafts may provide the best outcomes. Limitations The elevated cross-over rate between bilateral internal thoracic artery and single internal thoracic artery and the non-randomised use of radial artery grafts may have contributed to a loss of power to detect a difference in mortality between the two groups. Moreover, secondary analyses are prone to bias as they compare non-randomised groups. Conclusions The Arterial Revascularisation Trial is one of the largest long-term studies in cardiac surgery. The primary analysis did not show a mortality benefit for bilateral internal thoracic artery at 10 years, perhaps due to high crossover rates in the bilateral internal thoracic artery group and concomitant use of the radial artery. Secondary analyses suggest a mortality benefit for patients receiving multiple arterial grafts compared with single arterial graft with possible greater effects in patients with diabetes and separately in patients aged 70 years or above. The trial will follow patients to 15 years and the continuing Randomized Comparison of the Clinical Outcome of Single versus Multiple Arterial Grafts trial will further test the multiple arterial graft hypothesis. Trial registration This trial is registered as ISRCTN46552265. Funding This project was funded by the British Heart Foundation, the UK. Medical Research Council and the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation programme and will be published in full in Efficacy and Mechanism Evaluation; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

Staged Hybrid Coronary Revascularization in Acute Coronary Syndrome

BackgroundIn acute coronary syndrome (ACS) with non-ST elevation myocardial infarction, there is a subgroup of patients who are difficult to treat; these are patients with a complex left anterior descending artery (LAD) lesion or a non-LAD culprit lesion but who are not suitable for standard coronary artery bypass grafting (CABG). Staged hybrid coronary revascularization (HCR), combining primary percutaneous coronary intervention on the non-LAD culprit lesion with CABG, represents an attractive solution. MethodsWe conducted a retrospective observational study to compare effectiveness and safety of HCR vs CABG alone. From December 6, 2016, to December 21, 2021, at our institution, 339 patients underwent urgent CABG with or without previous primary percutaneous coronary intervention; 65 received HCR (study group) and 274 received CABG alone (control group). Primary outcomes were major adverse cardiac and cerebrovascular events at 30 days and at long-term follow-up. Secondary outcomes were in-hospital postoperative complications. ResultsSignificant preoperative differences were detected in the mean EuroSCORE II: 3.4 (1.5-7.8) in HCR vs 2.5 (1.1-4.5) in CABG (P < .05). Patients in the CABG group needed more blood transfusions than patients in the HCR group (P = .004). Conversely, no other significant differences were detected for in-hospital postoperative complications. Survival analysis did not show significant differences between HCR and CABG, either to 30 days (hazard ratio, 0.51 [95% CI, 0.03-4.04]; P = .52) or to longer follow-up (maximum 5 years; hazard ratio, 0.40 [95% CI, 0.09-1.68]; P = .21). ConclusionsOur data support the safety and effectiveness of staged HCR in the scenario of ACS.

Abstract 11483: Rationale and Design of Randomized Controlled Trial Evaluating an Atrial Appendage Micrograft Transplantation in Conjunction With Coronary Artery Bypass Surgery

Introduction: In addition to the revascularization therapies for ischemic heart disease (IHD), such as coronary artery bypass grafting (CABG), tissue-engineered cell therapies can help further improve myocardial repair. First clinical results on autologous right atrial appendage-derived micrograft (AAM) transplantation have demonstrated excellent safety and feasibility profiles and suggested a therapeutic effect on myocardial viability. This randomized clinical trial aims to extend the evaluation of efficacy of AAMs transplantation when combined with CABG surgery. Methods and objectives: This double-blinded randomized controlled AAMS2 trial will assess the benefits, safety, and feasibility of the perioperatively assembled and epicardially transplanted AAMs-patch in conjunction with CABG. The trial recruits a total of 50 patients, half of which are randomized to receive the AAMs-patch (CABG+AAMs) and the other half to undergo a standard CABG. Prior to surgery, cardiac structure and function are assessed with late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMRI), electrocardiogram, and transthoracic echocardiography (TTE). LGE-CMRI, electrocardiogram, and TTE are repeated at 6-month follow-up for structural and functional comparisons to baseline. The primary endpoints focus on the efficacy of the AAMs patch as evaluated by LGE-CMRI and TTE as well as changes in health-related quality of life assessments, 6-minute walk test or N-terminal-pro-BNP levels. The secondary endpoints centre on feasibility and safety. For molecular and especially RNA-level analysis of the response to therapy in blood, RNA-stabilized whole blood and plasma samples are collected. Conclusions: The AAMS2 trial is expected to provide further feasibility and safety data as well as insights for efficacy of epicardial AAMs-patch transplantation when administered during CABG surgery.

Results of CABG Using Microsurgical Technique and Endarterectomy for Diffuse Lesions of the Coronary Arteries

Background. The number of patients (pts) with diffuse lesions among coronary artery bypass grafting (CABG) candidates has increased; they are expected to have worse results. Complex reconstructions, such as coronary endarterectomy (CEAE) and prolonged anastomoses with arteries less than 1.5mm in diameter, are being used more often. There is no sufficient evidence data and accepted guidelines for surgical treatment of this most complicated category of pts. Aim to evaluate the effectiveness of CABG with and without endarterectomy in pts with diffuse lesion and compare it with standard CABG in pts with local lesion. Materials and methods. In 20102017 CABG were performed in 2.927 pts. 1276 had diffuse coronary artery disease and in 154 cases the surgeon was forced to perform CEAE. After excluding 38 pts with comorbidities, the study group was formed (group 1, n = 116). We selected 2 equally large control groups with propensity score matching: from pts with diffuse lesion operated without CEAE (group 2, n = 116) and pts with local lesion operated as standard (group 3, n = 116). Cardiopulmonary bypass and microsurgical techniques were used. Hospital and long-term (up to 8 years; median follow-up of 60 (42; 74) months results were compared. The endpoints were all-cause and cardiac mortality, myocardial infarction (MI), angina recurrence and repeated revascularization. Results. In group 1 the frequency of perioperative MI was significantly higher compared to groups 2 and 3 (6.9% vs 0.7 and 0.7% resp, p 0.05) Hospital mortality was comparable in groups (p = 0.444). In the long-term period, the angina recurrence frequency was insignificantly lower in both control groups compared with the study group (p = 0.418). Autovenous grafts had significantly more dysfunctions compared with the internal thoracic artery grafts in symptomatic pts (57.5 versus 12.1%, p 0.05; odds ratio OR = 9.82; 95% CI: 3.2429.79). Also the severity of the target coronary artery lesion 4 points scaled by the diffuse lesion index were more frequent cause of graft dysfunction in this group (60.9 versus 41.6%; p 0.05; OR = 2.13; 95% CI: 1.134.24). Conclusion. Coronary endarterectomy is related to the high risk of perioperative myocardial infraction, while do not significantly increase the hospital mortality and adverse events in the long-term period. It should be considered to use coronary endarterectomy when there is no other option for surgery. The using of other adjunctive techniques demonstrate high efficiency in patients with diffuse lesions of the coronary arteries, comparable to surgery in patients with local lesion.

Deep Sternal Wound Infections after Coronary Artery Bypass Grafting: Analysis of 29 Cases from Iraq

Background: Deep sternal wound infection (DSWI), or mediastinitis, is a devastating complication of coronary artery bypass grafting (CABG). This prospective study aimed to assess our management of DSWI in view of the published literature. Methods: Over 2-years (ending in January 2016), 29 patients (20 males) developed DSWI amongst 520 patients who underwent standard CABG surgeries (5.6%). Pre-, intra- and postoperative variables were documented. Whenever possible, the infections were culture-verified. Besides antibiotics, patients received one or more of the following therapies: drainage, debridement, closed irrigation, sternal re-wiring, vacuum-assisted closure (VAC), and bone resection. Results: the male to female ratio was 2.2:1. Mean age was 58.1 ± 7.3 years. The mean body mass index (BMI) was 27.9 ± 3.4 kg/m2. There were 18, 16 and 11 patients with diabetes mellitus (DM), hypertension and chronic obstructive pulmonary disease (COPD) respectively. Cardiopulmonary bypass (CPB) was utilized in 26 (89.7%) patients with a mean time of 117.5 ± 23.3 minutes. Most surgeries (n = 21, 72.4%) lasted 5 - 6 hrs. According to Pairolero classification, there were 3 (10.3%) Type I, 22 (75.9%) Type II and 4 (13.8%) Type III infections. Four (13.8%) cases were culture-verified. Twenty-three (79.3%) DSWIs were surgically managed. Sternal re-wiring was performed in 14 (48.3%) cases while VAC was added to other therapies in 2 (6.9%) patients. DSWIs completely resolved in 18 (62.0%) patients within 3 - 24 weeks while two (6.9%) patients died within 30 days. Conclusion: We have identified six independent risk factors for DSWI (male gender, obesity, DM, hypertension, COPD and CPB), five of them are modifiable.

Robotic off-pump totally endoscopic coronary artery bypass in the current era: report of 544 patients.

Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years. Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization. The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%. We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

TERMINATION OF ANTIPLATELET AND ANTICOAGULANT THERAPY BEFORE CORONARY ARTERY BYPASS GRAFTING

The aim of the study is to analyze the peculiarities of the timing of discontinuation of antiplatelet and anticoagulant therapy before coronary artery bypass grafting. The study is based on a retrospective analysis of 194 patients who were discharged after coronary artery bypass surgery from M. Amosov National Institute of Cardiovascular Surgery, National Academy of Sciences of Ukraine for the period of 2009 - 2019. The average age of the patients was 64.2±8.9 years. All the patients underwent standard laboratory tests, coronary angiography and coronary artery bypass grafting. The analysis of the regimen of antiplatelet and anticoagulant therapy showed that 44 (22.6%) patients discontinued this medication 1 day before surgery. 86 (44.3%) patients were recommended to discontinue the medication within 2-5 days before coronary artery bypass grafting, 40 (20.6%) patients discontinued antithrombotic drugs 6-10 days before the operation. 11 (5.6%) patients did not received anticoagulants and antiplatelet agents before the operation. The majority of patients (67.01%) terminated antiplatelet therapy 1-5 days before the operation; intraoperative blood loss in average was 334.7±89.7ml. A correlation analysis between the regimen of antiplatelet / anticoagulant therapy and intraoperative blood loss revealed a negative relationship (r = -, 0.85). The patients who were on triple therapy before coronary artery bypass grafting underwent hemotransfusion in 75% of cases; among the patients who received dual antiplatelet therapy, blood transfusion was performed in 26.04% of cases, and patients who were on monotherapy with acetylsalicylic acid, blood products were transfused in 22,8% of cases. Conclusions: earlier withdrawal of antiplatelet agents before coronary bypass grafting is associated with fewer blood transfusions - when antithrombotic therapy was terminated 1 day before coronary artery bypass grafting, the frequency of blood transfusions was 36.3%, and among the patients who did not receive antiplatelet therapy before surgery, blood transfusion was performed in 18.1% of cases.

Timelines of Philhealth Z Benefit Package for Standard Risk Coronary Artery Bypass Graft (CABG) Surgery at the University of the Philippines- Philippine General Hospital

Objective. The study evaluates the clinical profile of patients who underwent coronary artery bypass graft surgery (CABG) under the Philippine Health Insurance Corporation (Philhealth) Z Benefit Package (PZBP), as well as time intervals between PZBP screening, approval, and timing of surgery.&#x0D; Methods. A review of medical records was done to collect data on time intervals between the screening process and Philhealth approval in CABG patients under PZBP. The clinical profile and surgical outcomes of patients were also evaluated.&#x0D; Results. Sixty-three patients were included from March 2017 to December 2018. Most patients were under 61-70 years old. Hypertension was the most commonly observed comorbidity. Time intervals were analyzed including identification for surgery to eligibility screening (2–217 days, median 25 days), Philhealth approval (8–266 days, median 20 days), and surgery (9-403 days, median 33 days). Postoperative atrial fibrillation was seen in 22.58%. The most commonly observed complication prolonging hospitalization was pneumonia.&#x0D; Conclusion. This is the first local study which evaluated the timelines of PZBP. Results may be use as basis of follow up study in the future for identification of an acceptable timeline intervals. Several modifiable factors affecting time intervals were identified for further improvement of healthcare services. The leading cause of increase length in hospitalization were HAP and AF.

Temporary spinal cord stimulation to prevent postoperative atrial fibrillation after coronary surgery. First results of the feasibility study

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia after cardiac surgery with typical appearance at early days after operation and leads to increase morbidity and mortality in the short and long term follow up. Spinal cord stimulation (SCS) was proven to be effective in chronic pain and intractable angina pectoris treatment. Recently, animal studies demonstrated that spinal cord stimulation could suppress AF and reduce AF burden. Aim To test safety and efficacy of the temporary SCS in early postoperative period in patients undergoing coronary artery bypass grafting Methods Fifteen patients (10 men, mean age 61±7.5 years) with indications for coronary artery bypass grafting (CABG) and history of paroxysmal AF underwent percutaneous lead placement for temporary SCS. Under local anesthesia and fluoroscopic guidance, the leads were placed at C7-Th4 level according to patient's sense of paresthesia and connected with spinal cord stimulator externally fixed on patient's chest. Temporary SCS was performed 3 days before CABG and turned off during surgery. At the end of CABG, the SCS was turned on in the intensive care unit and continued for 7 days. After that the temporary leads were removed. The primary safety objective was to test safety of the temporary SCS in early postoperative period, including 30 days occurrence of MACE (Death, stroke or TIA, myocardial infarction), acute spinal cord and kidney injury. The efficacy endpoint included occurrence of AF or any atrial tachyarrhythmias lasting ≥30 seconds during 30 days after surgery. All patients had continuous external ECG monitoring for 30 days after surgery. Results In all (100%) patients temporary leads for SCS were implanted successfully and standard on-pump elective CABG was performed thereafter. There were no any adverse events related to temporary SCS in either patient till the end of follow up. There were no significant differences in CK-MB and creatinine levels as compared with baseline data (p=0.2 and 0.3, respectively). No patients developed AF or atrial tachyarrhythmias during follow up according 30-days ECG monitoring. Conclusions The first results of the temporary spinal cord stimulation to prevent AF after coronary surgery demonstrated safety and efficacy of this therapy. The parallel group randomizes study is under way (NCT 03539354) Funding Acknowledgement Type of funding source: None

Long-term outcomes of off-pump minimally invasive coronary artery bypass grafting of the left anterior descending artery

Aim. To evaluate the long-term results of off-pump minimally invasive direct coronary artery bypass grafting (MIDCAB) of the left anterior descending artery (LAD).Methods. From 2011 to 2017, 146 patients with stable coronary artery disease and hemodynamically significant LAD disease who underwent minimally invasive coronary artery bypass grafting of the left internal mammary artery (LIMA) to the LAD were enrolled in this single-centre prospective study. Patients with significant stenosis of the left main coronary artery and those referred to a concomitant cardiac surgery were excluded. Of the 146 patients, 31 (19.8%) were lost to follow up. The average follow-up duration was 31.4 ± 20.9 mon. The study endpoints included death, myocardial infarction (MI), stroke, repeated myocardial revascularisation, and delayed wound healing.Results. The rate of fatal outcomes within the follow-up period was 6% (n = 7). The MI incidence rate was 2.6% (n = 3). Of the three MIs, one was fatal. Stroke was registered in 6% (n = 7) of the patients. In one case, the stroke was fatal; 1.2% (n = 2) of the patients required repeat PCI with stenting. The length of stay in the intensive care unit following the index surgery was 1.0 ± 0.2 d. Total 108 (73.9%) patients were discharged within 10 d. There were no complications of delayed wound healing.Conclusion. Thus, an analysis of the long-term treatment results (31.4 ± 20.9 months) showed satisfactory outcomes in patients with isolated LAD and multivascular coronary atherosclerosis, comparable to the results of standard coronary artery bypass grafting techniques. The survival rate of the patients was 94%, which, combined with the absence of wound complications in the hospital and the long-term follow-up period, provides evidence in favour of more active use of the MIDCAB technology as a popular option that allows successful revascularisation of the myocardium with minimally invasive access and off-pump technologies.Received 16 April 2020. Revised 28 May 2020. Accepted 29 May 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.

Invited Commentary

Advanced hybrid coronary revascularization (AHCR) marries the long-term patency and survival benefits of multiple internal mammary arterial grafts to the effectiveness of drug-eluting stents for residual stenoses among patients with complex left main and 3-vessel coronary artery disease. This technique affords patients a sternal-sparing approach, potentially allowing patients an earlier return to full activity while avoiding the risk of sternal wound complications associated with standard coronary artery bypass grafting (CABG). In this issue of The Annals of Thoracic Surgery, Balkhy and colleagues1Balkhy H.H. Kitahara H. Hirai T. Matsukage H. Nathan S. Residual SYNTAX score after advanced hybrid robotic totally endoscopic coronary revascularization.Ann Thorac Surg. 2020; 109: 1826-1833Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar report outcomes from their series of AHCR using multiple internal mammary arterial grafts and second-generation drug-eluting stents. Patients were evaluated by an experienced heart team that calculated baseline and residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) scores. Compared with open surgical revascularization, operative times were prolonged, but the authors should be congratulated for excellent early outcomes with no 30-day mortality, surgical site infection, perioperative stroke, or reexploration for bleeding. Another strength of the current study was the routine use of follow-up angiography, leading to a more comprehensive assessment of the completeness of revascularization. Incomplete revascularization has been more rigorously defined by the residual SYNTAX score (rSS). A key finding by Balkhy and associates1Balkhy H.H. Kitahara H. Hirai T. Matsukage H. Nathan S. Residual SYNTAX score after advanced hybrid robotic totally endoscopic coronary revascularization.Ann Thorac Surg. 2020; 109: 1826-1833Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar is that patients with increased rSSs (suggesting incomplete revascularization) were associated with higher mortality and major adverse cardiac events, which indicates the importance of complete revascularization to optimize clinical results in complex coronary artery disease. As the authors noted, however, it is difficult to elucidate whether these outcomes arise directly from incomplete revascularization, as this group did have greater comorbidities and the sample size was too small to allow for adjustments. Inferior outcomes have been associated with incomplete revascularization in previous studies of percutaneous coronary intervention, and standard CABG and hybrid coronary revascularization, particularly in patients on renal dialysis. When heart teams consider AHCR options, the concept of a “predictive rSS” for all possible revascularization options may guide the optimal treatment strategy. Each lesion should be assessed regarding the feasibility of both percutaneous coronary intervention and CABG and hypothetical rSSs, presuming the failure of various revascularization strategies could be calculated. In this fashion, heart teams could assess revascularization options based on predictive “worst case” scenarios and their presumed likelihood, providing insight into the potential best strategy. To date, only one randomized controlled trial has been conducted.2Gąsior M. Zembala M.O. Tajstra M. et al.Hybrid revascularization for multivessel coronary artery disease.JACC Cardiovasc Interv. 2014; 7: 1277-1283Crossref PubMed Scopus (89) Google Scholar Although underpowered for long-term outcomes and lacking protocol-driven angiographic follow-up, reduced perioperative complications were demonstrated with an increased risk of long-term revascularization. Inclusion of large observational studies in meta-analyses has also demonstrated similar results.3Nolan S. Filion K.B. Atallah R. Moss E. Reynier P. Eisenberg M.J. Hybrid coronary revascularization vs. complete coronary artery bypass grafting for multivessel coronary artery disease: a systematic review and meta-analysis.J Invasive Cardiol. 2018; 30: E131-E149PubMed Google Scholar The effectiveness of AHCR can only be ascertained through a multicenter prospective randomized controlled trial of complex revascularization comparing standard CABG with AHCR. Ideally, this study would assess the differences in initial surgical complications along with long-term major adverse cardiac events and revascularization rates and include a cohort of protocol-driven angiographic follow-up to ascertain the mode of revascularization failure. The future for AHCR remains bright, but will rely heavily on experienced heart teams. With persistence in continued training, the development of simplified robotic techniques, and appropriate funding for dedicated prospective clinical trials to determine which patient subsets benefit most, AHCR may ultimately be proven to be the best approach for many patients to improve outcomes and minimize complications. Residual SYNTAX Score After Advanced Hybrid Robotic Totally Endoscopic Coronary RevascularizationThe Annals of Thoracic SurgeryVol. 109Issue 6PreviewAdvanced hybrid coronary revascularization (AHCR) combines multivessel robotic beating-heart totally endoscopic coronary artery bypass with percutaneous coronary intervention. The aim of this study was to quantify the remaining coronary artery disease after AHCR using the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) study score. Full-Text PDF

The feasibility of surgical patch osteoplasty in isolated left main coronary stenosis.

Background: Coronary artery bypass grafting (CABG) is perceived as the most common treatment for left main coronary artery (LMCA) disease with good results compared to left-main stenting or medical therapy. Surgical patch angioplasty (SPA) may present a substitute to the standard CABG in patients with isolated LMCA disease, and it offers physiological antegrade myocardial perfusion, keeps ostial patency and saves bypass material. The objective of this study is to demonstrate the feasibility of patch osteoplasty in patients with isolated LMCA stenosis.&#x0D; Methods: This is a retrospective study performed on eight patients with angiographically proven ostial or proximal LMCA stenosis who underwent surgical patch angioplasty. Two of them had associated right coronary artery bypass grafting. All patients were performed with cardiopulmonary bypass and saphenous vein patch. An anterior approach with transverse aortotomy was utilized in all cases. Patients were followed-up clinically for a mean period of 14 months (ranging from 26 to 6 months) for recurrence of symptoms and any postoperative complications.&#x0D; Results: The early postoperative period was uneventful in all patients. No perioperative mortality was reported. Two patients had postoperative atrial fibrillation, and one patient with poor left ventricular function required preoperative intra-aortic balloon pump. Angiography was done in the first three cases, and all showed no restenosis and no vein patch dilatation.&#x0D; Conclusion: Surgical patch angioplasty may be a safe and suitable alternative to CABG in selected patients with isolated ostial LMCA stenosis. Further studies are needed to compare the results of the SPA with those of standard CABG and LMCA stenting.

Initiation and modification of minimally invasive coronary artery bypass grafting

Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy has been proposed as an alternative to standard coronary artery bypass grafting. However, this technique is still limited to skillful surgeons. Off-pump multi-vessel bypass grafting and the use of bilateral internal thoracic arteries are particularly challenging via a small thoracotomy, while they are widely performed via a full median sternotomy. The purpose of this review is to serve as a guide for the proper introduction of MICS CABG in the current era. We examine the advances, current techniques, outcomes and learning curves of MICS CABG and discuss the safe introduction.

Hybrid myocardial revascularization.

In patients with advanced coronary artery disease (CAD), coronary artery bypass grafting (CABG) is associated with improved long-term outcomes while percutaneous coronary intervention (PCI) is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach, hybrid myocardial revascularization (HMR).Three strategies for timing of the hybrid revascularization exists, each with their own inherent advantages and shortcomings: (1) CABG followed by PCI, (2) PCI followed by CABG, or (3) simultaneous CABG + PCI in a hybrid suite. The results of the first randomized control trial comparing HMR (CABG first) and standard CABG, POL-MIDES (Prospective Randomized PilOt Study EvaLuating the Safety and Efficacy of Hybrid Revascularization in MultIvessel Coronary Artery DisEaSe), show HMR was feasible for 93.9% of patients whereas conversion to standard CABG was required for 6.1%. At 1year, both groups had similar all-cause mortality (CABG 2.9% vs. HMR 2%) and major adverse clinical event (MACE)-free survival rates (CABG 92.2% vs. HMR 89.8%). Results of observational and comparative studies show that minimally invasive HMR procedures in patients with multivessel CAD carry minimal perioperative mortality risk and low morbidity and do not increase the risk of postoperative bleeding. The advantage they offer in comparison to classical surgical revascularization is indeed faster rehabilitation and patient's return to normal life. Hybrid myocardial revascularization has been developed as a promising technique for the treatment of high-risk patients with CAD. Hybrid revascularization using minimally invasive surgical techniques combined with PCI offers to a part of patients an advantage of optimal revascularization of the most important artery of the heart, together with adequate myocardial revascularization in a relatively delicate way. Indeed, to patients with high operative risk of standard surgery, it offers an alternative which should be considered carefully.

On-Pump Coronary Artery Bypass Grafting in a Patient With Renal Transplant and Familial Hypercholesterolemia

A 19-year-old male patient presented to the cardiology clinic with complaints of chest pain during efforts for a month. He had a renal transplantation when he was 12 years old. He had been diagnosed with familial hypercholesterolemia. On-pump coronary artery bypass grafting (CABG) surgery (LIMA-LAD, DI, Cx (OMI), RCA (PD)) was performed. On-pump CABG can be performed successfully in patient with renal transplant. However, renal recipients have higher risk of infection and renal damage compared with patients without transplants. In addition, as in our case, familial hypercholesterolemia would affect the clinical outcome negatively. I would like to think the sensitivity and close follow-up in standard CABG cases, and it should be applied to the highest level in such patients. J Med Cases. 2018;9(1):8-10 doi: https://doi.org/10.14740/jmc2878w

On-Pump Coronary Artery Bypass Grafting in a Patient With Renal Transplant and Familial Hypercholesterolemia

A 19-year-old male patient presented to the cardiology clinic with complaints of chest pain during efforts for a month. He had a renal transplantation when he was 12 years old. He had been diagnosed with familial hypercholesterolemia. On-pump coronary artery bypass grafting (CABG) surgery (LIMA-LAD, DI, Cx (OMI), RCA (PD)) was performed. On-pump CABG can be performed successfully in patient with renal transplant. However, renal recipients have higher risk of infection and renal damage compared with patients without transplants. In addition, as in our case, familial hypercholesterolemia would affect the clinical outcome negatively. I would like to think the sensitivity and close follow-up in standard CABG cases, and it should be applied to the highest level in such patients. J Med Cases. 2018;9(1):8-10 doi: https://doi.org/10.14740/jmc2878w

An analysis of postoperative cognitive dysfunction in different methods of coronary artery bypass

To evaluate changes in cognitive functions in patients with coronary heart disease before and after coronary artery bypass grafting (CABG) in a planned manner. The study included 192 patients divided into 3 groups: in group 1 patients (n=88) underwent standard CABG; in group 2 (n=61) different methods of CABG were used; a control group consisted of 43 people. MMSE, FAB, Clock drawing test, Shultz tables, semantic verbal fluency, Wechsler adult intelligence scale were used for neurological testing. Postoperative cognitive dysfunction develops 3.2 times more often in patients after standard CABG. Patients in the group with a differentiated approach show a trend towards the improvement of cognitive functions after surgery.

Early Clinical Outcomes and Mortality of Coronary Endarterectomy in the Left Anterior Descending Artery: A Single-Center Experience

Introduction: Although coronary endarterectomy is not an ideal procedure, it is the only available option for cardiac surgeons in some patients with diffuse coronary artery disease. Based on the majority of conducted studies, the results of coronary endarterectomy (including survival, graft patency, and recurrence of the symptoms of myocardial ischemia) are less prevalent than standard coronary artery bypass grafting. Generally, the left anterior descending artery (LAD) is the most commonly involved artery in coronary endarterectomy. The aim of this study was evaluate clinical and early results of Endarterectomy of LAD artery. Materials & Methods: In total, 30 cases of coronary endarterectomy of the LAD were studied from January 2015 until January 2016.this is a retrospective study that Endarterectomy procedure was performed in Imamreza hospital of Mashhad university of medical sciences. Results: The mean age of the subjects was 63±4.5 years (range: 45-78 years). As the findings revealed, eighteen patients were male (60%), and the mean ejection fraction index was 43±5.1 (range: 15-60). Also, prior history of myocardial infarction was documented in 8 (26%) patients. The mortality rate among patients was estimated at 6.6% (n=2). In total, 12 (40%) and 7 (23%) patients required high-dose inotropic support and intra-aortic balloon pump, respectively. Risk of preoperative myocardial infarction was observed in 5 (16.5%) cases, and 3 (10%) patients required re-exploration due to significant hemorrhage. Conclusion: If coronary endarterectomy of the LAD is performed by experienced cardiac surgeons, favorable outcomes can be obtained.

Pretreatment with methylprednisolone improves myocardial protection during on-pump coronary artery bypass surgery.

This study was undertaken to determine whether methylprednisolone could improve myocardial protection by altering the cytokine profile toward an anti-inflammatory course in patients undergoing elective coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB). Forty patients who were scheduled for elective CABG surgery were randomized into two groups: the study group (n = 20), who received 1 g of methylprednisolone intravenously before CPB, and the control group (n = 20), who underwent a standard CABG surgery without any additional medication. Blood samples were withdrawn prior to surgery (T1) and then 4 hours (T2), 24 hours (T3), and 36 hours (T4) after CPB. Plasma levels of interleukin (IL)-6, IL-10, creatine kinase isoenzyme MB (CK-MB), cardiac troponin-t (cTnT), and blood glucose as well as neutrophil counts were measured at each sampling time. A comparison of patients between both groups revealed significantly high levels of IL-6 in the control group at T2, T3, and T4 with respect to T1 (T2: P &lt; .001; T3: P &lt; .001; T4: P &lt; .001). IL-10 levels were significantly higher in the study group at T2 compared with the control group (P = .007). CK-MB levels were significantly lower in the study group than in the control group at T4 (P = .001). The increase of cTnT was higher in the control group at T3 and T4 compared with the study group (T3: P = .002; T4: P = .001). This study demonstrates that methylprednisolone is effective for ensuring better myocardial protection during cardiac surgery by suppressing the inflammatory response via decreasing the levels of IL-6 and by increasing anti-inflammatory activity through IL-10.

Usefulness of Colchicine to Reduce Perioperative Myocardial Damage in Patients Who Underwent On-Pump Coronary Artery Bypass Grafting

The objective of the present study was to test whether a perioperative course of colchicine, in patients who underwent standard coronary artery bypass grafting, would result in reduced postoperative increase of myocardial injury biomarker levels. Patients were prospectively randomized to colchicine or placebo starting 48 hours before scheduled coronary artery bypass grafting and for 8 days thereafter (0.5 mg twice daily). The primary outcome parameter was maximal high-sensitivity troponin T (hsTnT) concentration within 48 hours after surgery. Secondary outcome measures were maximal creatine kinase-myocardial brain fraction (CK-MB) levels and area under the curve (AUC) of hsTnT and CK-MB concentrations; 59 patients were included. Maximal hsTnT was 616 pg/ml (396 to 986) in the colchicine group versus 1,613 pg/ml (732 to 2,587) in controls (p = 0.002). Maximal CK-MB was 44.6 ng/ml (36.6 to 68.8) and 93.0 ng/ml (48.0 to 182.3), respectively (p = 0.002). The median AUC for hsTnT was 40,755 pg h/ml (20,868 to 79,176) in controls versus 20,363 pg h/ml (13,891 to 31,661) in the colchicine group (p = 0.002). AUCs for CK-MB were 2,552 ng h/ml (1,564 to 4,791) in controls and 1,586 ng h/ml (1,159 to 2,073) in the colchicine group (p = 0.003). The main complaints associated with colchicine were, as expected, gastrointestinal, with 5 patients (16.7%) in the colchicine group reporting diarrhea versus 1 control (3.4%) (p = 0.195). In conclusion, a short perioperative course of colchicine was effective in attenuating postoperative increases of hsTnT and CK-MB compared with placebo. This finding, which needs confirmation in a larger clinical trial powered to assess clinical endpoints, suggests a potential role for this agent in reducing cardiac surgery-related myocardial damage.