Subsequent Coronary Artery Bypass Grafting Research Articles

Pre-Operative Serum Uric Acid Level is a Predictor of Acute Kidney Injury Subsequent off Pump Coronary Artery Bypass Grafting

Pre-Operative Serum Uric Acid Level is a Predictor of Acute Kidney Injury Subsequent off Pump Coronary Artery Bypass Grafting

*A Novel ABCG8 Variant and Apo(A) Short Isoform Associated with Premature Atherosclerosis and Familial Hypercholesterolemia Phenocopy.

Lead Author's Financial Disclosures Nothing to disclose. Study Funding None. Background/Synopsis We report a patient with a rare ABCG8 mutation, that when combined with Apo(a) short isoforms may represent a familial hypercholesterolemia (FH) phenocopy. Objective/Purpose A 44-year-old African American male with prior myocardial infarction (MI) at the age 24 with subsequent coronary artery bypass graft who had rapid progression of atherosclerosis despite having a corrected LDL of zero. Methods Lp(a) was 127 mg/dL and LDL was 40 mg/dL and he had been on evolocumab and rosuvastatin. The corrected LDL accounts for the cholesterol contained in Lp(a) using the formula LDLcorr =LDL- 0.3x Lp(a) mass. Thus, his LDLcorr was zero. He underwent genetic testing with GBinsight which demonstrated he had Apo(a) short isoforms, which is associated with elevated Lp(a). He was also heterozygous for an extremely rare ABCG8 variant p.Gly212Glu (rs1318623110) which has not been previously reported. This variant is predicted to be deleterious and Gly212 is highly conserved across vertebrates. Mutations in ABCG5 or ABCG8 can be associated with increased LDL and risk for CAD. In addition, elevation of Lp(a) can be associated with 3 to 4 folds increased risk. This novel mutation, along with the elevated Lp(a) may help to explain his FH phenocopy presentation. Results We hypothesized that his premature disease progression may have been secondary to inflammation, atherogenesis or prothrombosis associated with Lp(a) with the added potentially deleterious effect of the ABCG8 mutation. His clinical course with his first MI at age 24 mimics that of FH, thus making him a phenocopy. We enrolled him in the randomized Lp(a)HORIZON trial evaluating the effect of pelacarsen in lowering Lp(a). However, he subsequently had an episode of unstable angina requiring additional intervention. Conclusions When assessing patients with suspected FH, mutations in genes other than LDLR, APOB, and PCSK9 should be evaluated. In this case, a mutation in ABCG8 gene along with Apo(a) short form isoforms may help explain the patient's disease progression and FH phenocopy presentation. In addition, ezetimibe may be beneficial in patients with ABCG5/8 mutation. His marked disease progression despite having a LDLcorr of zero highlights the importance of considering factors other than just LDL. Nothing to disclose.

Outcomes of Coronary Artery By-Pass Grafting Under Dual Antiplatelet Therapy in ST Elevated Myocardial Infarction.

Patients with recent myocardial infarction (MI) or percutaneous coronary interventions (PCI) have a higher ischemic risk in addition to perioperative bleeding risk when undergoing coronary artery bypass grafting (CABG). Data regarding preoperative dual antiplatelet therapy (DAPT) failed to create a clear recommendation. In the present study, we assessed the relationship between preoperative DAPT use and adverse outcomes, particularly in ST-elevation MI (STEMI) patients. We retrospectively analyzed 748 consecutive patients with STEMI who underwent subsequent CABG surgery. Patients were divided into 2 groups: those on DAPT up to the day before CABG and those discontinued DAPT >5days before CABG. Predictors of in-hospital mortality and major bleeding were analyzed by multivariate analysis. Preoperative DAPT was not associated with in-hospital mortality (Odds Ratio (OR):1.81; 95% Confidence Interval (CI): .89-3.68, P = .10) and major bleeding (OR: 1.15; 95% CI: .63-2.08, P = .65) after multivariate analysis. However, glycoprotein (Gp) 2b/3a inhibitors were independently associated with higher major bleeding rates. Age, shock, and EF (ejection fraction) <30% were associated with in-hospital mortality. Previous MI, Gp 2b/3a inhibitors, and EF <30% were predictors of major bleeding. In conclusion, there were no association between pre-CABG DAPT use and in-hospital mortality and major bleeding.

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study

BackgroundWith increasing surgical workload, it is common for cardiac surgeons to perform coronary artery bypass grafting (CABG) after other procedures in a workday. To investigate whether prior procedures performed by...

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

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

Effect of Multiple Prior Percutaneous Coronary Interventions on Outcomes After Coronary Artery Bypass Grafting.

The effect of multiple prior percutaneous coronary interventions (PCIs) before subsequent coronary artery bypass grafting (CABG) on long-term outcomes has not been well elucidated.Methods and Results:Between 2007 and 2016, 1,154 patients undergoing primary isolated CABG in our institution had no prior PCI (Group N), 225 had a single prior PCI (Group S), and 272 had multiple prior PCIs (Group M). Cumulative incidences of all-cause death, cardiac death and myocardial infarction (MI) at 10 years post-CABG were highest in Group M. After adjusting for confounders, the risk of all-cause death was higher in Group M than in Group N (hazard ratio [HR] 1.45; 95% confidence interval [CI], 1.10-1.91; P<0.01). Between Groups N and S, however, the risk of all-cause death was not different. The risks of cardiac death and MI were likewise higher in Group M than in Group N (HR, 2.39; 95% CI, 1.55-3.71; P<0.01 and HR, 3.65; 95% CI, 1.16-11.5; P=0.03, respectively), but not different between Groups N and S. The risk of repeat revascularization was not different among any of the groups. Multiple prior PCIs was associated with higher risks of long-term death and cardiovascular events. The incidence of repeat revascularization after CABG was low regardless of the history of single/multiple PCIs.

There is a low rate of major adverse cardiovascular events in chest pain patients with a moderate risk heart score referred from urgent care for expedited outpatient cardiology evaluation: a multi-center study

Background The HEART score is an effective method of risk stratifying emergency department (ED) patients with chest pain. The rate of major adverse cardiovascular events (MACE) in patients with moderate HEART score referred from an urgent care (UC) for an expedited outpatient cardiology evaluation for 11 months was described in 133 patients in a previous study. This is a follow-up study with 18 months of data and 206 patients.Aim. The primary outcome was to examine the rate of MACE when patients with moderate HEART score were referred for an expedited outpatient cardiology follow-up after evaluation in urgent care. The secondary outcome was to determine if there is a decrease in rate of ED transfer after this protocol was introduced.Methods. A cross-sectional study was conducted by a multispecialty group in Las Vegas, Nevada, which included 206 patients with a HEART score of 4 to 6 (i.e.: moderate risk) who presented to one of five UC centers with chest pain or an anginal equivalent. A streamlined evaluation protocol to assess each HEART score component was adopted by all UC providers to facilitate an expedited outpatient cardiology follow-up, as an alternative to referral to the emergency department. Data was collected from February 14, 2019 through August 13, 2020. The population was followed for 6 weeks with a primary endpoint of MACE determined by electronic medical record review and direct phone contact with patients. Outcomes were confirmed in 98% of patients. Chest pain transfer data was compared between 12 months prior to implementing HEART protocol and 18 months of data analysis while using the new protocol.Results. Over the course of 18 months, 206 patients with a moderate risk HEART score were referred to outpatient cardiology in an expedited manner. The average age was 65 with 53% female and 47% male patients. 150 patients (73% of the 206) were seen within 3 days, 114 (55%) underwent stress testing, 6 (3%) had coronary computed tomography angiogram, and 6 (3%) received an invasive coronary angiogram. Five patients were found to have MACE: one patient who had a non-ST-elevation myocardial infarction and subsequent coronary stent, two patients were found to have obstructive disease after coronary angiography with subsequent coronary artery bypass graft, one patient had an abnormal stress test and subsequent coronary stent, and one patient had critical mitral stenosis, multi-vessel coronary artery disease and underwent coronary artery bypass graft with mitral valve replacement with complications of renal failure and COVID-19 and expired. The emergency department referral rate declined by 21%.Conclusion. Patients with a moderate risk HEART score referred from UC for an expedited outpatient cardiology evaluation had a low rate of MACE and no deaths due to delay of care. There was also a significant decrease in the rate of ED referrals.

Over Ten Years' Follow-Up of Chronic Total Coronary Occlusion Angioplasty

ObjectivesIt has been reported that successful percutaneous coronary intervention for chronic total occlusion (CTO-PCI) might be associated with symptom relief, a lower rate of subsequent myocardial infarction and coronary artery bypass graft surgery, and improved long-term survival, compared with unsuccessful PCI for CTO. However, the long-term benefit of percutaneous recanalization of CTO remains unclear. Therefore, we aimed to evaluate the long-term benefit of percutaneous recanalization of CTO. MethodsWe analyzed consecutive cases of CTO-PCI performed between January 2000 and December 2006. The health status of all patients on September 2017 was obtained via letter or from medical records. We collected relevant patient information as well as angiographic and procedural characteristics. ResultsA total of 477 patients (82.8% men, mean age, 65.7 years) underwent CTO-PCI. The procedural was successful in 382 cases (80.3%). Reference vessel diameter, occlusion length and angiographic stump of CTO site were associated with the success of CTO intervention. During the mean follow-up period of 139.8 months, successful CTO-PCI was associated with a higher survival rate when compared with failed CTO-PCI (Log-rank test: P = 0.0147). When categorized by target vessel, successful revascularization of left anterior descending (LAD) -CTO improved long-term survival (Log-rank test: P = 0.0041). On the other hand, successful revascularization of right coronary artery or left circumflex -CTO was not associated with improved long-term survival [Log-rank test: P = 0.5631 (RCA), P = 0.2774 (LCX)]. ConclusionsSuccessful CTO-PCI, especially the successful revascularization of LAD-CTO, improved long-term survival of patients.

Effect of previous coronary stenting on subsequent coronary artery bypass grafting outcomes

ObjectivesThe effect of previous coronary stenting on subsequent coronary artery bypass graft is inconclusive. MethodsWe used Taiwan's National Health Insurance Database to retrospectively evaluate patients with multivessel coronary artery bypass graft between January 2000 and December 2013. Overall, 32,335 patients who received coronary artery bypass graft were included, of whom 3028 had previous coronary stenting. Propensity-score matching yielded 2977 cases each for evaluation under the previous stenting and no stenting groups. The 30-day mortality and major adverse cardiac events, including all-cause mortality, acute myocardial infarction, and revascularization, were considered primary outcomes. ResultsThe number of coronary artery bypass grafts decreased per year. However, the percentage of patients who had previous coronary stent implantation before coronary artery bypass graft increased steadily (P for trend <.001), and the average number of stents implanted in a patient also increased per year (P for trend <.001). The previous stent group had a significantly greater 30-day mortality rate than did the no-stent group (7.2% vs 5.0%; odds ratio, 1.47; 95% confidence interval, 1.19-1.82). The previous stent group had a greater rate of revascularization (14.4% and 10.0%; subdistribution hazard ratio, 1.50; 95% confidence interval, 1.30-1.74) in the last follow-up at year 13. ConclusionsPrevious coronary stenting before coronary artery bypass graft for multivessel coronary artery disease significantly increased 30-day mortality but did not affect late survival. However, patients who had coronary stenting before coronary artery bypass graft experienced more revascularization events during late follow-up.

Successful Repeat Transcatheter Mitral Valve Replacement After Late Prosthesis Failure

An 80-year-old woman on oral anticoagulation therapy, with previous mitral valve reconstruction, subsequent coronary artery bypass grafting with aortic and mitral valve (29-mm Mosaic, Medtronic, Dublin, Ireland) replacement, and 10 years later, transcatheter mitral valve replacement (TMVR) with a 26

Invited Commentary

Invited Commentary

An Unexpected Cause of Iron Deficiency Anemia: Synchronous Development and Diagnosis of a Rare Gastric Collision Tumor

A 75-year-old man with diabetes and hypertension presented with chest pain and was found to have a ST-elevation myocardial infarction. He was taken to the cardiac catheterization lab for coronary angiography. Following the procedure, he described a several week history of post-prandial epigastric discomfort, for which he was taking naproxen. He denied symptoms of gastrointestinal bleeding. Laboratory data showed iron deficiency anemia (ferritin: 15 ng/mL, hemoglobin: 11.3 g/dL). Esophagogastroduodenoscopy (EGD) demonstrated an irregular, linear, non-bleeding 3 cm ulcer in the stomach body extending into the antrum with a hard consistency (Figure 1), as well as an irregular, cratered, non-bleeding 3 cm ulcer in the gastric cardia with heaped-up margins (Figure 2). Biopsies of the ulcer in the body revealed an invasive moderately differentiated gastric adenocarcinoma (Figure 3, top left and right). Biopsies of the ulcer in the cardia revealed diffuse large B-cell lymphoma (Figure 3, bottom left and right). Histopathology was negative for Helicobacter pylori (H. pylori). The patient underwent subsequent coronary artery bypass grafting and is following with an oncologist for further management. The EGD and histopathologic findings demonstrated synchronous development of a rarely reported collision tumor: gastric adenocarcinoma and diffuse large B-cell lymphoma, each having a distinct endoscopic appearance. Synchronous tumors in the stomach are uncommon. The majority of synchronous malignancies are gastric adenocarcinomas and mucosa associated lymphoid tissue (MALT) lymphomas.1 There have been less than 10 known published reports of the synchronous development of gastric adenocarcinoma and diffuse large B-cell lymphoma.1 This case is also unusual, as H. pylori was not detected on histology. This vignette is significant both for the rarity of the final diagnoses, as well as the reminder that the practicing gastroenterologist provide a thorough endoscopic examination and perform appropriate mucosal sampling, even in the presence of an already identified abnormality. These malignancies would likely have been diagnosed at a later stage had the patient not presented with acute coronary syndrome and undergone endoscopic evaluation for iron deficiency anemia.Figure: Gastric Body Adenocarcinoma.Figure: Gastric Cardia Diffuse Large B-Cell Lymphoma.Figure: Clockwise, from Top Left: Gastric Body Adenocarcinoma (H&E stain, 40x), Invasive Neoplastic Glands (H&E stain, 200x), Gastric Cardia Large Cell Lymphoma (H&E stain, 400x), Diffuse B-Cell Infiltrates Entrapping Benign Gastric Glands (H&E stain, 40x).

Impact of prior coronary stenting on the outcome of subsequent coronary artery bypass grafting

BackgroundThe percentage of patients referred for coronary artery bypass grafting (CABG) who have previously undergone percutaneous coronary interventions (PCIs) is increasing. The purpose of this study was to review the outcomes of patients who had received coronary stenting before CABG, and to examine the validity of a mortality risk stratification system in this patient group. MethodsFrom 2010 to 2012, 439 patients who underwent isolated CABG at our medical center were reviewed. The patients were divided into two study groups: those who had previously received coronary artery stenting (97 patients, 24.7%), and those who had not (342 patients, 75.3%). The patients who received balloon angioplasty were excluded. ResultsThere were no significant differences in baseline characteristics. The prior stenting group had a lower risk of mortality, although the difference was not significant. The prior stenting group had fewer graft anastomoses (p = 0.005), and hence a significantly shorter cardiopulmonary bypass time (p = 0.045) and shorter aortic cross-clamping time. Surgical mortality was similar between the two groups. The durations of intensive care unit stay and hospitalization were also similar. The discriminatory power of the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was lower in both group. ConclusionsPrior coronary stenting does not affect short-term mortality in patients subsequently undergoing CABG surgery. The EuroSCORE does not predict perioperative mortality well for the patients who undergo coronary stenting before CABG.

Contemporary Incidence, Management, and Long-Term Outcomes of Percutaneous Coronary Interventions for Chronic Coronary Artery Total Occlusions: Insights From the VA CART Program

ObjectivesThe aim of this study was to describe the contemporary incidence of chronic total occlusions (CTOs) and the success rates of CTO percutaneous coronary intervention (PCI), as well as the complications and long-term outcomes of these patients. BackgroundThe contemporary prevalence and management of coronary CTOs is understudied. MethodsConsecutive veterans undergoing coronary angiography at 79 Veterans Affairs sites between 2007 and 2013 were examined. Detailed baseline clinical, angiographic, and follow-up outcomes were evaluated using national data from the Veterans Affairs Clinical Assessment Reporting and Tracking program. ResultsAmong 111,273 patients with obstructive coronary artery disease, 29,399 (26.4%) had ≥1 CTO, most commonly in the right coronary artery distribution (n = 18,986 [64.6%]). Elective CTO PCI was attempted in 2,394 patients (8.1%), with a procedural success rate of 79.7%. The odds of CTO PCI success increased over the years of the study (odds ratio: 1.08; 95% confidence interval [CI]: 1.01 to 1.16; p = 0.03). Compared with failed CTO PCI, successful CTO PCI was associated with a decreased adjusted risk for mortality (hazard ratio: 0.67; 95% CI: 0.47 to 0.95; p = 0.02) and coronary artery bypass graft surgery (hazard ratio: 0.14; 95% CI: 0.08 to 0.24; p < 0.01) at 2 years but no significant change in the risk for hospitalization for myocardial infarction (hazard ratio: 0.89; 95% CI: 0.58 to 1.36; p = 0.58). ConclusionsApproximately 1 in 4 patients with obstructive coronary artery disease on coronary angiography had CTOs. Among patients who went on to elective CTO PCI, the success rate was 79.7%. Compared with failed CTO PCI, successful CTO PCI was associated with a decreased risk for mortality as well as a decreased need for subsequent coronary artery bypass graft surgery.

Long-term clinical outcomes of successful revascularization with drug-eluting stents for chronic total occlusions: A systematic review and meta-analysis.

To determine whether successful percutaneous coronary intervention (PCI) using drug-eluting stents (DESs) have beneficial effects on long-term outcomes in patients with chronic total occlusions (CTOs) compared with failed PCIs for CTOs. Several observational studies have evaluated the long-term clinical outcomes of successful PCIs using DESs for CTOs. However, the results of these studies were inconsistent and inconclusive. We searched five online electronic databases to identify all the publications assessing the long-term outcomes of successful and failed PCIs using DESs for CTOs. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by STATA software. A total of nine studies involving 5958 CTO patients who underwent successful PCI and 1511 CTO patients who underwent failed PCI were included in this meta-analysis. The results of the analysis indicated that successful CTO PCIs using DESs were associated with lower long-term all-cause mortality(OR = 0.55, 95% CI = 0.45-0.67, P < 0.001), lower risk of myocardial infarction (OR = 0.45, 95% CI = 0.23-0.74, P = 0.002), lower risk of major adverse cardiac events (MACEs, OR = 0.44, 95% CI = 0.27-0.72, P = 0.001), and less incidence of subsequent coronary artery bypass grafting (OR = 0.10, 95% CI = 0.05-0.21, P < 0.001) than failed CTO PCIs. However, there was no difference in the incidence of target vessel revascularization (OR = 1.06, 95% CI = 0.17-6.60, P > 0.05) between the two groups. Successful CTO PCI using DESs can reduce long-term all-cause mortality and the risks of MI, MACEs, and CABG in patients with CTOs. © 2017 Wiley Periodicals, Inc.

Previous Percutaneous Coronary Intervention Does Not Increase Adverse Events After Coronary Artery Bypass Surgery

Adverse effects of previous percutaneous coronary intervention (PCI) on clinical outcomes after coronary artery bypass grafting (CABG) are unclear. This study aimed to evaluate the effect of previous PCI on early outcomes after subsequent CABG by using data from the Japanese national database. This study analyzed data from 48,051 consecutive patients that were retrieved from the Japan Adult Cardiovascular Surgery Database. These patients underwent primary, isolated, elective CABG between January 2008 and December 2013. Early mortality and morbidity rates in patients with previous PCI (n= 12,457, 25.9%) were compared with those in patients with no PCI (n= 35,594, 74.1%) by using multivariate logistic regression analysis and propensity score analysis. Operative mortality rates (no PCI, 1.2%; previous PCI, 1.2%; P= 0.970) and morbidity rates (no PCI, 7.4%; previous PCI, 7.2%; p= 0.436) were similar between the two groups. In risk-adjusted multivariate logistic-regression analysis, previous PCI (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.82 to 1.22; p=0.995) and morbidity (OR, 0.97; 95% CI, 0.89 to 1.05; p= 0.391) were not significant risk factors of operative mortality. Inverse probability of treatment weighting using the propensity score confirmed these results. This study shows that a previous PCI procedure does not increase postoperative adverse events after subsequent CABG. In the setting of repeat coronary revascularization, the most appropriate method of revascularization should be selected by the heart team, without being affected by a history of a previous PCI procedure.

PERSONALIZED MODEL FOR SELECTING OPTIMAL REVASCULARIZATION STRATEGY IN PATIENTS WITH SIMULTANEOUS CAROTID AND CORONARY ARTERY DISEASE: PROGNOSIS OF IN-HOSPITAL OUTCOMES

Aim : To develop a prediction model for selecting op-timal revascularization strategy for patients with polyvascular disease based on the evaluation of hospital out-comes of various surgical treatment strategies for patients with simultaneous coronary and carotid artery disease. Methods : 391 patients with combined hemodynamically significant atherosclerotic lesions of the coronary and internal carotid arteries underwent reconstruction heart surgeries. Group 1 patients (n = 151, 38.6%) underwent coronary artery bypass grafting (CABG) and subsequent carotid endarterectomy (CEA). Group 2 patients (n = 141, 36%) underwent combined CABG and CEA. Group 3 patients (n = 28, 7.2%) underwent hybrid percutaneous coronary intervention (PCI) and CEA. Group 4 patients (n = 71, 18.2%) underwent CEA and subsequent CABG. 3 groups of risk factors (clinical and demographic risk factors, risk factors of coronary and cerebrovascular adverse events), were selected to develop the prediction model for evaluating the probability of in-hospital complications, such as death, myocardial infarction, acute cerebrovascular accident / transient ischemic attack, significant hemorrhagic complications > BARC type 3 bleeding. The prognostic coefficients of all risk factors for each surgical treatment strategy were evaluated to select optimal revascularization strategy. Then, the integrated indicators, representing a comprehensive assessment of the risk factors related to each surgical treatment strategy, were calculated. The ROC-analysis was performed to set a threshold allowing improving the quality of the prognosis (sensitivity and specificity). Results: Clinical and demographic factors and cere-brovascular risk factors were significantly associated with adverse prognosis in Group 1 and 2 patients according to the regression analysis. Coronary and cerebrovascular factors were reported to affect prognosis in patients undergoing hybrid revascularization, whereas clinical and demographic risk factors and cerebrovascular risk factors worsen the prognosis of patients undergoing CEA and subsequent CABG. The prediction model allowed creating an interactive calculator able to determine the probability of adverse cardiovascular events in patients with polyvascular disease undergoing four types of surgical treatment strategies and to select the optimal one that will be associated with a minimal risk of in-hospital complications. Conclusion: The prediction model and personalized calculator for selecting an optimal surgical treatment strategy based on the comprehensive risk assessment for adverse outcomes (clinical and demographic factors, cor-onary and cerebrovascular factors) allows predicting the probability of adverse cardiovascular events in patients with simultaneous carotid and coronary artery disease.

Management of Iatrogenic Pseudoaneurysms in Patients Undergoing Coronary Artery Bypass Grafting.

A plethora of papers have been written regarding postcatheterization femoral pseudoaneurysms. However, literature is lacking on pseudoaneurysmal management in patients undergoing coronary artery bypass grafting (CABG). Thus, we examined if pseudoaneurysms with subsequent CABG can be managed with the same strategies as those not exposed to the intense anticoagulation accompanying CABGs. During a 14-year study period, we retrospectively examined femoral iatrogenic pseudoaneurysms (IPSAs) diagnosed postheart catheterization in patients having a subsequent CABG. Patient information was obtained from electronic medical records and included pseudoaneurysm characteristics, treatment, and resolution. Outcomes of interest included the occurrence of IPSA treatment failures and complications. In the 66 patients (mean age, 66 ± 11 years, 46% male) meeting inclusion criteria, mean dose of heparin received during the CABG procedure was 34 000 ± 23 000 units. The IPSA size distribution was the following: 17% of IPSAs measured <1 cm, 55% between 1 and 3 cm, and 21% measured >3 cm. Pseudoaneurysms were managed with compression, duplex-guided thrombin injection, and surgical repair (1%, 27%, and 26% of cases, respectively). Thrombin injection and surgical repair were 100% effective at treating pseudoaneurysms, with 1 patient experiencing a surgical site infection postsurgical repair. Observation-only management was employed in 30 (45%) patients. Nine of 30 patients with no intervention beyond observation had duplex documented resolution/thrombosis during follow-up. One patient initially managed by observation required readmission and surgical repair of an enlarging pseudoaneurysm (6 cm growth) following CABG. Management of pseudoaneurysms in patients prior to CABG should be similar to those patients not undergoing intense anticoagulation. In appropriate cases, small aneurysms can be safely observed, while thrombin injections are effective and safe as well. Thus, routine open surgical repair is not routinely required in patients with femoral pseudoaneurysms at time of CABG.

Meta-Analysis of Clinical Outcomes of Patients Who Underwent Percutaneous Coronary Interventions for Chronic Total Occlusions

Successful percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) has been associated with clinical benefit. There are no randomized controlled trials on long-term clinical outcomes after CTO PCI, limiting the available evidence to observational cohort studies. We sought to perform a weighted meta-analysis of the long-term outcomes of successful versus failed CTO PCI. A total of 25 studies, published from 1990 to 2014, with 28,486 patients (29,315 CTO PCI procedures) were included. We analyzed data on mortality, subsequent coronary artery bypass grafting (CABG), myocardial infarction, major adverse cardiac events, angina pectoris, stroke, and target vessel revascularization using random-effects models. Procedural success was 71% (range 51% to 87%). During a weighted mean follow-up of 3.11 years, compared with unsuccessful, successful CTO PCI was associated with lower mortality (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.43 to 0.63), less residual angina (OR 0.38, 95% CI 0.24 to 0.60), lower risk for stroke (OR 0.72, 95% CI 0.60 to 0.88), less need for subsequent coronary artery bypass grafting (OR 0.18, 95% CI 0.14 to 0.22), and lower risk for major adverse cardiac events (0.59, 95% CI 0.44 to 0.79). There was no difference in the incidence of target vessel revascularization (OR 0.66, 95% CI 0.36 to 1.23) or myocardial infarction (OR 0.73, 95% CI 0.52 to 1.03). Outcomes were similar in patients who underwent balloon angioplasty only or stenting with bare metal or drug-eluting stents. Compared with failed procedures, successful CTO PCIs are associated with a lower risk of death, stroke, and coronary artery bypass grafting and less recurrent angina pectoris.

86 The Incidence of Cardiac Surgery Following Percutaneous Coronary Intervention: Insights from a High-volume Single-centre in the UK

IntroductionPercutaneous coronary intervention (PCI) has established itself as an effective alternative to coronary artery bypass grafting (CABG) in appropriate patients. However, the proportion of patients that undergo CABG and or...