Surgical Myocardial Revascularization In Patients Research Articles

Transit-time flowmetry measurement features of coronary bypass grafts after multiple percutaneous coronary interventions

The functionality of coronary bypass grafts after surgical myocardial revascularization in patients with coronary heart disease directly depends on the state of the target coronary arteries. In the presence of widespread and diff use atherosclerotic lesions or microcirculatory dysfunctions, a high frequency of coronary bypass dysfunctions is noted in the near future. In some cases, shunt dysfunction can lead to severe hemodynamic instability, accompanied by acute circulatory disorders.Aim: To assess the function of coronary bypass grafts during myocardial revascularization using the method of ultrasonic flowmetry in patients with and without a history of multiple percutaneous coronary interventions (PCI).Material and methods. The retrospective study included 47 patients who underwent coronary artery bypass surgery. A total of 145 coronary bypass grafts were performed. All patients were divided into 2 groups. Group 1 (PCI group) included patients after multiple previous PCI (n = 25; 74 coronary bypass grafts), group 2 (without PCI) included patients without previous PCI (n = 22; 71 coronary bypass grafts). All patients underwent intraoperative ultrasonic flowmetry of coronary bypass grafts using the VeriQ system (Medistim, Norway).Results. When analyzing the status of coronary bypass grafts in patients after multiple PCI, a significantly low mean volumetric blood flow rate was noted (29.5 ± 8.3 ml/min and 48.2 ± 11.6 ml/min, respectively, p = 0.0001) and lower diastolic filling (55.2 ± 8.2% and 71.9 ± 7.1%, p = 0.0001). Also in the group of patients after multiple PCI, there were 2 (2.7%) cases of revision of the distal anastomosis due to a high pulsatile index and low volumetric blood flow velocity. However, no such events were noted in the group without PCI.Conclusions. Previous percutaneous coronary interventions are compromising factors for the state of the coronary bed, which reduces the functional status of coronary bypass grafts and may increase the perioperative risk of surgical myocardial revascularization.

Complete surgical myocardial revascularization in patients with declined renal functions: 12-month outcomes

IntroductionThis retrospective observational study aimed to evaluate the feasibility and effectiveness of complete revascularization coronary artery bypass grafting (CABG) in patients with multi-vessel disease (MVD)-CAD and declined renal functions, addressing the knowledge gap regarding optimal treatment strategies and outcomes in this specific patient population.MethodsBetween 2020 and 2022, a total of 58 patients underwent on-pump coronary artery bypass grafting surgery for complete myocardial revascularization in this study. To assess overall survival, Kaplan–Meier with the log-rank test was conducted for statistical analysis.ResultsThe mean age of cohort was 60.7. The findings showed a high prevalence of medical conditions such as hypertension (50.0%), diabetes (50.0%), and anaemia (41.4%) among the participants. Intraoperatively, low cardiac output syndrome was reported in 5.2% of cases, while perioperative outcomes indicated a need for transfusions in 53.5% of cases and an in-hospital mortality rate of 3.4%. At the 12-month follow-up, no redo revascularization or renal replacement therapy was required, but cardiac mortality was 5.2% and all-cause mortality was 6.9%.ConclusionsThe study concluded that complete revascularization is safe for these patients and highlights the potential benefits, emphasizing the need for further research in optimizing revascularization techniques for this population.

Early clinical outcomes of surgical myocardial revascularization in patients with preoperative platelet dysfunction

Background/Aim. Coronary artery bypass grafting (CABG) is the treatment of choice for a significant number of patients with ischemic heart disease. Some of the postoperative complications are closely linked with the preoperative antiplatelet therapy (APT). The aim of this study was to compare the early clinical outcomes of CABG in patients with preserved platelet (PLT) function and patients with PLT function impaired by the residual therapeutic effect of APT. Methods. A total of 181 patients with isolated CABG were enrolled in this prospective, nonrandomized, observational study. Patients were divided into four groups: control group (arachidonic acid-dependent PLT aggregation group), with aspirin-induced platelet inhibition (ASPI) test ? 790 aggregation units (AU)/min; mild (M) acetylsalicylic acid (ASA) effect (MASAE) group, with ASPI test = 410?789 AU/min; pronounced (P) ASA effect (PASAE) group, with ASPI test ? 409 AU/min; dual (D) APT (DAPT) group, with ASPI test ? 789 AU/min and adenosine diphosphate (ADP) test ? 405 AU/min. Preoperative data, intraoperative characteristics, and postoperative outcomes were obtained and com-pared between the groups. Results. A significant difference was found regarding the average time of APT cessation be-tween groups (p < 0.001). The DAPT group had a significantly higher frequency of drainage compared to the control (p = 0.004), MASAE (p = 0.001), and PASAE (p = 0.006) groups. The PASAE group had a significantly higher rate of chest reexploration compared to the MASAE group (p = 0.032). The DAPT group required significantly more packed red blood cells (PRBC) compared to the control (p < 0.001) and MASAE (p = 0.009) groups. The PASAE group received significantly more PRBC compared to the control (p < 0.001) and MASAE (p = 0.019) groups. The DAPT group required higher amounts of PLTs compared to the control (p < 0.001), MASAE (p = 0.002), and PASAE (p < 0.001) groups. The DAPT group received higher amounts of cryoprecipitate compared to the control (p = 0.002), MASAE (p = 0.009), and PASAE (p = 0.016) groups. Conclusion. Patients with a residual effect of DAPT, as well as patients with a pronounced residual effect of ASA, have a higher risk of postoperative bleeding and chest reexploration, as well as increased transfusion demands.

Early Postoperative Complications in Patients with Acute Myocardial Infarction During Emergency Coronary Bypassing

Despite the success results of interventional cardiology, the indications for coronary artery bypass grafting in acute myocardial infarction, according to the recommendations, are quite limited. In recent years, the optimization of perioperative management of patients, including myocardial protection, has helped to improve the effects of treatment by emergency surgical revascularization in patients with cardiogenic shock. Thus, it is important to learn the results of emergency surgical myocardial revascularization in patients with acute myocardial infarction (AMI), which were previously considered incurable or in cases where interventional cardiology is ineffective. Therefore, the aim of the study was to conduct a prospective analysis of the immediate clinical results of the early postoperative period to determine the factors of early mortality in emergency coronary artery bypass grafting. Research methods. The research is based on the prospective investigation of 129 patients who were hospitalized in Kyiv “Heart Center” through the period from 2011 to 2015. At 100,0% the ST-elevated myocardial infarction (STEMI) of them it was verified, at 29,0 patients non- ST-elevated myocardial infarction (NSTEMI) was set. In early postoperative period, we have analyzed such events like inotropic support duration, necessity of intra-aortic balloon pump, the episodes of the development kidney injury and respiratory failure, complete atrioventricular blockade, supraventricular tachyarrhythmia episodes, encephalopathy, rethoracotomy needs. Also early postoperative mortality endpoints were evaluated. Research results. It has been proven that in the presence of STEMI type of acute myocardial injury compared with NSTEMI type, there is a higher risk of acute left ventricular failure (p <0.05) followed by intra-aortic balloon pulsation (IABP)- procedure (p <0,05) and inotropic support (p <0,05) in the early postoperative period. In patients of the STEMI group, acute kidney injury was recorded more often with reliable indexes of absolute and relative risks (p <0,05). All cases of transient atrioventricular block after emergency coronary artery bypass grafting (CABG) were registered in patients with STEMI injury with significant changes of odds ratio (p <0.05). It was established that the main structure of respiratory complications was due to prolonged mechanical ventilation, but the difference in the relative risk and odds ratio between the STEMI and NSTEMI groups is insignificant (p> 0.05), however the likelihood of supraventricular arrhythmia and encephalopathy in the NSTEMI group was reliably higher (p <0.05). Estimates of the level of early postoperative mortality (12.4%) proved the probable relative risk (p <0.05) and the odds ratio (p <0.05) of mortality in the STEMI group, which was confirmed by the analysis of cumulative survival by Kaplan-Meyer method (Criterion log-rank 2,74; p = 0,006). Mortality in the STEMI group was associated with previously diagnosed acute heart failure (56,2%), the onset of cardiogenic shock (31,3%) and the development of acute mitral regurgitation (12.5%). Conclusions. STEMI type of acute myocardial damage installed reliably higher absolute and relative risk of acute left ventricle failure (p<0,05) with following intra-aortic balloon pump (p<0,05), inotropic support (p<0,05) and acute kidney injury with glomerular rate reduction (p<0,05) in the early postoperative period. The higher absolute and relative risks of encephalopathy, as well as the possibility of supraventricular arrhythmia presented at NSTEMI patients (p<0,05). All cases of transient atrioventricular blockade and early hospital mortality with reliable odds ratio, absolute and relative risks changes registered at STEMI patients (p<0,05). Prospects for further research are long-term prospective observation, analysis of long-term clinical results of coronary artery bypass grafting in patients with acute myocardial infarction, as well as assessment of risk factors for long-term mortality.

Computed Tomography-Based Angiographic Evaluation of Graft Patency Rate After Coronary Artery Bypass Graft Surgery in Bangladesh.

BackgroundThis study aims to assess the graft patency rate following coronary artery bypass graft (CABG) surgery using noninvasive CT angiography. Materials and methodsA total of 68 patients were retrospectively evaluated with CT angiography (group I: 34 patients with coronary endarterectomy (CE) and group II: 34 patients without CE). CE was performed in multi-segmental diffuse coronary artery disease (CAD) or when calcified or extremely thick plaques made anastomosis troublesome. A team of two experts, an interventional radiologist and a cardiac surgeon, did the evaluations of graft patency rate.ResultsA total of 205 bypass grafts were evaluated in 68 post-CABG status patients (110 grafts in group I and 95 grafts in group II; moreover, 82 were arterial and 123 were venous grafts). Post CABG, CT angiography demonstrated a graft patency rate of about 90% in both study groups at five years follow up, which was statistically insignificant (P > 0.05) in terms of graft patency rate. Following CE, five-year angina-free survival rates were 89% and 91% in groups I and II, respectively.ConclusionCABG surgery with endarterectomy is reliable and effective. It achieves the desired surgical myocardial revascularization in patients with diffuse calcified CAD having no alternative options for adequate myocardial revascularization.

Adverse Events After Surgical Myocardial Revascularization in Patients With Preoperative Left Ventricular Diastolic Dysfunction

Background: A significant number of patients who underwent surgical myocardial revascularization (CABG) have various comorbidities, including left ventricular diastolic dysfunction (LVDD). Objective: The aim of this paper is to show that patients with preoperative LVDD are at an increased risk of postoperative adverse events and have a worse prognosis compared to patients without LVDD. Methods: The study included 116 patients who underwent myocardial revascularization (CABG) performed at Medical Institute Bayer in Tuzla over a period of 1 year. None of the patients had previously undergone CABG or valvular surgery, or undergone stent implantation (PCI). The presence of LV diastolic dysfunction was detected by echocardiography, and the patients were divided into two groups: with and without LVDD, and further classified into three degrees of LVDD. Results: Of the total number of subjects who underwent surgical revascularization of the myocardium without echocardiographically detected LVDD, 24.1% were patients, and 75.9% were patients with LVDD. In the group with LVDD, the range of days spent in the intensive care unit (ICU) is significantly higher compared to patients without LVDD. Also, patients with LVDD had a significantly higher number of hours of inotropic support, a significantly higher number of cases of tachycardia, predominantly atrial fibrillation (POAF). In this group of patients, a greater number of other adverse events were observed, such as myocardial infarction, cardiac or renal failure, TIA or CVI. Of the total number of patients in the study, 107 patients survived surgical myocardial revascularization and had a satisfactory recovery while 9 (7.8%) survived, all from the group with LVDD. Conclusion: Patients with preoperative diastolic dysfunction of the left ventricle, especially with III degree of dysfunction, are exposed to a higher postoperative risk of adverse events such as: atrial fibrillation, prolonged stay in the intensive care unit, the need for longer-term support with inotropes, and the fatal outcome was recorded exclusively in patients with LV diastolic dysfunction.

Complicações da revascularização do miocárdio em pacientes com diabetes mellitus

Este artigo buscou elucidar a relação entre a ocorrência de complicações peri e pós operatórias da cirurgia de revascularização do miocárdio em pacientes portadores de diabetes mellitus (DM). A DM é uma doença de importância mundial, capaz de causar importantes danos ao sistema cardiovascular, aumentando significativamente o risco e a gravidade da doença aterosclerótica. Trata-se de uma revisão de literatura que avalia o prognóstico de pacientes portadores dessa doença crônica submetidos a diferentes métodos cirúrgicos de revascularização miocárdica, associado a outros fatores de risco. Os resultados apontam que pacientes com DM possuem maior risco de pior evolução após a cirurgia, entretanto, esse é um grupo heterogêneo de pacientes, e outras condições como esquema de tratamento hipoglicemiante, etnia, sexo, idade e história clínica, também contribuem para o desfecho. Conclui-se que a abordagem da doença arterial coronariana em portadores de DM depende de uma abordagem individualizada do paciente e de suas comorbidades.

Levosimendán preoperatorio en cirugía coronaria con disfunción ventricular severa: ¿tiene sentido?

Introduction and objectivesNumerous studies have demonstrated the benefit of levosimendan in patients with chronic and acute heart failure. However, when it comes to its preoperatory use in coronary by-pass surgery in patients with severe ventricular dysfunction, there are some contradictory results. The objective of this study is assessing preconditioning efficiency with levosimendan in surgical myocardial revascularization in patients with severe ventricular dysfunction. MethodsWe design a propensity score-matched cohort study. The study included patients with a LVEF less or equal to 35% who underwent isolated coronary artery by-pass grafting or associated to ischemic/functional mitral surgery from January 2009 to October 2019. They were split into two cohorts whether they received levosimendan preoperatively (Levo) or not (NoLevo); after matching there were 64 patients per cohort. Outcome variables were postoperative morbi-mortality, readmission and follow-up mortality. Statistical analysis: categorical data were compared with a Chi-square or Fisher exact test, and quantitative data with a t-Student or W-Wilcoxon tests. RR/HR were estimated for assessing the association between preoperative use of levosimendan and outcomes. ResultsPreoperative levosimendan use did not decreased in-hospital mortality (RR = 0,86, p = 0.770), and neither do hospital stay, nor postoperative complications. Event-free survival was similar between cohorts in terms of cardiological readmissions, all-cause and cardiological follow-up mortality. ConclusionsOur results do not support the widespread use of levosimendan previously to myocardial revascularization surgery in patients with severe ventricular dysfunction.

Early Results After Coronary Artery Bypass Grafting in Patients With Severe Ischemic Left Ventricular Dysfunction

Introduction. The number of patients with severe ischemic left ventricular dysfunction (ILVD), who undergo coronary artery bypass, increasing each year. ILVD is an established risk factor for mortality in patients after myocardial revascularization during the early and late postoperative periods.Aim of study. To evaluate the early results of surgical myocardial revascularization in patients with coronary artery disease (CAD) and severe ILVD.Material and methods. The study included 149 patients with coronary artery disease with severe left ventricular dysfunction (ejection fraction (EF) ≤39%), operated from January 2002 to December 2018. different variables were assessed (pre- and postoperative), including LV ejection fraction and end systolic volume index (ESVI).Results.The average age of the patients was 59.36±8.97 years (from 30 to 78 years), 93% of the patients were men. In 28 patients (19%), ILVD developed against the background of myocardial infarction (MI) and in 121 (81%) due to ischemic cardiomyopathy (ICMP) with a history of myocardial infarction. The mean EF before surgery was 36.64±3.17 (from 21 to 39%). In the postoperative period, there was an increase in EF, which averaged 44.92±4.92 (from 36 to 59%) (p value <0.001). The mean LV ESVI before surgery was 60.23±11.52 ml/m2. In the immediate postoperative period ESVI decreased to 46.26±12.40 ml/m2(the value of p<0.001). The average number of bypass coronary arteries in one patient was 3.9±0.87. There was also a decrease in the degree of mitral regurgitation in most patients after coronary artery bypass grafting (CABG) (p value <0.001). Hospital mortality was 2% (3 patients).Conclusion. Coronary artery bypass grafting in patients with severe ischemic left ventricular dysfunction can be performed with low mortality. Surgical myocardial revascularization can be considered a safe and effective operation for patients with coronary artery disease with a satisfactory condition of the distal coronary arteries, low ejection fraction, and with a predominance of viable myocardium.

Surgical Myocardial Revascularization in Patients with Severe Left Ventricular Dysfunction: Experience in the Cardiac Surgery Department of the Military Hospital Mohammed V of Rabat

Patients with coronary artery disease associated with severe left ventricular dysfunction, candidates for surgical myocardial revascularization, are with high operative risk. The aim of this study was to assess short and long-term morbidity and mortality and to identify their predictive factors. Methods: We conducted a retrospective study in the cardiac surgery department of the Military Instruction Hospital Mohammed V- Rabat, between 2000 and 2015. The statistical analysis was executed by SPSS. There were 74 patients (mean age 74±10 years, ejection fraction [FE]: 30.07%±4 .5, Euroscore: 6.6±2.9). Results: Hospital mortality was 9.5%, with a follow up time of 59.2 ± 36 months. The survival rate at 10 years was 57%. There was also an improvement in their clinical symptoms and echocardiographic parameters (postoperative FE: 40.36%±11.2). Conclusion: In this group of patients with high operative risk, the long-term results of several studies demonstrate the superiority of surgical treatment on medical treatment.

Assessment of the effectiveness of treatment in patients after acute coronary syndrome

Aim. To assess the effectiveness of secondary drug prevention and surgical myocardial revascularization in patients with coronary artery disease (CAD) during long-term follow-up after acute coronary syndrome (ACS).Material and methods. The study involved 400 patients with ACS discharged from the hospital in 2012-2016. The diagnosis was verified according to the European Society of Cardiology (ESC) guidelines. There were no exclusion criteria. We analyzed the data of medical records (complaints, medical history, physical examination, laboratory and instrumental data). Repeated data collection was carried out by distance survey and during a face-to-face examination during 2018. According to the clinical course of CAD, all patients were divided into 2 groups. Group 1 consisted of 151 patients with complicated course of CAD, group 2 — 249 patients with stable CAD. We analyzed drug therapy recommended at hospital discharge and taken at the time of the repeated examination. The drug names and daily dosage used for the secondary prevention of CAD were recorded. Assessment of survival without cardiovascular complications was carried out according to the Kaplan-Mayer analysis.Results. Seven-year mortality was 22,5%. The total number of cardiovascular events was 37,7%. The main reason for the frequent complications was the insufficient secondary prevention of CAD after ACS. We found that the drugs and their dosage did not have a significant effect on survival. Statin use is associated with a paradoxical increase in the number of complications. The increased frequency of use and dosage of statins are a consequence of unfavorable course of CAD and do not have the proper preventive effect. For some groups of drugs, we observed irregular intake over the observation period. The low effectiveness of therapy is not only due to insufficient doses, but also in the frequent use of generic drugs. The significant effect of coronary angiography on the probability of cardiovascular complications compared with stenting is due to high proportion of coronary angiography use without revascularization.Conclusion. The combination of following factors of drug therapy can explain the low effectiveness of secondary CAD prevention: low dose (26,1±2,8 mg for atorvastatin), irregular intake and common use of generic drugs (97,6% for statins), present in different ratios. The contribution of surgical treatment to reducing cardiovascular complications is lower, the more significant residual coronary artery stenosis.

Early surgical myocardial revascularization as an effective method of treating patients with acute coronary syndrome.

One of the main methods of treating patients with acute coronary syndrome (ACS) is percutaneous coronary intervention (PCI), however in patients with multivascular, abnormal, or technically complicated coronary lesions, early surgical myocardial revascularization is more promising. Despite modern development of surgical and interventional techniques, the application of one strategy for all patients with acute coronary syndrome is problematic and should be based on the heart team's decision and patient data. The study was aimed at assessing the results of early surgical myocardial revascularization in patients with acute coronary syndrome. Retrospectively with continuous sampling the study included 342 patients who underwent surgical treatment of acute coronary syndrome at the Federal Centre of High Medical Technologies from January 1st, 2014 to December 31st, 2018. Myocardial revascularization using two internal thoracic arteries was performed in 220 (64.3%) cases. The mean age of the patients was 64.2±10.8 years. Prevailing in the study were men - 69.3%. The average number of affected vessels amounted to 3.1±0.9. Fifty-six (16.4%) patients had cardiogenic shock at the time of operation, with 9 (2.6%) patients diagnosed as having severe mitral insufficiency and 5 (1.5%) with interventricular septal defect. All patients were on antiplatelet therapy. In-hospital mortality was 5.2% (18 patients). The mean time of operation amounted to 205.3±58.9 min, with that of artificial circulation to 57.9±13.2 min. Such complication as postoperative haemorrhage was observed in 20 cases (5.8%). The average volume of drainage losses amounted to 507.3±66.7 ml. The average length of stay in the ICU was 3.8±1.4 days, with that of hospital stay being 16.6±2.1 days. Twenty-seven (7.9%) patients after removal of drainages were diagnosed as having exudative pericarditis which resolved on the background of medicamentous therapy. Early surgical myocardial revascularization in patients with acute coronary syndrome may be performed safely and effectively, and should be considered individually in each patient by the heart team.

Features of coronary artery bypass grafting in young patients with acute coronary syndrome

Aim: Purpose of the study was retrospective analysis of hospital and early (up to six monthes after operation) results of the surgical myocardial revascularization in patients, third and fourth decates of life, with acute coronary syndrome. Material and Methods: Since 2012 year up to November, 2018 year in CCH by the same brigade, performed 500 coronary artery bypass grafting operations in the patients with acute coronary syndrome, at the age of 30-83 years old, including 15 operations in patients ≤ 40 years old (3%). Clinical manifestation of acute coronary syndrome was presented: unstable angina in 13 (86.7%) patients, 6 (40%) of them with pass myocardial infarction in anamnesis; acute myocardial infarction, accompanied by S-T segment elevation (STEMI) in 2 (13.3%) patients. In coronarography: multivessel lesion of coronary arteries was revealed in 10 (66.7%) patients, 3 of them with lesion of trunk of the left coronary artery; bivascular lesion in 4 (26.7%) patients, single vessel lesion in 1 (6.6%). In 13 (86.7%) patients were performed coronary artery bypass grafting under the cardiopulmonary bypass (CPB). Average duration of the CPB= 127±9.66 min. Mean aortic clamp time = 68±6.91 min. Number of shunts for the whole group of 15 operated were from 1 to 5, at the average (3.28±0.31). In 6 patients (40%) performed three-branches CPB, in 5 patients (33.3%) fourth-branches, in 1 patient (6.7%) fifth-branches, in 2 patients (13.3%) double-branches and in 1 patient (6.7%) single branch CPB. Used conduits: left internal mammary artery in all 15 patients (100%), autovein in 12 (80%), radial artery in 10 (66.7%) patients. In last group with using radial artery, average amount of shunts was 1.5±0.1. Results: The structure of postoperative complications consist: low cardiac output syndrome in two patients; bleeding in 2 patients. In analyzed series, no lethal outcomes watched in duration up to 30 days after operation. All patients were watched during 6 monthes after discharge. It was not watches necessity for reinterventions and lethal outcomes. Conclusion: Hospital and immediate results of myocardial revascularization in young people with acute coronary syndrome very encouraging, while long-term results are not so optimistic and unsatisfactory. Therefor, considering the long life expectancy and higher functional and social demands of the patients at age ≤ 40 years, preference is given to hybrid interventions or isolated shunting using arterial conduits in both variants of revascularization.

The strategy of surgical revascularization of coronary arteries in a multi-vessel lesion

This review presents the basic approaches for the surgical myocardial revascularization in patients with multivessel coronary lesions. The methods of coronary artery bypass grafting, balloon angioplasty, stenting using holometallic stents and drug-coated stents are discussed, the main studies comparing the above methods with each other and with the optimal drug therapy are presented. The concepts of complete and incomplete revascularization of the coronary bed are also explained.

Comparability of scintigraphy data with coronary angiography after surgical myocardial revascularization

Introduction. Radionuclide imaging is included in diagnostic methods after PCI and CABG in patients with symptoms, but the recommendations caution against routine testing in all asymptomatic patients after revascularization. The paper shows the results of single-photon emission computed tomography after hybrid coronary myocardial revascularization; an analysis of the sensitivity and specificity of three methods of surgical myocardial revascularization was carried out in 12 months.Aim of the study was to determine the sensitivity and specificity of SPECT in determining coronary artery stenosis ≥ 50 % after performing three methods of surgical myocardial revascularization: CABG, PCI, and hybrid myocardial revascularization in patients with coronary artery disease and multi-vascular coronary lesion.Material and methods. A retrospective analysis of 82 patients with stable forms of coronary artery disease who underwent myocardial revascularization for the presence of the multivascular coronary lesion was carried out. The patients were divided into three groups: the first group consisted of 40 patients who underwent CABG, the second – 29 patients after PCI, and the third – 23 patients who underwent hybrid myocardial revascularization.Results. All patients after myocardial revascularization, on average, after 21.8±8.6 months, were hospitalized, where singlephoton emission computed tomography of the myocardium with 99mTc-technetril (SPECT) and control coronarography/ shuntography were performed. The frequency of the presence of significant stenosis during coronary angiography with a perfusion defect of ≥5 % on SPECT during exercise was 50, 50 and 33 % in the CABG, PCI, and hybrid revascularization, respectively (p=0.894). The least sensitivity of SPECT was after hybrid myocardial revascularization (20 %), while in the CABG group, the sensitivity was 71.4 % (p = 0.190). The SPECT specificity indices were much higher: in the GABG, PCI, and hybrid revascularization groups, respectively, 75.8, 79 and 88.9 % (p=0.530).Conclusion. There is no significant relationship between the size of the defect on SPECT and coronary angiography data, regardless of the type of surgical myocardial revascularization in patients after myocardial revascularization. Detection of a perfusion defect with a load of more than 10% in SPECT after surgical myocardial revascularization is the basis for coronary angiography in order to exclude stent restenosis or shunt dysfunction, as well as progression of coronary atherosclerosis.

Immediate results of three methods of surgical myocardial revascularization in multivessel lesion of the coronary bed

Percutaneous coronary intervention (PTI) and coronary artery bypass grafting (CABG) are currently the most commonly used techniques of myocardial revascularization. However, each of the methods has its own advantages and disadvantages. The creation of hybrid coronary revascularization (HCR) was based on an attempt to combine the benefits of CABG and PTI. The study was aimed at assessing the immediate results of three methods of surgical myocardial revascularization in patients with multivessel lesions of the coronary bed in stable ischaemic heart disease. The study enrolled a total of 155 patients randomized into three groups of myocardial revascularization: HCR, CABG and PTI. In the HCR group, the first stage consisted in minimally invasive myocardial revascularization with the anterior descending artery (ADA) followed by PTI (within 1-3 days) with implantation of drug-eluting second-generation stents Xience to other coronary vessels. In the CABG and PTI groups we performed CABG and PTI, respectively, using the Xience stents. In all three groups we assessed the procedural success, frequency of major adverse cardiovascular events and bleeding. Full myocardial revascularization was achieved in all three groups in more than 90% of cases. No statistically significant differences in either the procedural success rate or frequency of major adverse cardiovascular events between the CABG, PTI and HCR were revealed. The PTI group was characterized by the lowest frequency of bleeding, need for rehabilitation, and length of hospital stay. Hybrid revascularization with the use of minimally invasive direct myocardial revascularization with the ADA followed by PTI with second-generation drug-eluting stents to other coronary arteries is a method of choice in treatment of patients with multivessel lesions of coronary arteries.

CABG for patients with heart dysfunction: when and why to refuse surgery.

Surgical myocardial revascularization in patients with reduced left ventricular function has been a matter of debate for decades. A recently-published 10-year extension follow-up of the STICH trial has conclusively demonstrated the benefit of surgical myocardial revascularization in patients with significant coronary artery disease and low left ventricular ejection fraction. However, patient selection for surgery remains challenging, and so does the decision to perform percutaneous rather than surgical revascularization in this class of patients. New evidence helped to clarify the role of preoperative patients' characteristics as risk factors for surgery and to identify those patients who may benefit the most from surgery. Focus of this review is to review epidemiology and results of observational and investigational studies on revascularization in patients with reduced left ventricular function with a particular emphasis on relative indication of coronary artery bypass grafting and percutaneous coronary intervention.

Prophylactic intra-aortic balloon counterpulsation before surgical myocardial revascularization in patients with acute myocardial infarction.

Prophylactic intra-aortic balloon counterpulsation (pIABC) is recommended for high-risk patients undergoing coronary artery bypass grafting (CABG) surgery. Criteria for high-risk patients benefiting from pIABC are unclear. This study aimed to specifically describe the effect of pIABC on outcomes of patients with acute myocardial infarction (AMI) undergoing CABG. In 178 of 484 AMI patients (non-ST-segment elevation myocardial infarction [NSTEMI] or ST-segment elevation myocardial infarction [STEMI] ≤5 days before surgery) without cardiogenic shock who underwent CABG between 2008 and 2013, pIABC was initiated preoperatively. After propensity score matching, the outcomes of 400 patients were analyzed (pIABC: 150; Control: 250). After propensity score matching, baseline and operative characteristics were balanced between the groups except for a higher rate of patients with a left ventricular ejection fraction (LVEF)≤30% in the pIABC group (26% vs. Control: 13%; p=0.032). Seven point two percent (7.2%) of the control patients received an IABP intraoperatively or postoperatively. Postoperative extracorporeal life support (ECLS) was only needed in the control group (1.2% vs. 0%; p=0.01). Postoperative plasma curves of troponin I, creatine kinase (CK) and creatine kinase isoform MB (CK-MB) levels were reduced in the pIABC group compared with the control group. In-hospital mortality was reduced in the pIABC group (3.3% vs. control: 6.4%; p=0.18). After multivariate adjustment for other preoperative risk factors, pIABC was significantly protective concerning in-hospital mortality (HR 0.56; 95%-CI 0.023-0.74; p=0.021). Mortality (pIABC vs. control) was more affected in patients with preoperative LVEF≤30% (2/36 (5.6%) vs. 6/31 (19%); heart rate (HR) 0.25; 95%-CI 0.046-1.3; p=0.13) compared with LVEF>30% (3/114 (2.6%) vs. 10/219 (4.6%); HR 0.56; 95%-CI 0.15-2.1; p=0.55). Long-term survival did not differ between the groups. pIABC in CABG for AMI is associated with reduced perioperative cardiac injury and in-hospital mortality. Long-term survival is not affected.

低左心機能例に対する血行再建PCI vs CABG

低左心機能例に対する血行再建PCI vs CABG

Milrinone echocardiographic viability test: A pilot study

We assessed the utility of milrinone to predict recovery of function after surgical myocardial revascularization in patients with severe baseline left ventricular systolic dysfunction caused by coronary artery disease (CAD). Prediction of viable myocardial segments that will regain function after revascularization may help in the selection of patients who will benefit from coronary artery bypass graft surgery (CABG) as well as aid in the choice of target sites for coronary revascularization. We investigated 20 consecutive patients with CAD and left ventricular ejection fraction ≤40% who had evidence of myocardial viability by either thallium scan or dobutamine viability test and were candidates for elective CABG. Left ventricular regional wall motion and global ejection fraction were assessed by transesophageal echocardiography in the operating room. Measurements were done before and 10 minutes after milrinone infusion, and immediately after CABG. Left ventricular wall motion score was derived by means of a 12-segment model. Functional improvement for each segment was defined as a wall motion change >1. Baseline ejection fraction was 27% ± 5% (mean ± SD). Ejection fraction increased to 35% ± 5% after milrinone infusion ( P < .0001) and to 36% ± 6% after CABG ( P < .0001). Post-CABG ejection fraction was significantly correlated with postmilrinone ejection fraction ( r = 0.65, P < .0001). Milrinone infusion resulted in augmentation of contraction in 98 of the 209 abnormal segments (wall motion score ≥2); 91 (92.9%) of these improved after CABG. One hundred nine of the 111 segments that showed no improvement with milrinone did not improve after revascularization (98.2%). Seventy-three segments were akinetic or dyskinetic at baseline; 46 (63.0%) of these improved with milrinone. Improvement in regional wall motion after revascularization was detected in 84.8% of the segments that improved with milrinone versus only 3.7% of the segments that did not improve with milrinone. In patients with ischemic cardiomyopathy, improvement in left ventricular function (segmental wall motion and global ejection fraction) during milrinone infusion is highly predictive of improvement after CABG. (J Am Soc Echocardiogr 2001;14:668-75.)