Urgent Coronary Artery Bypass Surgery Research Articles

Efficacy of Perioperative Infusion of N(2)-L-alanyl-L-glutamine in Glycemic Control for Patients With Uncontrolled Diabetes Mellitus Presented for Urgent Coronary Artery Bypass Surgery: A Randomized Controlled Trial

To evaluate the efficacy of preoperative glutamine infusion in reducing insulin requirements in patients with uncontrolled type 2 diabetes, defined as glycated hemoglobin (HbA1c) >7%, undergoing urgent coronary artery bypass graft (CABG) surgery. A randomized controlled trial. At Ain Shams University Hospital, Cardiothoracic Academy. Ninety-three patients (of both sexes) with uncontrolled diabetes presenting for urgent CABG were categorized into 2 groups. The dipeptiven group (n=46) was given an infusion of dipeptiven 1.5 mL/kg body weight dissolved in normal saline (200 mL) over 3 hours before surgery. The control group (n=47) received a normal saline infusion (200 mL). The dipeptiven group demonstrated statistically significant lower intraoperative (173.74 ± 19.97 mg/dL v 198.22 ±14.64 mg/dL) and postoperative (162.36 ±13.11 mg/dL v 176.13 ±14.86 mg/dL) mean blood glucose levels. In addition, dipeptiven infusion was found to reduce mean total insulin requirements intraoperatively by 3.64 ± 0.56 units/h and postoperatively by 37.109 ± 4.30 units/24 h in comparison to placebo (50.98 ± 16.55 units/24 h and 5.10 ± 2.28 units/h, respectively). A preoperative infusion of dipeptiven can contribute to ameliorating stress hyperglycemia in uncontrolled diabetic patients undergoing urgent CABG.

Mehran and AGEF Risk Scores in Contrast-Induced Nephropathy Among Patients Undergoing Primary Percutaneous Coronary Intervention

AbstractBackground: Primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-segment elevation myocardial infarction (STEMI). Contrast induced nephropathy (CIN) is a serious complication which complicates PCI, resulting in increased morbidity, hospital stay, short and long term adverse outcomes. Prediction of high risk patients for development of CIN is of great importance to conduct pre-ventive measures. Various scoring systems were developed to set up high risk criteria.Aim of Study: To detect the relation between Mehran and AGEF risk scores and CIN. Also, to report other high risk criteria to predict CIN.Patients and Methods: The study included 250 patients with acute STEMI treated by primary PCI. Patients with coronary anatomy not suitable for PCI, with pre-existing renal troubles, on chronic dialysis and who need urgent coronary artery by-pass surgery were excluded.Results: CIN developed among 90 patients (36%). There was no significant association between CIN and patients' age or weight. The independent predictors of the occurrence of CIN were, in order, Mehran score (OR=6.4), Diabetes (OR= 5.8), AGEF score (OR=3.3) creatinine clearance (OR=1.02), non-osmolar contrast volume (OR=0.991). Females, those with low ejection fraction (EF) or previous history of is-chemic heart disease (IHD) were susceptible for CIN.Conclusion: CIN is a challenging health problem among patients undergoing primary PCI. Mehran risk score has a better predictive power that AGEF score in predicting CIN. Several other factors are associated with CIN development like diabetes, female gender, low EF history of IHD and use of non-osmolar contrast.

Unstable angina in the era of high-sensitivity troponin testing: a genuine entity and a cautionary tale

High-sensitivity cardiac troponin assays have emerged as a powerful tool in the management of patients presenting acutely to hospital with suspected cardiac chest pain. Recent guidelines emphasize the reassurance offered by low troponin concentrations early after admission. We describe a patient with known coronary artery disease, who presented with a classical history of recurrent myocardial ischaemia. High-sensitivity cardiac Troponin-I concentrations remained in the low-normal sex-specific reference range, despite serial testing on the day of admission, and despite recurrent pain with dynamic ECG changes. Urgent coronary angiography confirmed severe multi-vessel disease. He required an intra-aortic balloon pump within 24 h due to clinical instability, and had urgent coronary artery bypass surgery a few days later. This case confirms that "unstable angina" remains a genuine entity. It highlights the hazards of over-reliance on any single test and serves as a reminder of the importance of integrating tests with clinical assessment.

PP-071 [AJC » Acute Coronary Syndromes] Urgent Right Coronary Artery Bypass Surgery Due to Stent Distortion by a Stitched Guidewire

PP-071 [AJC » Acute Coronary Syndromes] Urgent Right Coronary Artery Bypass Surgery Due to Stent Distortion by a Stitched Guidewire

Pregnancy and the Risk of Spontaneous Coronary Artery Dissection: An Analysis of 120 Contemporary Cases.

Because of the rarity of this condition, information on pregnancy-associated spontaneous coronary artery dissection is limited. We reviewed a large number of contemporary pregnancy-associated spontaneous coronary artery dissection cases in an attempt to define the clinical characteristics and provide management recommendations. A literature search for cases of pregnancy-associated spontaneous coronary artery dissection reported between 2000 and 2015 included 120 cases; 75% presented with ST-segment-elevation myocardial infarction, and 80% had anterior myocardial infarction. Left anterior descending coronary artery was involved in 72% of cases, left main segment in 36%, and 40% had multivessel spontaneous coronary artery dissection. Ejection fraction was reduced to <40% in 44% of cases. Percutaneous coronary intervention was successful in only 50% of cases. Coronary artery bypass surgery was performed in 44 cases because of complex anatomy, hemodynamic instability, or failed percutaneous coronary intervention. Maternal complications included cardiogenic shock (24%), mechanical support (28%), urgent percutaneous coronary intervention (28%), urgent coronary artery bypass surgery (27.5%), maternal mortality (4%), and fetal mortality (2.5%). During follow-up for 305±111 days, there was a high incidence of symptoms because of persistent or new spontaneous coronary artery dissections, and 5 women needed heart transplantation or ventricular assist device implantation. Pregnancy-associated spontaneous coronary artery dissection is commonly associated with left anterior descending, left main, and multivessel involvement, which leads to a high incidence of reduced ejection fraction, and life-threatening maternal and fetal complications. Percutaneous coronary intervention is associated with low success rate and high likelihood of complications, and coronary artery bypass surgery is often required. Recurrent ischemic events because of persistent or new spontaneous coronary artery dissection are common during long-term follow-up.

Unusual and Unexpected Complications of Atherosclerotic Coronary Artery Aneurysms

A series of four patients with coronary aneurysms who were thought to have benign coronary ectasia in last decade but had acute coronary syndrome in last two years are presented First patient had triple vessel coronary ectasia and myocardial infarction (MI) 10 years back and had bare metal stent to aneurysmal left circumflex artery. He represented with inferior MI. Repeat angiogram showed triple vessel disease with thrombotic sub-total occlusion of aneurysmal right coronary artery (RCA) and was managed by urgent coronary artery bypass surgery(CABG). Second patient presented with inferior MI on multiple occasions requiring percutaneous interventions (PCI) with thrombosuction. On third occasion, he had PCI and bare metal stent to distal RCA. Subsequently he is doing well on oral anticoagulation and aspirin. Third subject had PCI to RCA, a decade earlier following inferior MI with concurrent aneurysm of circumflex artery. He represented with large NSTEMI with ongoing chest pain. Repeat angiogram showed thrombotic occlusion of aneurysmal segment and was managed with covered stent to aneurysmal segment with good result. The last patient presented with inferior MI and had drug eluting stent to proximal aneurysmal RCA. He represented with inferior MI. Repeat angiogram and OCT both showed large protruding thrombus into the stented aneurysmal segment and was excluded by covered stent along with anticoagulation and aspirin. In summary, coronary aneurysms are rare compared to stenotic CAD. Once thought to be benign are more sinister. Judicious use of PCI, CABG and combination of anticoagulation and antiplatelet are currently the mainstay of therapy.

Platelet function recovery after ticagrelor withdrawal in patients awaiting urgent coronary surgery.

Dual antiplatelet therapy with ticagrelor and aspirin is associated with an increased risk of perioperative bleeding complications. Current guidelines recommend therefore discontinuation of ticagrelor 5 days before surgery to allow sufficient recovery of platelet function. It is not known how the time to recovery varies between individual patients after discontinuation of ticagrelor. Twenty-five patients accepted for urgent coronary artery bypass surgery and treated with ticagrelor and aspirin were included in a prospective observational study. Platelet aggregation was evaluated with impedance aggregometry at five timepoints 12-96 h after discontinuation of ticagrelor. In a subset of patients ( n = 15), we also tested the ex vivo efficacy of platelet concentrate supplementation on platelet aggregation. There was a gradual increase in mean adenosine diphosphate-induced platelet aggregation after discontinuation of ticagrelor. After 72 h, mean aggregation was 38 ±23 aggregation units (U), which is above a previously suggested cut-off of 22 U, when patients can be operated without increased bleeding risk. However, there was a large interindividual variability (range 4‒88 U at 72 h) and 6/24 patients (25%) had <22 U after 72 h. Ex vivo administration of platelet concentrate did not improve adenosine diphosphate-induced aggregation at any timepoint after ticagrelor discontinuation. Adenosine diphosphate-induced aggregation was acceptable after 72 h in the majority of patients but with a large interindividual variability. Due to the large variability, platelet function testing may prove to be a valuable tool in timing of surgery in patients with ongoing or recently stopped ticagrelor treatment. Adenosine diphosphate-induced aggregation was not improved by addition of platelet concentrate.

Collaborative quality improvement vs public reporting for percutaneous coronary intervention: A comparison of percutaneous coronary intervention in New York vs Michigan

Public reporting (PR) is a policy mechanism that may improve clinical outcomes for percutaneous coronary intervention (PCI). However, prior studies have shown that PR may have an adverse impact on patient selection. It is unclear whether alternatives to PR, such as collaborative quality improvement (CQI), may drive improvements in quality of care and outcomes for patients receiving PCI without the unintended consequences seen with PR. Using National Cardiovascular Data Registry CathPCI Registry data from January 2011 through September 2012, we evaluated patients who underwent PCI in New York (NY), a state with PR (N = 51,983), to Michigan, a state with CQI (N = 53,528). We compared patient characteristics, the quality of care delivered, and clinical outcomes. Patients undergoing PCI in NY had a lower-risk profile, with a lower proportion of patients with ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or cardiogenic shock, compared with Michigan. Quality of care was broadly similar in the 2 states; however, outcomes were better in NY. In a propensity-matched analysis, patients in NY were less likely to be referred for emergent, urgent, or salvage coronary artery bypass surgery (odds ratio [OR] 0.67, 95% CI 0.51-0.88, P < .0001) and to receive blood transfusion (OR 0.7, 95% CI 0.61-0.82, P < .0001), and had lower in-hospital mortality (OR 0.72, 95% CI 0.63-0.83, P < .0001). Public reporting of PCI data is associated with fewer high-risk patients undergoing PCI compared with CQI. However, in comparable samples of patients, PR is also associated with a lower risk of mortality and adverse events. The optimal quality improvement method may involve combining these 2 strategies to protect access to care while still driving improvements in patient outcomes.

Improving patients' readiness for coronary artery bypass graft surgery.

Preoperative interventions improve outcomes for patients after coronary artery bypass surgery (CABG). To reduce mortality for patients undergoing urgent CABG. Eight centers implemented preoperative aspirin and statin, preinduction heart rate less than 80/min, hematocrit greater than 30%, blood sugar less than 150 mg/dL (8.3 mmol/L), and delayed surgery at least 3 days after a myocardial infarction. Data were collected on the last 150 isolated, urgent CABGs at each center (n=1200). A "bundle" score of 0 to 100 was calculated for each patient to represent the percentage of interventions used. Scores ranged from 33 to 100. About 56% of patients had a perfect score. Crude mortality and composite rates were lower in patients with higher scores, but once adjusted for patient and disease characteristics, the difference in scores was not significant. Higher scores were associated with shorter intubation: 6.0 hours (score 100), 8.0 hours (score 80-99), 8.4 hours (score<80) (log-rank P<.001). Median length of stay was shorter for patients with higher scores: 5 days (score 100), 6 days (scores 80-99), and 6 days (scores <80) (log-rank P<.001). Implementation of interventions to optimize patients' "readiness for surgery" is associated with shorter intubation times and shorter hospital stays after CABG.

Outcome of primary PCI – An Indian tertiary care center experience

ObjectiveTo assess the feasibility and outcomes of primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) in Indian Scenario.MethodsBetween January 2005 and December 2012, consecutive STEMI patients who underwent PPCI within 12 h of onset of chest pain were prospectively enrolled in a PPCI registry. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital and 30 day major adverse cardiovascular events (MACE) [death, reinfarction, bleeding, urgent coronary artery bypass surgery (CABG) and stroke] were assessed.ResultsA total of 672 patients underwent PPCI during this period. The mean age was 52 ± 13.4 years and 583 (86.7%) were males, 275 (40.9%) were hypertensives and 336 (50%) were diabetics. Thirty one (4.6%) patients had cardiogenic shock (CS). Anterior myocardial infarction was diagnosed in 398 (59.2%) patients. The median chest pain onset to hospital arrival time, door-to-balloon time and total ischemic times were 200 (10–720), 65 (20–300), and 275 (55–785) minutes respectively. In-hospital adverse events occurred in 54 (8.0%) patients [death 28 (4.2%), reinfarction 8 (1.2%), major bleeding 9 (1.3%), urgent CABG 4 (0.6%) and stroke 1 (0.14%)]. Nineteen patients with CS died (mortality rate – (61.3%)). At the end of 30 days, 64 (9.5%) patients had MACE [death 35 (5.2%), reinfarction 10 (2.1%), major bleeding 10 (1.5%), urgent CABG 4 (0.6%) and stroke 1 (0.1%)].ConclusionOur study has shown that PPCI is feasible with good outcomes in Indian scenario. Even though the recommended door-to-balloon time can be achieved, the total ischemic time remained long. CS in the setting of STEMI was associated with poor outcomes.

EComment. Delirium after cardiac surgery: incidence and risk factors

Smulter et al. provide a very detailed study on an important postoperative issue following cardiac surgery, that is associated with increased morbidity and mortality [1]. Their work, however, raises a number of issues. Smulter et al. identified maximum temperature in the intensive care unit as a risk factor for delirium. As hyperpyrexia is caused by an excessive inflammatory response, this finding is not unexpected. However, no mention is made of the rate of rewarming and the maximum temperature at the end of cardiopulmonary bypass (CPB). Both the rate and the final temperature are known risk factors post-CPB for cerebral damage [2]. A difference exists with regard to cerebral embolic load and whether a cardiac procedure is open (valve replacement), or closed [coronary artery bypass surgery (CABG)]. No mention is made about whether open or closed procedures were utilised as independent covariates in their analysis. We would recommend that isolated CABG should be separately analysed from isolated valve procedures, as they are fundamentally different operations with regard to neurological risk [3]. The identification of sodium as an independent risk factor for postoperative delirium confirms previous work [4]. Valve replacement patients are more likely to suffer from this complication secondary to diuretic therapy. Unfortunately, preoperative sodium levels were not reported. Identification of volume loading during surgery as being a significant risk factor raises the possibility of reduced oxygen delivery being an issue. Quantifying reduced oxygen delivery is difficult, and may involve epoch analysis [5]. The finding of gastritis and peptic ulcer history as a significant risk factor is difficult to interpret, as pointed out by Smulter et al. No comment on an interaction analysis with other covariates was mentioned. In our practice, urgent (not emergency) CABG patients have a high incidence of gastric issues secondary to intense dual antiplatelet therapy. Urgent CABG is a known risk factor for neurological issues. As the Mini-Mental State Examination (MMSE) and the Organic Brain Syndrome Scale (OBS) used are linear scales, and delirium is not a binary issue, it would be interesting if multiple linear regression analysis would reveal the same risk factors as logistic regression, as used by Smulter et al. With regard to the logistic regression, it is customary to use a maximum of 10 events per covariate. In this study, this would limit covariate numbers to a maximum of 8, however, 18 variables from univariate analysis were utilised to develop their final model of 7 variables. Conflict of interest: none declared

Myocardial Protection by Glucose-Insulin-Potassium in Acute Coronary Syndrome Patients Undergoing Urgent Multivessel Off-Pump Coronary Artery Bypass Surgery

Background The aim of this randomized and controlled trial was to investigate the effect of a glucose–insulin–potassium (GIK) solution on myocardial protection in acute coronary syndrome (ACS) patients undergoing urgent multivessel off-pump coronary artery bypass (OPCAB) surgery. Methods Sixty-six patients were randomly allocated either to receive 0.3 ml kg−1 h−2 GIK solution (potassium 80 mEq and regular insulin 325 IU in 500 ml of 50% glucose) or equivalent volume of normal saline (control) upon anaesthetic induction until 6 h after reperfusion. The primary endpoints were to compare the concentrations of creatine kinase-MB (CK-MB) and troponin-T between the groups after reperfusion. The secondary endpoints were to compare the incidences of postoperative troponin-T >0.8 ng ml−1 and myocardial infarction (MI) between the groups. Results Highest CK-MB [8.7 (4.4) vs 13.1 (7.9) ng ml−1, P=0.006] and troponin-T [0.20 (0.13–0.49) vs 0.48 (0.18–0.91) ng ml−1, P 0.8 ng ml−1 after reperfusion compared with the control group (3 vs 11, P=0.033). The incidence of postoperative MI was similar between the groups. Conclusions GIK administration in ACS patients undergoing urgent multivessel OPCAB significantly attenuated the degree of ensuing myocardial injury without complications related to glycaemic control. Clinical Trial Registry. URL: http://clinicaltrials.gov/ct2/show/NCT01384656?term=GIK+AND+OPCAB&rank=1 . Unique identification number NCT01384656.

EComment. Early coronary artery bypass surgery for acute non-ST elevation myocardial infarction

The clinical spectrum of acute myocardial infarction (MI) may alter from ST elevation MI (STEMI) to non-ST elevation MI (NSTEMI) or unstable angina. It has commonly been suggested that early coronary artery bypass surgery (CABG) after acute MI may be associated with increased morbidity and mortality. However, advances in technology, surgical methods and myocardial protection techniques provide a chance for cardiovascular surgeon to achieve treatment of all these clinical scenarios [1]. We read with great interest the paper by Dayan and colleagues [2]. The authors have attempted to seek the answers to an important question: Does early CABG improve survival in NSTEMI? They concluded that CABG may be safely performed in patients with NSTEMI at any time after the first 6 h of MI in patients with cTnI <0.15 ng/ml. We fully agree with their implications regarding this subject and would also like to add a short comment. Patients with NSTEMI represent a heterogeneous group and are subject to a significant risk of adverse cardiac events. Early risk stratification is essential to identify patients at highest risk. CABG for complete revascularization may be frequently put into practice as a therapeutic option in patients with NSTEMI. Therefore, cardiac surgeons are faced with the difficult decision of determining the optimal surgical timing in clinically stable patients. Various studies have been designed to inform us about the risk of CABG according to the time elapsed from the event. Practice guidelines recommend delaying CABG for a few days after index admission in STEMI patients to minimize risk. However, the optimal surgical timing after the event is not addressed in most recent guidelines for NSTEMI patients. There is no consensus as to which acute MI classification poses a greater risk after CABG. Recently, Zhang and colleagues [3] studied 2412 patients who underwent isolated CABG within 21 days after acute MI. The authors suggested that MI subtype (STEMI vs NSTEMI) did not predict in-hospital mortality or major adverse events. The GRACE (Global Registry of Acute Coronary Events) score is an easily applicable and validated tool to aid the decision-making process in patients with NSTEMI. Senanayake and colleagues [4] compared the outcomes of patients undergoing urgent CABG after 24 h of NSTEMI with the GRACE predicted in-hospital and 6-month survival. In their study, urgent CABG was associated with in-hospital mortality and 6-month survival superior to that predicted by the GRACE risk score in all risk groups. The impact of early or deferred CABG on clinical outcomes of NSTEMI has not been well established. Zhang and colleagues [5] conducted a systematic literature search. In their meta-analysis, early CABG was not superior to deferred CABG for the prevention of all-cause death in patients with NSTEMI. However, a significant decrease in refractory ischaemia was observed in the early CABG patients, and the procedure also showed a tendency toward decreasing major bleeding events. In our opinion, early CABG may be performed with favourable results when the surgical timing and selected subset of patients with NSTEMI are appropriate. Conflict of interest: none declared.

Myocardial protection by glucose–insulin–potassium in acute coronary syndrome patients undergoing urgent multivessel off-pump coronary artery bypass surgery

The aim of this randomized and controlled trial was to investigate the effect of a glucose-insulin-potassium (GIK) solution on myocardial protection in acute coronary syndrome (ACS) patients undergoing urgent multivessel off-pump coronary artery bypass (OPCAB) surgery. Sixty-six patients were randomly allocated either to receive 0.3 ml kg(-1) h(-2) GIK solution (potassium 80 mEq and regular insulin 325 IU in 500 ml of 50% glucose) or equivalent volume of normal saline (control) upon anaesthetic induction until 6 h after reperfusion. The primary endpoints were to compare the concentrations of creatine kinase-MB (CK-MB) and troponin-T between the groups after reperfusion. The secondary endpoints were to compare the incidences of postoperative troponin-T >0.8 ng ml(-1) and myocardial infarction (MI) between the groups. Highest CK-MB [8.7 (4.4) vs 13.1 (7.9) ng ml(-1), P=0.006] and troponin-T [0.20 (0.13-0.49) vs 0.48 (0.18-0.91) ng ml(-1), P<0.0001] values after reperfusion were significantly lower in the GIK group compared with the control group. The area under the curve of serially measured troponin-T was also significantly smaller in the GIK group compared with the control group [0.83 (0.43-1.81) vs 0.46 (0.31-1.00), P=0.036]. Significantly fewer patients in the GIK group showed troponin-T >0.8 ng ml(-1) after reperfusion compared with the control group (3 vs 11, P=0.033). The incidence of postoperative MI was similar between the groups. GIK administration in ACS patients undergoing urgent multivessel OPCAB significantly attenuated the degree of ensuing myocardial injury without complications related to glycaemic control. Clinical Trial Registry. URL: http://clinicaltrials.gov/ct2/show/NCT01384656?term=GIK+AND+OPCAB&rank=1. Unique identification number NCT01384656.

Fatal postpartal dissection of all coronary arteries in an in vitro-fertilized woman

Myocardial infarction complicates approximately 1 in 10,000 pregnancies [1]. Coronary artery dissection is the leading cause of pregnancy-related myocardial infarction during the postpartum period. Proposed etiologies include altered endocrine status, hemodynamic stress, eosinophilic inflammatory infiltrate, and disruption of vasa vasorum. Definitive diagnosis is made by coronary angiography. Treatment has not been well defined. Strategies include medical management, stenting, and coronary artery bypass grafting. Here, we report the postpartal dissection of all 3 coronary arteries and of the left main coronary in an in vitro-fertilized, 40-year-old woman who, after giving birth to a newborn by cesarean section, presented with myocardial infarction and required urgent coronary artery bypass surgery. Spontaneous coronary dissection that predominantly affects young women is rare and is often dramatic. One-third of the cases occur during pregnancy or in the postpartum period. Our case report is unique; postpartum coronary artery dissection in a patient of any age that was fertilized in vitro is very rare.

Effects of Preoperative Short Term Use of Atorvastatin on Endothelial Progenitor Cells after Coronary Surgery: A Randomized, Controlled Trial

We investigated the effects of short-term use of atorvastatin on CD34+/VEGF-R2+/CD133+/CD45- endothelial progenitor cell (EPC) count after on-pump coronary artery bypass surgery (CABG). Between Feb-2010 and May-2010, we randomly assigned, in a placebo-controlled, double-blind study, 60 consecutive patients who underwent isolated, first-time CABG to receive either 14-day atorvastatin (40 mg/day) or placebo preoperatively. Urgent CABG and recent myocardial infarction were excluded. EPCs were quantified (cells/μl) by flow cytometric phenotyping obtained from venous blood samples collected preoperatively (T(1)), 6-hours (T(2)), and on the 5th day postoperatively (T(3)). Levels of markers of inflammation and serum cardiac troponin I were also measured preoperatively and daily until day-5 after surgery. There were no differences in baseline risk factors including cholesterol profiles, and EuroSCORES between the groups. The composite primary end-point, favored statin group with higher amount of circulating, early EPC count (cells/μl) at all time points compared with placebo (T(1), 2.30±0.02 versus 1.58±0.03, p<0.001; T(2), 5.00±0.06 versus 2.19±0.06, p<0.001; T(3), 3.03±0.08 versus 1.78±0.02, p<0.001). Postoperative hsCRP rise were inversely correlated with EPC count, and were significantly lower in the statin group (T(1), 0.8 ± 0.1 versus 2.2±1.5, p<0.001; T(2), 72.9±3.2 versus 96.0±3.6, p<0.001; T(3), 4.3±1.2 versus 11.4±4.1, p<0.001). Furthermore, the incidence of postoperative atrial fibrillation was significantly lower in the statin group compared to placebo (3.3% versus 23%, p=0.02). Short-term atorvastatin use increases circulating early EPCs both pre- and post-operatively and is associated with better preservation of sinus rhythm and reduced hsCRP levels. (ClinicalTrials.gov number, NCT01096875).

Importance of strict patient selection criteria for combined carotid endarterectomy and coronary artery bypass grafting

BackgroundManagement of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria. MethodsFrom 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43–88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis. ResultsThirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies. ConclusionCombined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery.

Impact of clopidogrel use on mortality and major bleeding in patients undergoing coronary artery bypass surgery☆

Patients who received clopidogrel prior to coronary bypass surgery are at increased risk for bleeding that must be balanced with risk of ongoing ischemia if coronary artery bypass grafting is delayed. This study aimed to evaluate the impact of clopidogrel on mortality and major bleeding in patients undergoing urgent coronary bypass surgery. We reviewed 451 consecutive patients who underwent urgent isolated coronary bypass surgery; 262 had not received clopidogrel, whereas 189 received clopidogrel < or = 5 days preoperative. The primary endpoint was in-hospital death, massive transfusion or massive blood loss. Patient characteristics were almost similar between groups. There was no difference in in-hospital death or massive bleeding indices between groups (clopidogrel: 7% vs. no clopidogrel: 6%, P = 0.9). No difference was observed even after adjusting for the date of stopping clopidogrel preoperatively. Multivariate regression analysis showed that clopidogrel or the duration it was stopped preoperatively, did not predict adverse outcomes. Significant independent predictors included preoperative renal dysfunction, hemoglobin level and peripheral vascular disease. clopidogrel, or the time it was stopped prior to surgery, was not a risk factor for in-hospital death, massive bleeding, or other poor early outcomes in patients undergoing urgent coronary artery bypass surgery.

Long-term Survival after Surgery for Acute Coronary Syndromes in Relation to Perioperative Troponin T Release and Angina Class – A Prospective Study in 200 Patients

Patients with acute coronary syndrome have an increased risk of cardiac death or myocardial infarction after urgent coronary artery bypass surgery (CABG). Symptoms and signs of ongoing ischemia, such as elevated cardiac troponin T and angina at rest at the time of the operation identify patients at particular risk of early death, but the impact of these parameters on long-term survival is poorly investigated. Two hundred patients, 100 with acute coronary syndrome and 100 with stable angina pectoris, underwent primary isolated CABG. Troponin T levels were assayed immediately before the operation and at 64 hours after the aortic cross-clamp had been removed. The severity of the patients' unstable symptoms was classified according to Braunwald. Early outcome and long-term survival were analyzed. Among the unstable patients 3 deaths occurred within 30 days of the operation, and there were 12 late deaths. In the control group there were no early and 19 late deaths. The patients were followed up for 6.5 years (0-7.7 years), a total of 1 294 patient years. The cumulative long-term survival was 85 % for the unstable and 81 % for the stable patients ( P = 0.75). Freedom from cardiac death was 92 % in unstable and 94 % in stable patients. Five unstable and one of the stable patients suffered postoperative myocardial infarction ( P = 0.01). A troponin T level > 0.1 microg/L immediately prior to the operation was associated with an increased need for postoperative pharmacological inotropic support ( P < 0.001) and intra-aortic balloon counterpulsation ( P = 0.004). Symptoms and signs of ongoing ischemia (angina at rest and elevated troponin T immediately prior to the operation) had no predictive value for long-term survival. In patients with acute coronary syndrome, parameters such as elevated troponin T and angina at rest herald an increased risk of postoperative myocardial infarction and indicate the need for pharmacological and mechanical inotropic support but have no bearing on long-term survival.

Sarcoidosis and Coronary Bypass Surgery: A Case Report

Sarcoidosis, a chronic granulomatous disease with unknown etiology and pathogenesis, affects the skin and many other organs and has a course characterized by remissions and relapses. We describe a patient with sarcoidosis, which we diagnosed retrospectively after we had difficulties in harvesting the left internal thoracic artery because of giant and disseminated mediastinal lymphadenopathies on the anterior thoracic wall during urgent coronary artery bypass surgery.