151
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Bardají A, Rodriguez-López J, Torres-Sánchez M. Chronic total occlusion: To treat or not to treat. World J Cardiol 2014; 6:621-629. [PMID: 25068022 PMCID: PMC4110610 DOI: 10.4330/wjc.v6.i7.621] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/16/2014] [Indexed: 02/06/2023] Open
Abstract
Over the last two decades, there has been increasing interest in new techniques for the percutaneous treatment of coronary chronic total occlusions (CTO), which have a success rate that is much higher than that of a few years ago. The rise in percutaneous treatment for these lesions is due to its ability to improve the symptoms and prognosis of patients in the chronic and stable phase of coronary disease. Current data suggest that successful percutaneous coronary intervention for CTO is associated with improvement in patient symptoms, quality of life, left ventricular function, and survival, compared with those with unsuccessful CTO PCI. However, all the scientific evidence supporting this treatment comes from observational studies, and no randomized study comparing percutaneous treatment with medical treatment has yet been published. A major limitation of these studies is their observational design, with limited information with regard to potential baseline differences between the successful vs unsuccessful cohorts. Pending randomized studies, patients should be selected very carefully, especially if they are asymptomatic or very few symptoms, and the benefits obtained in terms of complications during the procedure, the quality of life obtained and further ischemic events avoided should be evaluated systematically. In this review, we will consider the available information supporting percutaneous treatment for chronic occlusions, as well as the areas of uncertainty where more research projects are required.
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152
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Sachdeva R, Agrawal M, Flynn SE, Werner GS, Uretsky BF. Rebuttal: change in donor artery fractional flow reserve after recanalization of a chronic total occlusion-not as impressive as some might have us believe. Catheter Cardiovasc Interv 2014; 83:1187-9. [PMID: 24259449 DOI: 10.1002/ccd.25304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 11/16/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Rajesh Sachdeva
- WellStar Cardiology, North Fulton Hospital, 3000 Hospital Boulevard, Roswell, Georgia
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153
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Sur S, Sugimoto JT, Agrawal DK. Coronary artery bypass graft: why is the saphenous vein prone to intimal hyperplasia? Can J Physiol Pharmacol 2014; 92:531-45. [PMID: 24933515 DOI: 10.1139/cjpp-2013-0445] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Proliferation and migration of smooth muscle cells and the resultant intimal hyperplasia cause coronary artery bypass graft failure. Both internal mammary artery and saphenous vein are the most commonly used bypass conduits. Although an internal mammary artery graft is immune to restenosis, a saphenous vein graft is prone to develop restenosis. We found significantly higher activity of phosphatase and tensin homolog (PTEN) in the smooth muscle cells of the internal mammary artery than in the saphenous vein. In this article, we critically review the pathophysiology of vein-graft failure with detailed discussion of the involvement of various factors, including PTEN, matrix metalloproteinases, and tissue inhibitor of metalloproteinases, in uncontrolled proliferation and migration of smooth muscle cells towards the lumen, and invasion of the graft conduit. We identified potential target sites that could be useful in preventing and (or) reversing unwanted consequences following coronary artery bypass graft using saphenous vein.
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Affiliation(s)
- Swastika Sur
- a Department of Biomedical Science, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
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154
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Olomu AB, Stommel M, Holmes-Rovner MM, Prieto AR, Corser WD, Gourineni V, Eagle KA. Is quality improvement sustainable? Findings of the American college of cardiology's guidelines applied in practice. Int J Qual Health Care 2014; 26:215-22. [DOI: 10.1093/intqhc/mzu030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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155
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Singh I, Achuthan S, Chakrabarti A, Rajagopalan S, Srinivasan A, Hota D. Influence of pre-operative use of serotonergic antidepressants (SADs) on the risk of bleeding in patients undergoing different surgical interventions: a meta-analysis. Pharmacoepidemiol Drug Saf 2014; 24:237-45. [DOI: 10.1002/pds.3632] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 03/25/2014] [Accepted: 03/29/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Inderjeet Singh
- Department of Pharmacology; Post Graduate Institute of Medical Education and Research (PGIMER); Chandigarh India
| | - Shyambalaji Achuthan
- Department of Pharmacology; Post Graduate Institute of Medical Education and Research (PGIMER); Chandigarh India
| | - Amitava Chakrabarti
- Department of Pharmacology; Post Graduate Institute of Medical Education and Research (PGIMER); Chandigarh India
| | - Sujit Rajagopalan
- Department of Pharmacology; Post Graduate Institute of Medical Education and Research (PGIMER); Chandigarh India
| | - Anand Srinivasan
- Department of Pharmacology; Post Graduate Institute of Medical Education and Research (PGIMER); Chandigarh India
| | - Debasish Hota
- Department of Pharmacology; All India Institute of Medical Sciences (AIIMS); Bhubaneshwar Odisha India
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156
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Gonzalez AA, Dimick JB, Birkmeyer JD, Ghaferi AA. Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue. JAMA Surg 2014; 149:119-23. [PMID: 24336902 DOI: 10.1001/jamasurg.2013.3649] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE To effectively guide interventions aimed at reducing mortality in low-volume hospitals, the underlying mechanisms of the volume-outcome relationship must be further explored. Reducing mortality after major postoperative complications may represent one point along the continuum of patient care that could significantly affect overall hospital mortality. OBJECTIVE To determine whether increased mortality at low-volume hospitals performing cardiovascular surgery is a function of higher postoperative complication rates or of less successful rescue from complications. DESIGN, SETTING, AND PARTICIPANTS We used patient-level data from 119434 Medicare fee-for-service beneficiaries aged 65 to 99 years undergoing coronary artery bypass grafting, aortic valve repair, or abdominal aortic aneurysm repair between January 1, 2005, and December 31, 2006. For each operation, we first divided hospitals into quintiles of procedural volume. We then assessed hospital risk-adjusted rates of mortality, major complications, and failure to rescue (ie, case fatality among patients with complications) within each volume quintile. EXPOSURE Hospital procedural volume. MAIN OUTCOMES AND MEASURES Hospital rates of risk-adjusted mortality, major complications, and failure to rescue. RESULTS For each operation, hospital volume was more strongly related to failure-to-rescue rates than to complication rates. For example, patients undergoing aortic valve replacement at very low-volume hospitals (lowest quintile) were 12% more likely to have a major complication than those at very high-volume hospitals (highest quintile) but were 57% more likely to die if a complication occurred. CONCLUSIONS AND RELEVANCE High-volume and low-volume hospitals performing cardiovascular surgery have similar complication rates but disparate failure-to-rescue rates. While preventing complications is important, hospitals should also consider interventions aimed at quickly recognizing and managing complications once they occur.
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Affiliation(s)
- Andrew A Gonzalez
- Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago2Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - John D Birkmeyer
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
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Mannacio V, Meier P, Antignano A, Mottola M, Di Tommaso L, Musumeci F, Vosa C. Continuative statin therapy after percutaneous coronary intervention improves outcome in coronary bypass surgery: a propensity score analysis of 2501 patients. J Thorac Cardiovasc Surg 2014; 148:1876-83. [PMID: 24667027 DOI: 10.1016/j.jtcvs.2014.02.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/04/2014] [Accepted: 02/14/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVES A history of percutaneous coronary intervention increases the risk of death and complications of coronary artery bypass grafting. This retrospective multicenter study evaluated the impact of continuative use of statin on postoperative outcomes when subsequent elective coronary artery bypass grafting is required after percutaneous coronary intervention. METHODS Among 14,575 patients who underwent isolated first-time coronary artery bypass grafting between January 2000 and December 2010, 2501 who had previous percutaneous coronary intervention with stenting and fulfilled inclusion criteria were enrolled. Continuative statin therapy was used in 1528 patients and not used in 973 patients. Logistic multiple regression and propensity score analyses were used to assess the risk-adjusted impact of statin therapy on in-hospital mortality and major adverse cardiac events. The Cox proportional hazards model was constructed to assess the effect of continuative statin therapy on 24-month outcome. RESULTS At multivariate analysis, age more than 70 years, 3-vessel or 2-vessel plus left main coronary disease, multivessel percutaneous coronary intervention, ejection fraction 0.40 or less, diabetes mellitus, and logistic European System for Cardiac Operative Risk Evaluation 5 or greater were independent predictors of hospital mortality and major adverse cardiac events. After propensity score matching, conditional logistic regression analysis demonstrated that continuative statin therapy before coronary artery bypass grafting reduced the risk for hospital and 2-year mortality (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.12-0. 57; P=.004 and OR, 0.6; 95% CI, 0.36-0.96; P=.04, respectively) and major adverse cardiac events (OR, 0.31; 95% CI, 0.18-0.78; P=.003 and OR, 0.5; 95% CI, 0.34-0.76; P=.006, respectively). CONCLUSIONS Long-term statin treatment after percutaneous coronary intervention improves early and midterm outcome when surgical revascularization will be required.
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Affiliation(s)
- Vito Mannacio
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.
| | - Pascal Meier
- Divisions of Cardiology and Cardiac Surgery, Yale Medical School, New Haven, Conn; Cardiology, University College London Hospital, London, United Kingdom
| | - Anita Antignano
- Department of Cardiology, Azienda Ospedaliera Santobono-Pausillipon, Naples, Italy
| | - Michele Mottola
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy
| | - Luigi Di Tommaso
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy
| | - Francesco Musumeci
- Department of Cardiac Surgery, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | - Carlo Vosa
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy
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158
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Cause and effects of decreasing coronary revascularization procedures in California hospitals, 2006 to 2010. Am J Cardiol 2014; 113:465-70. [PMID: 24321898 DOI: 10.1016/j.amjcard.2013.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/05/2013] [Accepted: 10/05/2013] [Indexed: 11/21/2022]
Abstract
Coronary revascularization procedures decreased markedly in California after the introduction of drug-eluting stents and the initiation of public reporting in 2003, resulting in a large number of low-volume heart programs. California hospital discharge data were analyzed from 2006 to 2010 to study the impact of this change. In-hospital mortality and hospital readmission for major adverse events at 90 days and 365 days were determined for patients who underwent isolated coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) either with acute coronary syndrome (ACS) or PCI without acute coronary syndrome (PCI-noACS). Three terciles were chosen by case volume as follows: high-volume (747 ± 336 [SD]/yr total PCI, 210 ± 130 isolated CABG), intermediate volume (362 ± 47 PCI, 106 ± 27 CABG), and low-volume (211 ± 6 PCI, 53 ± 17 CABG) terciles were studied. PCI-noACS procedures decreased 33% and CABG 20%, whereas PCI-ACS procedures increased slightly. Risk-adjusted in-hospital mortality was slightly better in high-volume compared with low-volume terciles for CABG (2.0% vs 2.6%) and PCI-noACS (0.64% vs 0.85%). There was no difference in major adverse events at 90 days or 365 days among volume terciles within procedure groups, and no change in event rates was noted over the 5-year period. Wide variation in outcomes, associated with low volume, contributed to poor statistical discrimination among providers. In conclusion, lower volume hospitals had similar overall outcomes with wider variation. Conservative treatment strategies apparently contributed to decreased procedure volume. Collaboration among hospitals of similar structure and case volume may be the most appropriate performance improvement model to reduce variability among providers.
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159
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Ferraris VA, Bolanos MD. Use of Antiplatelet Drugs After Cardiac Operations. Semin Thorac Cardiovasc Surg 2014; 26:223-30. [DOI: 10.1053/j.semtcvs.2014.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2014] [Indexed: 01/24/2023]
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160
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Pantoni CBF, Mendes RG, Di Thommazo-Luporini L, Simões RP, Amaral-Neto O, Arena R, Guizilini S, Gomes WJ, Catai AM, Borghi-Silva A. Recovery of linear and nonlinear heart rate dynamics after coronary artery bypass grafting surgery. Clin Physiol Funct Imaging 2013; 34:449-56. [PMID: 24666784 DOI: 10.1111/cpf.12115] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 11/15/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND Conventional coronary artery bypass grafting (C-CABG) and off-pump CABG (OPCAB) surgery may produce different patients' outcomes, including the extent of cardiac autonomic (CA) imbalance. The beneficial effects of an exercise-based inpatient programme on heart rate variability (HRV) for C-CABG patients have already been demonstrated by our group. However, there are no studies about the impact of a cardiac rehabilitation (CR) on HRV behaviour after OPCAB. The aim of this study is to compare the influence of both operative techniques on HRV pattern following CR in the postoperative (PO) period. METHODS Cardiac autonomic function was evaluated by HRV indices pre- and post-CR in patients undergoing C-CABG (n = 15) and OPCAB (n = 13). All patients participated in a short-term (approximately 5 days) supervised CR programme of early mobilization, consisting of progressive exercises, from active-assistive movements at PO day 1 to climbing flights of stairs at PO day 5. RESULTS Both groups demonstrated a reduction in HRV following surgery. The CR programme promoted improvements in HRV indices at discharge for both groups. The OPCAB group presented with higher HRV values at discharge, compared to the C-CABG group, indicating a better recovery of CA function. CONCLUSION Our data suggest that patients submitted to OPCAB and an inpatient CR programme present with greater improvement in CA function compared to C-CABG.
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Affiliation(s)
- Camila Bianca Falasco Pantoni
- Cardiopulmonary Physiotherapy Laboratory, Nucleus of Research in Physical Exercise, Federal University of São Carlos, São Carlos, Brazil
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161
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A Randomized Controlled Trial of Preoperative Intra-Aortic Balloon Pump in Coronary Patients With Poor Left Ventricular Function Undergoing Coronary Artery Bypass Surgery*. Crit Care Med 2013; 41:2476-83. [DOI: 10.1097/ccm.0b013e3182978dfc] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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162
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163
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Halkos ME, Walker PF, Vassiliades TA, Douglas JS, Devireddy C, Guyton RA, Finn AV, Rab ST, Puskas JD, Liberman HA. Clinical and angiographic results after hybrid coronary revascularization. Ann Thorac Surg 2013; 97:484-90. [PMID: 24140212 DOI: 10.1016/j.athoracsur.2013.08.041] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/15/2013] [Accepted: 08/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND With hybrid coronary revascularization (HCR), minimally invasive left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) grafting is combined with percutaneous coronary intervention (PCI) of non-LAD vessels. The purpose of this study was to examine the short-term clinical and angiographic results in one of the largest HCR series to date. METHODS From 2003 to 2012, 300 consecutive patients (aged 64±12 years, female 31.7%, predicted risk of mortality 1.6%±2.1%) underwent HCR on an intent-to-treat basis at a single institution. After robotic or thoracoscopic LIMA harvest, off-pump LIMA to LAD grafting was performed through a 3- to 4-cm sternal-sparing, non-rib-spreading thoracotomy. PCI was utilized to treat non-LAD lesions either before, after, or concomitant with the surgical procedure. RESULTS Of the 300 patients undergoing HCR on an intent-to-treat basis, HCR was performed with surgery first in 192 patients (64.0%), PCI first in 56 (18.7%), and as a concomitant procedure in 21 (7.0%). Of the 31 patients (10.1%) who did not undergo HCR, 24 patients (8.0%) did not have PCI and thus were incompletely revascularized. For all patients, 30-day mortality, stroke, and nonfatal myocardial infarction occurred in 4 (1.3%), 3 (1.0%), and 4 (1.3%), respectively. Angiographic LIMA evaluation was performed in 248 patients and revealed a FitzGibbon A LIMA patency rate of 97.6% (242 of 248 patients). Repeat revascularization was required in 13 of 300 patients (4.3%). CONCLUSIONS Hybrid coronary revascularization represents an alternative approach for patients with multivessel coronary disease with excellent short-term outcomes. It provides a minimally invasive alternative to traditional coronary artery bypass graft surgery and may prove more durable than multivessel PCI.
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Affiliation(s)
- Michael E Halkos
- Division of Cardiothoracic Surgery, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia.
| | - Patrick F Walker
- Division of Cardiothoracic Surgery, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - Thomas A Vassiliades
- Division of Cardiothoracic Surgery, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - John S Douglas
- Division of Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - Chandan Devireddy
- Division of Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - Robert A Guyton
- Division of Cardiothoracic Surgery, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - Aloke V Finn
- Division of Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - S Tanveer Rab
- Division of Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - John D Puskas
- Division of Cardiothoracic Surgery, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
| | - Henry A Liberman
- Division of Cardiology, Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
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164
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Basiskoronarchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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165
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Anastasiadis K, Asteriou C, Antonitsis P, Argiriadou H, Grosomanidis V, Kyparissa M, Deliopoulos A, Konstantinou D, Tossios P. Enhanced Recovery After Elective Coronary Revascularization Surgery With Minimal Versus Conventional Extracorporeal Circulation: A Prospective Randomized Study. J Cardiothorac Vasc Anesth 2013; 27:859-64. [DOI: 10.1053/j.jvca.2013.01.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 11/11/2022]
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166
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Mild anastomotic stenosis in patient-specific CABG model may enhance graft patency: a new hypothesis. PLoS One 2013; 8:e73769. [PMID: 24058488 PMCID: PMC3772875 DOI: 10.1371/journal.pone.0073769] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 07/02/2013] [Indexed: 12/05/2022] Open
Abstract
It is well known that flow patterns at the anastomosis of coronary artery bypass graft (CABG) are complex and may affect the long-term patency. Various attempts at optimal designs of anastomosis have not improved long-term patency. Here, we hypothesize that mild anastomotic stenosis (area stenosis of about 40–60%) may be adaptive to enhance the hemodynamic conditions, which may contribute to slower progression of atherosclerosis. We further hypothesize that proximal/distal sites to the stenosis have converse changes that may be a risk factor for the diffuse expansion of atherosclerosis from the site of stenosis. Twelve (12) patient-specific models with various stenotic degrees were extracted from computed tomography images using a validated segmentation software package. A 3-D finite element model was used to compute flow patterns including wall shear stress (WSS) and its spatial and temporal gradients (WSS gradient, WSSG, and oscillatory shear index, OSI). The flow simulations showed that mild anastomotic stenosis significantly increased WSS (>15 dynes⋅cm−2) and decreased OSI (<0.02) to result in a more uniform distribution of hemodynamic parameters inside anastomosis albeit proximal/distal sites to the stenosis have a decrease of WSS (<4 dynes⋅cm−2). These findings have significant implications for graft adaptation and long-term patency.
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167
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Rudersdorf PD, Abolhoda A, Carey JS, Danielsen B, Milliken JC. Adverse events after coronary revascularization procedures in California 2000 to 2010. Am J Cardiol 2013; 112:483-7. [PMID: 23668638 DOI: 10.1016/j.amjcard.2013.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 11/18/2022]
Abstract
Public reporting of coronary artery bypass grafting (CABG) mortality in California was initiated in 2003. Drug-eluting stents were widely introduced in the same year. Adverse events after percutaneous coronary intervention (PCI) and CABG were analyzed to study the impact of these events. Annual California hospital discharge data were collected from 2000 through 2010. In-hospital mortality and hospital readmission for adverse events <1 year were determined for patients undergoing isolated CABG, PCI for acute coronary syndrome (PCI-ACS), and all other PCIs (PCI-noACS). CABG volume peaked in 2000 and subsequently decreased by 58%; PCI volume peaked in 2005 and subsequently decreased by 20%. After 2003, in-hospital mortality and 1-year mortality for CABG decreased whereas mortality after PCI remained unchanged. Event rates for acute myocardial infarction and stroke varied little over the decade; acute myocardial infarction at 1 year was 2.5% to 2.8% (CABG), 4.5% to 5.4% (PCI-ACS), and 4.6% to 5.8% (PCI-noACS); stroke rate was 1.4% to 1.7% (CABG), 1.2% to 1.6% (PCI-ACS), and 1.0% to 1.2% (PCI-noACS). Reintervention for PCI decreased markedly, from 18.8% to 12.8% (PCI-ACS) and 22.5% to 13.3% (PCI-noACS). Multiple adverse cardiovascular and cerebral events rate at 1 year decreased from 10.8% to 9.4% (CABG), 26.5% to 21.2% (PCI-ACS), and 26.8% to 18.4% (PCI-noACS). Excluding reinterventions, multiple adverse cardiovascular and cerebral events rate at 1 year was 8.3% (CABG), 14.6% (PCI-ACS), and 10.1% (PCI-noACS) in 2010. In conclusion, the volume of coronary interventions in California decreased whereas adverse event rates decreased after the introduction of public reporting and drug-eluting stents. Lower procedure volume combined with improved outcomes resulted in an annual decrease of >6,000 adverse events by the end of the decade.
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Affiliation(s)
- Patrick D Rudersdorf
- Department of Surgery, Division of Cardiothoracic Surgery, University of California, Irvine, California
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168
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Kolh P. Invited commentary. Ann Thorac Surg 2013; 96:542. [PMID: 23910103 DOI: 10.1016/j.athoracsur.2013.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 05/10/2013] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Philippe Kolh
- CT Surgery, University Hospital of Liege, CHU Sart Tilman B35, Liege 4000, Belgium.
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169
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Choi SP, Wee JH, Park JH, Park KN, Hong SJ, Lee SH. Therapeutic hypothermia following emergent coronary artery bypass grafting after failed percutaneous coronary intervention in a comatose post-cardiac arrest patient. J Korean Med Sci 2013; 28:1257-9. [PMID: 23960458 PMCID: PMC3744719 DOI: 10.3346/jkms.2013.28.8.1257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 02/27/2013] [Indexed: 11/25/2022] Open
Abstract
We report the case of 60-yr-old female in which therapeutic hypothermia (TH) was successfully induced maintaining the target temperature of 34℃ for 12 hr despite a risk of hypothermia-induced coagulation abnormalities following an emergent coronary artery bypass grafting (CABG) due to failed percutaneous coronary intervention, who suffered a cardiac arrest. Emergent CABG may be a relative contraindication for TH in post-cardiac arrest patients because hypothermia may increase the risk of infection and bleeding. However, the possibility of an improved neurologic outcome outweighs the risk of bleeding, although major surgery may be a relative contraindication for TH.
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Affiliation(s)
- Seung Pill Choi
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hee Wee
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Jin Hong
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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White RW, West R, Howard P, Sandoe J. Antimicrobial Regime for Cardiac Surgery
: The Safety and Effectiveness of Short-Course Flucloxacillin (or Teicoplanin) and Gentamicin-Based Prophylaxis. J Card Surg 2013; 28:512-6. [DOI: 10.1111/jocs.12155] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ralph W. White
- Department of Cardiothoracic Surgery; Leeds Teaching Hospitals NHS Trust; Leeds UK
| | - Robert West
- Department of Biostatistics; University of Leeds; Leeds UK
| | - Philip Howard
- Department of Pharmacy; Leeds Teaching Hospitals NHS Trust; Leeds UK
| | - Jonathan Sandoe
- Department of Microbiology; Leeds Teaching Hospitals NHS Trust; Leeds UK
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Harskamp RE, Lopes RD, Baisden CE, de Winter RJ, Alexander JH. Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions. Ann Surg 2013; 257:824-33. [PMID: 23574989 DOI: 10.1097/sla.0b013e318288c38d] [Citation(s) in RCA: 237] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To review our current understanding of the epidemiology and pathogenesis of vein graft failure (VGF), give an overview of current preventive and interventional measures, and explore strategies that may improve vein graft patency. BACKGROUND VGF and progression of native coronary artery disease limit the long-term efficacy of coronary artery bypass graft surgery. METHODS We reviewed the published literature on the pathophysiology, prevention, and/or treatment of VGF by searching the MEDLINE (January 1, 1966-January 1, 2012), EMBASE (January 1, 1980-January 1, 2012), and Cochrane (January 1, 1995-January 1, 2012) databases. In addition, we reviewed references from the selected articles for studies not identified in the initial search. Basic science and clinical studies were included; non-English language publications were excluded. RESULTS Acute thrombosis, neointimal hyperplasia, and accelerated atherosclerosis are the 3 mechanisms that lead to VGF. Preventive measures include matching and quality assessment of conduit and target vessel, lipid-lowering drugs, antithrombotic therapy, and cessation of smoking. Treatment of VGF includes medical therapy, percutaneous intervention, and redo coronary artery bypass graft surgery. In patients undergoing graft intervention, the use of drug-eluting stents, antiplatelet agents, and embolic protection devices may improve clinical outcomes. CONCLUSIONS Despite advances in management, VGF remains one of the leading causes of poor in-hospital and long-term outcomes after coronary artery bypass graft surgery. New developments in VGF prevention such as gene therapy, external graft support, fully tissue-engineered grafts, hybrid grafts, and synthetic conduits are promising but unproven. Future efforts to reduce VGF require a multidisciplinary approach with a primary focus on prevention.
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Affiliation(s)
- Ralf E Harskamp
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA
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172
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Liu TJ, Shih MS, Lee WL, Wang KY, Liu CN, Hung CJ, Lai HC. Hypoxemia during one-lung ventilation for robot-assisted coronary artery bypass graft surgery. Ann Thorac Surg 2013; 96:127-32. [PMID: 23731612 DOI: 10.1016/j.athoracsur.2013.04.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 04/09/2013] [Accepted: 04/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Robot-assisted coronary artery bypass grafting requires continuous one-lung ventilation (OLV) to evacuate the thoracic cavity. Whether this ventilatory mode subjects patients to serious hypoxemia remains underinvestigated. METHODS From 2005 to 2010, all patients receiving robot-assisted coronary artery bypass graft surgery using OLV with active capnothorax for internal mammary artery harvesting and then passive pneumothorax for minithoracotomy direct-vision coronary bypass graft surgery were included. Patients' variables of oxygenation were monitored and compared throughout the whole surgical period. Persistent oxygen desaturation (arterial oxygen pressure <70 mm Hg) refractory to primary managements was defined as a hypoxemic event, and predictors of such events were identified by multivariate regression analysis. RESULTS A total of 255 consecutive patients were enrolled. Average oxygen saturation decreased modestly during the first stage of OLV with active capnothorax, causing hypoxemic events in 9 patients (4.3%) leading to death in 2 (0.8%), whereas it dropped drastically in the second stage of OLV with passive pneumothorax, resulting in hypoxemic events in 32 patients (12.6%) and death in 1 (0.4%). Multivariate regression analysis identified high pulmonary vascular resistance and low left ventricular ejection fraction as predictors of hypoxemia during internal mammary artery takedown, whereas prolonged procedure and chronic obstructive pulmonary disease were identified as predictors during minithoracotomy bypass grafting. CONCLUSIONS Robot-assisted two-stage coronary artery bypass surgery employing OLV could be complicated by serious hypoxemia especially at the minithoracotomy grafting stage and in patients with specific risk factors. Thus, when managing such patients, invasive monitoring and aggressive treatment of arterial desaturation are mandatory to ensure the patient's safety and procedural smoothness.
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Affiliation(s)
- Tsun-Jui Liu
- Department of Anesthesiology and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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173
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Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, , Rotterdam, The Netherlands
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174
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Unprotected left main coronary artery disease. Surgical therapy. Herz 2013; 38:143-6. [PMID: 23471358 DOI: 10.1007/s00059-013-3773-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Coronary artery bypass grafting (CABG) has been established as a safe concept in the treatment of unprotected left main coronary artery (ULMCA) disease and is considered the first-line treatment in current interdisciplinary guidelines. Regardless of the complexity of the lesion and the concomitant diseases, CABG is associated with excellent long-term results. Randomized controlled trials investigating the role of percutaneous coronary intervention in the setting of ULMCA lesions are frequently underpowered and suggest that, when restricted to less complex lesions, percutaneous coronary intervention is associated with results comparable to surgery. Thus, there is an urgent need for further randomized controlled trials RCTs with all-comers design to supply precise data under real-life conditions representative of the left main stem anatomy. Until then, an interdisciplinary approach to patients with ULMCA lesions is mandatory in view of the existing guidelines.
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175
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Hoffman DM, Dimitrova KR, Decastro H, Friedmann P, Geller CM, Ko W, Tranbaugh RF. Improving long term outcome for diabetic patients undergoing surgical revascularization by use of the radial artery conduit: a propensity matched study. J Cardiothorac Surg 2013; 8:27. [PMID: 23421972 PMCID: PMC3598974 DOI: 10.1186/1749-8090-8-27] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 02/01/2013] [Indexed: 02/06/2023] Open
Abstract
Background Diabetes predicts worse outcomes after coronary artery bypass grafting (CABG) We hypothesized that a strategy using radial artery (RA) conduit(s) would improve outcomes and long term survival for diabetic patients undergoing CABG with Left Internal Thoracic Artery (LITA) and RA grafts, with or without additional saphenous vein (SV) when compared with outcomes for patients bypassed with LITA and SV but no RA. Methods A propensity matched study of long term survival in diabetic patients who had isolated first time CABG from January 1995 to June 2010 at an urban academic medical center in New York City. Our primary endpoint was all cause mortality determined from the Social Security Death Index in December 2010. Results We compared our 15 year outcomes in diabetic patients after isolated, primary CABG: 642 patients received LITA + RA +/− SV (RA group) vs. 1201 patients who had LITA + SV only (SV group). Propensity scoring for multiple preoperative and operative variables matched 409 patients from each group: 68% were male with an average age of 61 years and ejection fraction averaged 47%. Average grafts per patient was 3.7 for both groups with 2.3 arterial grafts per patient for the RA group. Operative (30 day) mortality was 0.1% RA vs. 1.9% SV, (p<0.0001) For propensity matched patients, mortality was 0.25 RA vs 0.5% SV. (p<0.001) The incidence of major complications was similar in both groups. Kaplan Meier actuarial survival at 1, 5, 10 and 12 years was 98%, 89%, 77 and 70% for RA vs. 96%, 87%, 64% and 59% for SV (p<0.006.) By Cox multivariate analysis significant predictors of mortality were: age, stroke, peripheral vascular disease, COPD, creatinine > 2.5mg/dl and low ejection fraction but only RA use predicted better survival [HR 0.683, CI 0.507- 0.920, p=0.0122]. Conclusion For diabetic patients having CABG with LITA, use of radial artery conduit adds a substantial and sustained survival advantage compared to LITA and vein. Optimal revascularization for diabetics with multi vessel disease is redefined.
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Affiliation(s)
- Darryl M Hoffman
- Division of Cardiac Surgery and Office of Grants and Research Administration, Beth Israel Medical Center, New York, NY 10003, USA.
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176
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Heilmann C, Stahl R, Schneider C, Sukhodolya T, Siepe M, Olschewski M, Beyersdorf F. Wound complications after median sternotomy: a single-centre study. Interact Cardiovasc Thorac Surg 2013; 16:643-8. [PMID: 23355648 DOI: 10.1093/icvts/ivs554] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Sternal wound complications following median sternotomy remain a challenge in cardiac surgery. Changes in both patient profile and type of operations have been observed in recent years. Therefore, we analysed current wound healing complications after median sternotomy at our centre. METHODS All adult patients undergoing a median sternotomy between January 2009 and April 2011 were included in this retrospective analysis. Transplants and assist devices implantations were omitted. We assessed outcome, prognostic factors and microbiological results of standardized wound swabs. RESULTS In total, 1297 patients with an average age of 67.0 ± 12.7 years were analysed. Operation types included 598 solitary coronary artery bypass grafts (CABGs), 213 solitary valve procedures, 105 CABGs with aortic valve replacement and 116 solitary aortic operations or conduit implantations. Furthermore, 255 of the remaining 265 were combined or otherwise complex procedures. Superficial healing disorders occurred in 43 patients (3.3%), while 33 (2.5%) developed deep wound complications. Six patients with sternal wound complications (7.9%) died in-hospital. In 7 patients, no pathogen was identified and the wound appeared uninfected (21% of all deep complications or 0.05% of all patients). These healing disorders were considered deep dehiscences. Patients with insulin-dependent diabetes mellitus, BMI of >40 kg/m(2) and who underwent reoperation were prone to superficial infections. Risk factors for all deep sternal wound complications were insulin-dependent diabetes mellitus, COPD and reoperation. Moreover, multivariate analysis revealed 'emergency' as an independent prognostic factor for all sternal wound complications. Microbial swabs of the sternal wound were taken in 82 of the 1297 patients (6.6%). Pathogens of the normal skin flora represented the majority of pathogens in both superficial and deep wound complications. Eight patients with deep, but only 2 patients with superficial complications suffered from polymicrobial infections. All deep polymicrobial infections involved coagulase-negative Staphylococci. CONCLUSIONS Wound complications following median sternotomy remain a challenge to cardiac surgery. Redo and emergency operations are the most important risk factors in this contemporary series. More efforts seem mandatory to decrease this arduous morbidity and the costs of prolonged treatment.
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Affiliation(s)
- Claudia Heilmann
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany. claudia.heilmann@universitaets-herzzentrum
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177
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Abstract
Although the modern surgical era is highlighted by multiple technological advances and innovations, one area that has remained constant is the dependence of the surgeon's vision on white-light reflectance. This renders different body tissues in a limited palette of various shades of pink and red, thereby limiting the visual contrast available to the operating surgeon. Healthy tissue, anatomic variations, and diseased states are seen as slight discolorations relative to each other and differences are inherently limited in dynamic range. In the upcoming years, surgery will undergo a paradigm shift with the use of targeted fluorescence imaging probes aimed at augmenting the surgical armamentarium by expanding the "visible" spectrum available to surgeons. Such fluorescent "smart probes" will provide real-time, intraoperative, pseudo-color, high-contrast delineation of both normal and pathologic tissues. Fluorescent surgical molecular guidance promises another major leap forward to improve patient safety and clinical outcomes, and to reduce overall healthcare costs. This review provides an overview of current and future surgical applications of fluorescence imaging in diseased and nondiseased tissues and focus on the innovative fields of image processing and instrumentation.
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Affiliation(s)
- Ryan K Orosco
- Division of Head and Neck Surgery, University of California San Diego, La Jolla, CA 92093-0647, USA
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178
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Wehman B, Taylor B. Coronary Revascularization Using Bilateral Internal Thoracic Arteries: Safe with Skeletonization? ACTA ACUST UNITED AC 2013; Suppl 7:007. [PMID: 24761259 PMCID: PMC3992858 DOI: 10.4172/2155-9880.s7-007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Substantial evidence exists to support a long-term survival benefit with bilateral internal thoracic artery (BITA) revascularization in coronary artery bypass grafting. However, this technique remains grossly underutilized worldwide and especially in the United States. In this review, we discuss evidence for the advantages of BITA grafting as well as the associated the risk of sternal wound complications. We then review a growing body of literature that suggests 'skeletonization' of the internal thoracic artery during harvest confers a protective benefit against sternal wound infection in patients receiving BITA.
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Affiliation(s)
- Brody Wehman
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Bradley Taylor
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, MD, USA
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179
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Tong BC, Huber JC, Ascheim DD, Puskas JD, Ferguson TB, Blackstone EH, Smith PK. Weighting composite endpoints in clinical trials: essential evidence for the heart team. Ann Thorac Surg 2012; 94:1908-13. [PMID: 22795064 PMCID: PMC3751408 DOI: 10.1016/j.athoracsur.2012.05.027] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 04/29/2012] [Accepted: 05/03/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Coronary revascularization trials often use a composite endpoint of major adverse cardiac and cerebrovascular events (MACCE). The usual practice in analyzing data with a composite endpoint is to assign equal weights to each of the individual MACCE elements. Noninferiority margins are used to offset effects of presumably less important components, but their magnitudes are subject to bias. This study describes the relative importance of MACCE elements from a patient perspective. METHODS A discrete choice experiment was conducted. Survey respondents were presented with a scenario that would make them eligible for the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial three-vessel disease cohort. Respondents chose among pairs of procedures that differed on the 3-year probability of MACCE, potential for increased longevity, and procedure/recovery time. Conjoint analysis derived relative weights for these attributes. RESULTS In all, 224 respondents completed the survey. The attributes did not have equal weight. Risk of death was most important (relative weight 0.23), followed by stroke (0.18), potential increased longevity and recovery time (each 0.17), myocardial infarction (0.14), and risk of repeat revascularization (0.11). Applying these weights to the SYNTAX 3-year endpoints resulted in a persistent, but decreased margin of difference in MACCE favoring coronary artery bypass graft surgery compared to percutaneous coronary intervention. When labeled only as "procedure A" and "procedure B," 87% of respondents chose coronary artery bypass graft surgery over percutaneous coronary intervention. When procedures were labeled as "coronary stent" and "coronary bypass surgery," only 73% chose coronary artery bypass graft surgery. Procedural preference varied with demographics, sex, and familiarity with the procedures. CONCLUSIONS The MACCE elements do not carry equal weight in a composite endpoint, from a patient perspective. Using a weighted composite endpoint increases the validity of statistical analyses and trial conclusions. Patients are subject to bias by labels when considering coronary revascularization.
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Affiliation(s)
- Betty C Tong
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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180
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Fattouch K, Punjabi P, Lancellotti P. Definition of moderate ischemic mitral regurgitation: it’s time to speak the same language. Perfusion 2012; 28:173-5. [DOI: 10.1177/0267659112464095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- K Fattouch
- Department of Cardiac Surgery, GVM Care and Research, Palermo, Italy
| | - P Punjabi
- Department of Cardiothoracic Surgery, Imperial College Healthcare, London, UK
| | - P Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège, CHU Sart Tilman, Liège, Belgium
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181
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Hajj-Chahine J. eComment. Haemodynamic goal-directed therapy in cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:887. [PMID: 23100554 DOI: 10.1093/icvts/ivs378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jamil Hajj-Chahine
- Department of Cardio-Thoracic Surgery, University Hospital of Poitiers, Poitiers, France
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182
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Augoustides JG. The Inflammatory Response to Cardiac Surgery With Cardiopulmonary Bypass: Should Steroid Prophylaxis Be Routine? J Cardiothorac Vasc Anesth 2012; 26:952-8. [DOI: 10.1053/j.jvca.2012.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Indexed: 11/11/2022]
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183
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The American Heart Association/American College of Cardiology Foundation guideline for coronary artery bypass grafting: 2011 updates. J Thorac Cardiovasc Surg 2012; 143:35-6. [DOI: 10.1016/j.jtcvs.2011.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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