Frequency of Stroke After Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting (from an Eleven-Year Statewide Analysis)

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Alternative Approaches to Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention, How Do They Compare?: A Systematic Review and Meta-Analysis

Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.

Determinants and clinical outcomes of stroke following revascularization among patients with reduced ejection fraction

OBJECTIVE

Stoke after revascularization including both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is an uncommon but devastating complication. Patients with reduced ejection fraction (EF) had an increased risk of stroke after revascularization. However, little is known about the determinants and outcomes of stroke among patients with reduced EF following revascularization.

MATERIALS AND METHODS

A cohort study of patients with preoperative reduced EF (≤40%) who received revascularization by either PCI or CABG between January 1, 2005 and December 31, 2014 was performed. Multivariate logistic regression was used to identify independent correlates of stroke. Logistic regression models were applied to evaluate the association of stroke with clinical outcomes.

RESULTS

A total of 1937 patients were enrolled in this study. Of these, 111 (5.7%) patients suffered from stroke during the median 3.5-year follow-up. Older age (odds ratio [OR], 1.03; 95% CI, 1.01-1.05; p = .009), history of hypertension (OR, 1.79; 95% CI, 1.18-2.73; p = .007), and history of stroke (OR, 2.00; 95% CI, 1.19-3.36; p = .008) were found to be independent predictors for stroke. Patients with and without stroke had similar risk of all-cause death (OR, 0.91; 95% CI, 0.59-1.41; p = .670). However, stroke was associated with higher odds ratio of heart failure (HF) hospitalization (OR, 2.77; 95% CI, 1.74-4.40; p < .001) and composite end point (OR, 1.61; 95% CI, 1.07-2.42; p = .021).

CONCLUSIONS

Further research appears warranted to minimize the complication of stroke and improve long-term outcomes among patients with reduced EF who underwent such high risk revascularization procedural.

Neurological Complications of Cardiac Procedures

Neurological complications after cardiac surgery and percutaneous cardiac interventions are not uncommon. These include periprocedural stroke, postoperative cognitive dysfunction after cardiac surgery, contrast-induced encephalopathy after percutaneous interventions, and seizures. In this article, we review the incidence, pathophysiology, diagnosis, and management of these complications. Improved understanding of these complications could lead to their prevention, faster detection, and facilitation of diagnostic workup and appropriate treatment.

Ten-Year Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Patients with Type 2 Diabetes Mellitus Suffering from Left Main Coronary Disease: A Meta-Analysis

INTRODUCTION

In this meta-analysis, we aimed to systematically compare the 10-year outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with type 2 diabetes mellitus (T2DM) suffering from left main coronary artery disease (LMCD).

METHODS

Medical Literature Analysis and Retrieval System Online (MEDLINE), http://www.ClinicalTrials.gov , Excerpta Medica dataBASE (EMBASE), Cochrane Central, Web of Science, and Google scholar were searched for publications comparing 10-year outcomes of PCI versus CABG in patients with T2DM suffering from LMCD. Cardiovascular outcomes were considered as the clinical endpoints. Statistical analysis was carried out using RevMan software (version 5.4). Risk ratios (RR) with 95% confidence intervals (CI) were used to represent the data after analysis.

RESULTS

Eight studies (three randomized trials and five observational studies) with a total number of 3835 participants with T2DM were included in this analysis; 2340 participants were assigned to the PCI group and 1495 participants were assigned to the CABG group. Results of this analysis showed that mortality (RR 0.85, 95% CI 0.73-1.00; P = 0.05), myocardial infarction (RR 0.53, 95% CI 0.35-0.80; P = 0.002), repeated revascularization (RR 0.34, 95% CI 0.26-0.46; P = 0.00001), and target vessel revascularization (RR 0.26, 95% CI 0.18-0.38; P = 0.00001) were significantly higher with PCI when compared to CABG in these patients with diabetes and LMCD. Major adverse cardiac and cerebrovascular events were also significantly higher with PCI at 10 years (RR 0.67, 95% CI 0.49-0.92; P = 0.01). However, CABG was associated with a significantly higher risk of stroke (RR 2.16, 95% CI 1.39-3.37; P = 0.0007).

CONCLUSIONS

During a long-term follow-up time period of 10 years, PCI was associated with worse clinical outcomes compared to CABG in these patients with T2DM suffering from LMCD. However, a significantly higher risk of stroke was observed with CABG. This piece of information might be vital in order to carefully choose and prevent complications following revascularization in such patients.

Stroke Rates Following Surgical Versus Percutaneous Revascularization for Ischemic Heart Disease

PURPOSE OF REVIEW

Coronary revascularization is a commonly performed major procedure in the hospitals. Stroke is one of the dreaded complications after coronary revascularization procedures. The focus of this review is to understand the stroke risk in percutaneous cutaneous intervention (PCI) and coronary artery bypass grafting (CABG) procedures.

RECENT FINDINGS

Available data show that PCI offers less procedural stroke risk compared to CABG although the survival benefits of CABG are better in certain scenarios. Innovative advancements in techniques, pre-procedural optimum medical therapy (OMT), intraoperative neuro-monitoring, and multidisciplinary post procedural care are the few strategies in early detection and reduce stroke risk. Despite several innovations and strategies, it is evident that there is not enough data available to make concrete conclusions related to stroke risk after coronary revascularization, which warrants further investigation.

Myocardial Infarction Complicated by Ischemic Stroke: Risk Factors, Prognosis, Unresolved Problems and Possible Methods of Prevention

The present work is devoted to the analysis of modern publications on various aspects of the development and course of ischemic stroke in the presence of acute myocardial infarction. A literature search was conducted on the websites of cardiological and neurological societies, as well as on the PubMed, EMBASE, eLibrary databases using the keywords: myocardial infarction, acute coronary syndrome, stroke, acute cerebrovascular accident, myocardial infarction, acute coronary syndrome, stroke. The authors of this review found that although stroke is a relatively rare complication of myocardial infarction, its prevention is an extremely significant task, since it is associated with high mortality, disability and a significant increase in the cost of treatment. So, it is extremely important to detect thrombosis of the left ventricular cavity in a timely manner, to register preexisting atrial fibrillation that occurs earlier or for the first time, followed by the appointment of anticoagulant therapy. Timely reperfusion treatment, the use of statins and modern dual antithrombotic therapy can reduce the risk of developing cerebrovascular accident in patients with myocardial infarction. It is likely that a decrease in the activity of subclinical inflammation after myocardial infarction will also reduce the risk of stroke, as was recently shown in the COLCOT study. Currently, it remains relevant to search for new knowledge about the risk factors for stroke, which complicated the course of myocardial infarction, which will allow developing more effective and personalized preventive measures in a patient with acute coronary syndrome.

Periprocedural Stroke After Coronary Revascularization (from the CREDO-Kyoto PCI/CABG Registry Cohort-3)

There is a scarcity of data on incidence, risk factors, especially clinical severity, and long-term prognostic impact of periprocedural stroke after coronary revascularization in contemporary real-world practice. Among 14,867 consecutive patients undergoing first coronary revascularization between January 2011 and December 2013 (percutaneous coronary intervention [PCI]: N = 13258, and coronary artery bypass grafting [CABG]: N = 1609) in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG registry Cohort-3, we evaluated the details on periprocedural stroke. Periprocedural stroke was defined as stroke within 30 days after the index procedure. Incidence of periprocedural stroke was 0.96% after PCI and 2.13% after CABG (log-rank p <0.001). Proportions of major stroke defined by modified Rankin Scale ≥2 at hospital discharge were 68% after PCI, and 77% after CABG. Independent risk factors of periprocedural stroke were acute coronary syndrome (ACS), carotid artery disease, advanced age, heart failure, and end-stage renal disease after PCI, whereas they were ACS, carotid artery disease, atrial fibrillation, chronic obstructive pulmonary disease, malignancy, and frailty after CABG. There was excess long-term mortality risk of patients with periprocedural stroke relative to those without after both PCI and CABG (hazard ratio 1.71 [1.25 to 2.33], and hazard ratio 4.55 [2.79 to 7.43]). In conclusion, incidence of periprocedural stroke was not negligible not only after CABG, but also after PCI in contemporary real-world practice. Majority of patients with periprocedural stroke had at least mild disability at hospital discharge. ACS and carotid artery disease were independent strong risk factors of periprocedural stroke after both PCI and CABG. Periprocedural stroke was associated with significant long-term mortality risk after both PCI and CABG.

Risk of Ischemic Stroke After Acute Myocardial Infarction in Patients Undergoing Coronary Artery Bypass Graft Surgery

Only sparse epidemiological data are available regarding the risk of ischemic stroke (IS) after coronary artery bypass surgery (CABG). Here we aimed to describe the incidence and predictors of IS associated with CABG performed after acute myocardial infarction (AMI), as well as trends over time. We analyzed data for 248,925 unselected AMI patients. We separately analyzed groups of patients who underwent CABG early or late after the index infarction. IS incidence rates per year at risk were 15.8% (95% confidence interval, 14.5–17.1) and 10.9% (10.6–11.2), respectively, among patients with and without CABG in the early cohort, and 4.0% (3.5–4.5) and 2.3% (2.2–2.3), respectively, among patients with and without CABG in the late cohort. Predictors of post-AMI IS included prior IS, CABG, prior atrial fibrillation, prior hemorrhagic stroke, heart failure during hospitalization, older age, diabetes mellitus, and hypertension. Reduced IS risk was associated with use of statins and P2Y12 inhibitors. IS incidence markedly decreased among patients who did not undergo CABG, while no such reduction over time occurred among those who underwent CABG. This emphasizes the need to optimize modifiable risk factors and to consistently use treatments that may reduce IS risk among CABG patients.

The epidemiology of coronary artery bypass surgery in a community hospital: A comparison between 2 periods

During the last decades, the increased number of percutaneous interventions procedures causes a significant change in the profile of patients referred to coronary artery bypass grafting (CABG). We aimed to study changes in patients' characteristics and procedural outcomes of patients referred to CABG in a community hospital during the first 15 years of the millennium.A historical cohort study of all patients who underwent CABG in Cape Cod Hospital was performed. The period was divided into 2 sub-periods, 2000 to 2008 and 2009 to 2014. Patients' characteristics and procedure outcomes were compared. Data on age, sex, comorbidities, Society of Thoracic Surgery risk scores and surgical adverse outcomes (stroke, coma, and 30-days mortality) were collected.During the study period, 1108 patients underwent CABG; 612 were operated before 2009 and 496 after. Age and sex were similar in the 2 periods. The patients in the later period presented lower risk for mortality and stroke (P <.001). Diabetes (DM) was more common in the later period (P <.001) while peripheral vascular disease (PVD) (P <.001) and left main disease (LM) (P = .017) were more common in the earlier period. Mortality rates were similar between the 2 periods. Post-operative stroke (1.8%) and coma (0.8%) were presented only in the later period. In conclusion, a significant change in CABG patients' characteristics was observed.In conclusion, patients in the later period had lower risk score and were more likely to present with DM and less with PVD and LM. Despite the lower risk, the mortality rate was similar.

Clampless versus clamped coronary bypass grafting: does it make a difference?

PURPOSE OF REVIEW

The techniques of coronary artery bypass grafting (CABG) have evolved remarkably over the last two decades since the introduction of off-pump coronary artery bypass (OPCAB). This article focuses on the clinical outcomes of 'clampless' CABG strategies, that include OPCAB with a partial clamp, OPCAB with a proximal suture device, and aorta no-touch OPCAB.

RECENT FINDINGS

Observational studies have shown the superiority of OPCAB for preventing strokes and pulmonary complications. Conversely, recent large-scale randomized controlled trials (RCTs) have been unable to demonstrate the benefits of OPCAB. Because of these differing results across numerous studies, the debate about the overall superiority of OPCAB versus on-pump CABG remains controversial. However, the literature regarding the OPCAB technique with minimized manipulation of the aorta suggests this has likely benefits, especially for high-risk patients.

SUMMARY

Previous large RCTs did not focus on specific approaches of OPCAB or the importance of the experience of surgeons and institutions, and so further studies are needed. Observational studies and meta-analyses have indicated that improved outcomes can be achieved by applying specific OPCAB approaches according to each patient's characteristics.

Meta-Analysis of Randomized Control Trials Comparing Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Significant Left Main Coronary Narrowing

Previous meta-analyses showed that drug-eluting stent (DES) implantation may serve as an alternative to coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) stenosis, largely driven by data from registries. Hence, we performed a meta-analysis of randomized controlled trials (RCTs) to overcome this limitation. PubMed, the Cochrane Library, and Scopus were systematically searched through October 2016 to identify eligible RCTs. The primary outcomes were major adverse cardiac and cerebrovascular events (MACCE) at 1-year and long-term (≥3 years) follow-ups. This meta-analysis included 5 RCTs, totaling 4,595 patients with ULMCA disease. Compared with CABG, DES showed similar 1-year rates of MACCE (risk ratio [RR] 1.14, 95% confidence interval [CI] 0.91-1.42), all-cause death, and myocardial infarction, with a higher incidence of revascularization (RR 1.68, 95% CI 1.24-2.27) and lower incidence of stoke (RR 0.43, 95% CI 0.23-0.78). At long-term follow-up, DES placement was inferior to CABG in terms of MACCE (RR 1.27, 95% CI 1.13-1.43) and revascularization (RR 1.70, 95% CI 1.43-2.01). There was no difference in long-term risk of other outcomes between these 2 strategies. In conclusion, DES stenting and CABG for ULMCA disease yield comparable rates of MACCE at 1-year follow-up; however, CABG is associated with a decreased risk of long-term MACCE compared with DES, exclusively driven by the considerable reduction in revascularization events.