Trends in Emergency Coronary Artery Bypass Grafting After Percutaneous Coronary Intervention, 1994–2003

Effects of cardiac surgical support on long-term outcomes of emergent or complex percutaneous coronary intervention cases: a sub-analysis of the SHINANO 5-year registry

Significant improvements in percutaneous coronary intervention (PCI) technology have enabled cardiovascular procedures to be performed without onsite cardiac surgery facilities. However, little is known about the association between onsite cardiac surgical support and long-term outcomes of PCI, particularly among emergent and complex cases. We investigated whether the presence or absence of cardiovascular surgery affects the long-term prognosis after PCI, emergent and complex elective cases. The SHINANO 5-year registry, a prospective, observational, and multicenter cohort study registry in Nagano, Japan, consecutively included 1665 patients who underwent PCI between August 2012 and July 2013. The procedures were performed at 11 hospitals with onsite cardiac surgery facilities [onsite surgery (+) group; n = 1257] and 8 hospitals without onsite cardiac surgery facilities [onsite surgery (-) group; n = 408]. The primary endpoint was all-cause mortality and the secondary endpoint was major adverse cardiac and cerebrovascular events [MACCE: all-cause death, Q-wave myocardial infarction, non-fatal stroke, and target lesion revascularization]. The onsite surgery group (+) had a lower rate of emergent PCI and ST-segment elevation myocardial infarction (40.8% vs. 51.7%, p < 0.01 and 24.9% vs. 39.2%, p < 0.01, respectively), and a higher prevalence of hemodialysis and history of peripheral artery disease (7.6% vs. 2.45%, p < 0.01 and 12.1% vs. 6.9%, p < 0.01, respectively). However, the Kaplan-Meier analysis showed no difference in the 5-year mortality rate (16.4% vs. 15.2%, p = 0.421) and MACCE incidence (31.6% vs. 28.9%, p = 0.354) between the groups. Also, there were no differences in the mortality rate and incidence of MACCE among emergent cases of ST-segment elevation myocardial infarction and complex elective cases who underwent PCI. Long-term outcomes of PCI appear to be comparable between institutions with and without onsite cardiac surgical facilities.

Incidence, Characteristics, and Outcomes of Emergent Isolated Coronary Artery Bypass Grafting

Data on emergency coronary artery bypass surgery (CABG) are limited. We studied patients who underwent isolated CABG at Mayo Clinic between 1993 and 2019. Baseline characteristics and in-hospital outcomes of emergent CABG were described in consecutive eras (1993 to 2000, 2001 to 2010, and 2011 to 2019). Cumulative survival was estimated by the Kaplan Meier method for the overall group, and stratified by the indication of surgery. In the 14,455 isolated CABG included, 427 (2.95%) were emergent. The number of emergent CABG decreased from 222 to 150 and 55 in the consecutive study eras. There was a temporal increase in the prevalence of heart failure, but no change in mean age, and prevalence of hypertension, diabetes, renal failure, or atrial fibrillation. The proportion of patients with failed/complicated percutaneous coronary intervention decreased from 38.2% in 1993 to 2000 to 22.7% in 2001 to 2010 and 25.5% in 2011 to 2019 (p = 0.003). In 2011 to 2019, 100% of patient received an internal mammary graft compared with 75.6% in 1993 to 2000 (p < 0.001). Operative mortality was 8.7% overall (8.6% in 1993 to 2000, 10.0% in 2001 to 2010, and 5.5% in 2011 to 2019, p = 0.56). There were no differences in postoperative complications except for the incidence of renal failure and new dialysis which increased over time. Predicted 10-year survival was 57.0% and was not different according to CABG indication (p = 0.12). In conclusion, we documented a temporal decrease in the incidence of emergent CABG between 1993 and 2019, especially those performed due to complications of coronary interventions. Despite the higher prevalence of left ventricular dysfunction and the more complete revascularization in more recent years, in-hospital mortality did not increase.

Revascularisation of left main stem disease: a prospective analysis of modern practice and outcomes in a non-surgical centre

Purpose

In this study, we sought to prospectively analyse the management and long term outcomes associated with revascularisation of left main stem disease via percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in our centre.

Methods

This prospective study enrolled all patients with unprotected left main stem disease undergoing revascularisation from January 2013 to June 2014. Baseline characteristics, hospital presentation and hospital stay length were collected. Patients were followed up at 1, 2 and 3 years. Primary outcomes of Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) were defined as death, Q wave myocardial infarction, stroke, repeat revascularisation and readmission within 30 days.

Results

56 patients with significant left main stem coronary artery disease were identified from the clinical registry. 27 patients underwent PCI (median age 67.7) and 29 CABG (median age 68.6). PCI patients had a higher surgical risk as measured by mean euroSCORE (4.95±5.8 vs 3.11±3.85). At 3 years, total MACCE occurred in 29.6% of the PCI cohort and 27.5% of the CABG cohort. Death occurred in three patients in the PCI group within the first 6 months. Death occurred in one patient in the CABG group over 2 years postprocedure. Two patients in the CABG cohort presented with Transient Ischemic Attacks (TIAs) at 2-year follow-up. At 3 years, revascularisation occurred in three patients in the PCI cohort. There were no revascularisation events in the CABG cohort.

Conclusions

PCI with modern drug eluting stents is a reasonable treatment option for unprotected left main stem disease in a non surgical centre.

Outcome of emergency coronary artery bypass grafting

OBJECTIVES

The aim of this study was to evaluate the immediate and late outcome of emergency coronary artery bypass grafting (CABG) in a multicenter setting.

DESIGN

Multicenter, retrospective study.

SETTING

Four university hospitals.

PARTICIPANTS

596 patients were included in this study.

INTERVENTIONS

Included patients underwent isolated, emergency CABG.

MEASUREMENTS AND MAIN RESULTS

Sixty patients (absolute rate: 10.1%, pooled rate: 8.7%) died during the in-hospital stay period. Increasing emergency CABG classes (p<0.0001), recent myocardial infarction (p=0.019), left ventricular ejection fraction≤30% (p=0.034), on-pump surgery (p=0.012), and participating centers (p<0.0001) were independent predictors of in-hospital mortality. Survival rates at 1, 3, and 5 years were 86.4%, 81.6%, and 76.1%, respectively. Extracorporeal membrane oxygenation was used in 6 patients and 3 of them (50.0%) survived the immediate postoperative period. Patient populations of participating centers differed significantly in most of baseline characteristics. The preoperative use of intra-aortic balloon pump (8% to 51%) and off-pump surgery (2.8% to 56.3%) varied significantly between institutions. In-hospital mortality (2.8%, 5.9%, 7.7% and 19.8%, p<0.0001), as well as midterm survival, significantly differed between institutions (at 3 years, 90.6%, 89.8%, 81.2%, and 67.2%, p<0.0001).

CONCLUSIONS

The outcome after emergency CABG is satisfactory despite a significant operative risk. However, the results of emergency CABG significantly differed between the participating institutions, likely due to differences in the referral pathways and perioperative treatment strategies. Evaluation of these factors is crucial for implementation of treatment in centers with suboptimal results.

Immediate rescue operations after failed diagnostic or therapeutic cardiac catheterization procedures

OBJECTIVES

Although rare, life-threatening complications requiring emergency cardiac surgery do occur after diagnostic and therapeutic cardiac catheterization procedures. The operative mortality has been persistently reported to remain high. The purpose of this observational study was to evaluate and report the outcomes, with particular emphasis on early mortality, of these risky operations that were performed in a single highly specialized cardiac centre.

METHODS

Between June 1997 and August 2007, 100 consecutive patients, 13 after diagnostic complicated cardiac catheterization (0.038% of 34,193 angiographies) and 87 after crashed percutaneous coronary intervention (PCI; 0.56% of 15,544 PCIs), received emergency operations at the Feiring Heart Center. In the same period, 10,192 other patients underwent open cardiac surgery. Early outcome data were analysed and compared between the cohorts. Follow-up was 100% complete.

RESULTS

The preoperative status of the 100 patients was that 4 had ongoing external cardiac massage, 24 were in cardiogenic shock, 32 had frank enduring ST-segment infarction but without shock and 40 had threatened acute myocardial infarction. There was 1% (1 patient) 30-day mortality in the study group, which is equal (0.9%, P=0.60) to that of all other operations. Postoperative myocardial infarction and prolonged ventilator use were significantly higher in the crash group, whereas the rate of stroke, renal failure, reopening for bleeding and mediastinitis were similar between the groups.

CONCLUSIONS

With rapid transfer to an operation room, minimizing the time of warm myocardial ischaemia, and by performing complete coronary revascularization, it is possible to obtain equally low operative mortality in patients with life-threatening cardiac catheterization-associated complications, as is the case with open cardiac operations in general.

Risk stratification and prognostic effects of internal thoracic artery grafting during acute myocardial infarction

OBJECTIVE

Surgeons are occasionally requested to perform coronary artery bypass grafting during acute myocardial infarction. We intended to test the safety of coronary artery bypass grafting and internal thoracic artery grafting early after myocardial infarction using the Society of Thoracic Surgeons database.

METHODS

The database was queried for isolated coronary artery bypass grafting less than 24 hours after a myocardial infarction from 2002 to 2008. By using multivariable logistic regression and classification trees, risk models were created to stratify this group of patients. The independent prognostic effect of internal thoracic artery grafting was examined using standard risk-adjusted mortality comparisons.

RESULTS

A total of 44,141 patients were identified, with an overall operative mortality of 7.9%. Cardiogenic shock occurred in 21%, percutaneous coronary intervention within 6 hours before surgery was performed in 11%, myocardial infarction within 6 hours before surgery occurred in 37%, preoperative intra-aortic balloon pump was used in 50%, and internal thoracic artery grafting was performed in 79% of the patients. Myocardial infarction in less than 24 hours was associated with higher operative mortality (odds ratio, 3.25) and major morbidity (odds ratio, 2.54). Emergency/salvage status (odds ratio, 6.43), age more than 80 years (odds ratio, 4.07), dialysis (odds ratio, 3.08), and cardiogenic shock (odds ratio, 2.79) were independent mortality predictors. Patients with nonemergence salvage status, absence of cardiogenic shock, creatinine less than 1.5 mg/dL, and age less than 70 years represented 48% of the population and exhibited a lower mortality rate of 2%. Internal thoracic artery grafting was independently associated with a lower risk of mortality (odds ratio, 0.52; P < .0001) and did not seem to compromise outcomes.

CONCLUSIONS

Coronary artery bypass grafting less than 24 hours after myocardial infarction carries a higher operative risk but can be performed safely in selected patients. Although confounding variables may exist, internal thoracic artery grafting was associated with improved outcomes. Internal thoracic artery use in this setting is less than ideal, and taking time to harvest internal thoracic artery grafts in patients with acute myocardial infarction might be encouraged.

Percutaneous coronary interventions in facilities without cardiac surgery on site

Prior to the widespread adoption of intracoronary stent implantation, potential complications of percutaneous coronary intervention (PCI) necessitated the presence of backup cardiac surgery. However, as stent implantation has become the predominant form of PCI, the incidence of emergent cardiac surgery has declined exponentially. Despite this, current guidelines recommend against the performance of elective PCI at hospitals without on-site cardiac surgery and recommend that primary PCI for ST-segment elevation myocardial infarction (STEMI) might be considered at hospitals without backup cardiac surgery. These recommendations are based predominantly on two principles: (1) hospital volume for PCI is strongly associated with clinical outcomes, and (2) results from a large registry study, in which the authors reported a substantial increase in mortality among patients undergoing non-primary/rescue PCI at hospitals without backup cardiac surgery. Since that time, evidence from multiple studies has suggested that performance of PCI at hospitals without backup cardiac surgery is feasible, safe, and both clinically and cost effective. Among STEMI patients, in particular, performance of primary PCI at hospitals without on-site cardiac surgery reduces time to reperfusion and subsequent adverse cardiovascular events as well as likely reducing infarct size. In this review, we will examine the evidence surrounding the performance of PCI for stable and unstable coronary disease at hospitals without on-site backup cardiac surgery.

A short history of the Society of Thoracic Surgeons national cardiac database: perceptions of a practicing surgeon

The Society of Thoracic Surgeons database was developed as an initiative to standardize nationwide outcomes in adult cardiac surgery, and it has currently expanded into general thoracic and congenital cardiac surgery databases. For more than 19 years since its inception, the Society of Thoracic Surgeons database has grown as a powerful source of risk-adjusted outcomes, large scale scientific contributions, and invaluable information for healthcare policy making. This review article provides a snapshot of the genesis, history, growth, and scientific contributions of the Society of Thoracic Surgeons database to stimulate the participation of thoracic surgery programs and maximize its future use for investigational purposes.

Sex- and ethnic group-specific nationwide trends in the use of coronary artery bypass grafting in the United States

OBJECTIVE

This study examined nationwide trends in use of coronary artery bypass grafting between 1988 and 2004.

METHODS

The Nationwide Inpatient Sample database was used to calculate age-adjusted rate of coronary artery bypass grafting from 1988 to 2004. Specific International Classification of Diseases, Ninth Revision, Clinical Modification codes for coronary artery bypass grafting were used to compile data. Patient demographic data were also analyzed.

RESULTS

The database recorded 1,145,285 patients older than 40 years who underwent coronary artery bypass grafting from 1988 to 2004. Mean age was 60.21 +/- 10.55 years. Male patients underwent coronary artery bypass grafting more than twice as frequently as female patients (70.6% vs 29.4%). From 1988, total age-adjusted rate gradually increased for 10 years until 1997 (79.29 per 100,000 with 95% confidence interval 70.88-87.71 per 100,000 in 1988, 131.31 per 100,000 with 95% confidence interval 119.02-143.59 per 100,000 in 1997, P < .01), with ensuing rapid decline to nearly the lowest level at end of study in 2004 (83.01 per 100,000 with 95% confidence interval 75.68-90.33 per 100,000, P < .01). Although trends were similar across ethnicity and sex, female and ethnic minority patients had lower rates of bypass surgery than did male and white patients.

CONCLUSIONS

Use of coronary artery bypass grafting has decreased dramatically in recent years, with even lower use among female and ethnic minority patients. This decline may be related to significant advances in percutaneous coronary interventions and improved medical treatment of atherosclerosis in the past 10 years.

Global Trends in Cardiology and Cardiothoracic Surgery – An Opportunity or a Threat?

Coronary heart disease is currently the leading cause of death globally, and is expected to account for 14.2% of all deaths by 2030. The emergence of novel technologies from cardiothoracic surgery and interventional cardiology are welcome developments in the light of an overwhelming chronic disease burden. However, as these complementary yet often competing disciplines rely on expensive technologies, hastily prepared resource plans threaten to consume a substantial proportion of limited healthcare resources. By describing procedural and professional trends as well as current and emerging technologies, this review aims to provide useful knowledge to help managers make informed decisions for the planning of cardiovascular disease management. Since their inception, developments in both specialties have been very rapid. Owing to differences in patient characteristics, interventions and outcomes, results of studies comparing cardiothoracic surgery and interventional cardiology have been conflicting. Outcomes for both specialties continue to improve through the years. Despite the persistent demand for coronary artery bypass surgery (CABG) as a rescue procedure following percutaneous coronary intervention (PCI), there is a widening gap between the numbers of PCI and CABG. Procedural volumes seem to have affected career choices of physicians. Emerging technologies from both disciplines are eagerly awaited by the medical community. For long-term planning of both disciplines, conventional health technology assessment methods are of limited use due to their rapid developments. In the absence of established prediction tools, planners should tap alternative sources of evidence such as changes in disease epidemiology, procedural volumes, horizon scan reports as well as trends in disease outcomes. Key words: Cardiac surgery, Interventional cardiology, Planning

Clopidogrel in the management of acute coronary syndromes: indications, results, obstacles

Atherothrombosis is the underlying pathology of the acute coronary syndromes (ACS), in which platelet activation plays a key role. Therefore, antiplatelet therapy is an essential component of guideline-recommended ACS management. Considerable evidence clearly demonstrates the benefits of the antiplatelet agent clopidogrel in reducing mortality, decreasing recurrent cardiovascular events, and increasing arterial patency in ACS patients. Despite this evidence, data from patient registries and clinical initiatives such as CRUSADE (Can Rapid stratification of Unstable angina Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines) and GRACE (Global Registry of Acute Coronary Events) indicate that clopidogrel is underused in patients with ACS. This is especially true for patients receiving conservative medical management, many of whom have significant risk for recurrent ischemic events. The purpose of this review is to compare "real-life" clopidogrel therapy with evidence-based guidelines, and to highlight clinical factors that drive clopidogrel implementation or provide barriers to its use in ACS patients.

The role of invasive therapies in elderly patients with acute myocardial infarction

INTRODUCTION

In elderly patients with acute myocardial infarction, very little is known about the role of surgical myocardial revascularization and percutaneous coronary intervention (invasive therapies--IT), especially in the context of long-term outcomes after hospital discharge.

METHODS

We analyzed 1588 patients with MI who had been included prospectively in a databank and followed for up to 7.5 years. In this population, 548 patients were >70 years old (elderly group--EG), and 1040 were <70 years of age (younger group--YG); 1088 underwent IT during hospitalization, and the remaining 500 were treated medically (conservative therapy--CT). Patients were monitored either by visit or by phone at least once a year. A standard questionnaire was administered to all patients. The impact of IT was analyzed with both non-adjusted and adjusted models.

RESULTS

By the end of the follow-up period, the survival rates for the IT and CT groups were, respectively, 71.9% versus 47.2% in the global population (hazard ratio=0.55, P<0.001), 81.5% versus 66.6% in the YG (hazard ratio=0.68, P=0.018) and 48.8% versus 20.3% in the EG (hazard ratio=0.58, P<0.001). In the adjusted models, the hazard ratios were 0.62 (P<0.001) in the global population, 0.74 in the YG (P=0.073) and 0.64 (P=0.001) in the EG.

CONCLUSION

Long-term follow-up of patients with myocardial infarction revealed that IT during the in-hospital phase was at least as effective in elderly patients as in younger patients.

2007 update to the ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: implications for emergency department practice

The American College of Cardiology and American Heart Association have updated their guidelines for the management of non-ST-segment-elevation acute coronary syndrome for the first time since 2002. In the interim, several important studies affecting choices of therapy potentially begun in the emergency department have been completed, and care patterns have changed and matured significantly. In this review, we present the new recommendations that are pertinent to emergency medicine practice and comment on their potential implementation into an evidence-based, multidisciplinary approach to the evaluation and management of this challenging patient population.

The year in cardiovascular surgery

This paper highlights information from cardiovascular surgical articles published in 2006 that are likely to have a broad impact on the practice of cardiovascular specialists in years ahead. Preference was given to articles that are innovative in purpose, thoughtful in design, and definitive in conclusions.