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Ikeda M, Niinami H, Morita K, Saito S, Yoshitake A. Long-term results following off-pump coronary-artery bypass grafting in left ventricular dysfunction. Heart Vessels 2024; 39:571-581. [PMID: 38461187 PMCID: PMC11189952 DOI: 10.1007/s00380-024-02383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/28/2024] [Indexed: 03/11/2024]
Abstract
Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women's Medical University).
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Affiliation(s)
- Masahiro Ikeda
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan.
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Kozo Morita
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Satoshi Saito
- Department of Cardiovascular Surgery, Tokyo Women's Medical University Hospital, 8-1, Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
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Cao J, Yu M, Xiao Y, Dong R, Wang J. Effects of different surgical strategies and left ventricular remodelling on the outcomes of coronary artery bypass grafting in heart failure patients with reduced ejection fraction. Front Cardiovasc Med 2024; 11:1398700. [PMID: 38895539 PMCID: PMC11183324 DOI: 10.3389/fcvm.2024.1398700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Background Ischaemic heart failure with reduced ejection fraction (HFrEF) caused by coronary artery disease accounts for the largest proportion of heart failure cases with the worst prognosis. Coronary artery bypass grafting (CABG) is the most effective treatment for ischaemic HFrEF. On-pump and off-pump are the two surgical methods used for CABG. Whether patients with HFrEF should undergo on- or off-pump CABG is controversial in coronary heart disease surgery. The left ventricular end-systolic volume index (LVSEVI) is the gold standard for evaluating the severity of left ventricular remodelling; however, its effect on the perioperative risk and long-term survival rate of patients with HFrEF undergoing CABG remains unclear. Methods This single centre prospective cohort analysis included 118 coronary heart disease patients with symptoms and signs of heart failure and a left ventricular ejection fraction (LVEF) of <40% who were enrolled consecutively from January 2019 to December 2023. Operative mortality, perioperative complications, and long-term survival were compared among patients treated with various LVESVIs and surgical methods. The primary outcomes were cardiac death, myocardial infarction, heart failure, stroke, and revascularization, (percutaneous coronary intervention or redo CABG) with a median follow-up of 38 ± 10 months. Results The 30-day postoperative mortality of 118 patients was 6.8%. Patients in the off-pump group had significantly higher perioperative mortality than those in the on-pump group (12.5% vs. 3.8%, p = 0.03). In the off-pump group, a higher proportion of patients required perioperative mechanical assistance, such as intra-aortic artery balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO), compared to those in the on-pump group (IABP: 75% vs. 47.4%, p = 0.004; ECMO: 22.5% vs. 1.3%, p = 0.000). Patients in the off-pump group were more likely to have postoperative atrial fibrillation (AF) (35% vs. 14.1%, p = 0.01). In the on-pump group, the incidence of postoperative AF (25% vs. 6.5%, p = 0.02) and IABP use (62.5% vs. 36.9%, p = 0.03) were significantly higher in patients with more severe left ventricular remodelling than in those with less severe left ventricular remodelling. In the off-pump group, patients with more severe left ventricular remodelling had higher ECMO usage (38.9% vs. 9.1%, p = 0.04), incidence of postoperative AF (61.1% vs. 13.6%, p = 0.02), and perioperative mortality (22.2%). Major adverse cardiac event (MACE)-free survival rate was significantly higher in the on-pump group than in the off-pump group, and there was no significant difference in MACE free survival rates between the two groups of patients with different degrees of left ventricular remodelling. Conclusion On-pump bypass is a better surgical procedure for patients with ischaemic HFrEF, especially those with severe left ventricular remodelling. Left ventricular remodelling increases perioperative mortality but has no effect on long-term survival.
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Affiliation(s)
| | | | | | | | - Jiayang Wang
- Department of Cardiac Surgery, Beijing Institute of Heart, Lung and Blood Vessel Diseases- Beijing Anzhen Hospital, Affiliated of Capital Medical University, Beijing, China
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Medina M, Wenzel P, Fathallah B, Ruf T, Oezkur M. Protected high risk percutaneous coronary intervention-Impella 5.0 as a single-access technique: a case report. Eur Heart J Case Rep 2024; 8:ytae060. [PMID: 38374984 PMCID: PMC10875922 DOI: 10.1093/ehjcr/ytae060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 02/21/2024]
Abstract
Background Patients requiring coronary intervention after acute myocardial infarction, with decompensated heart failure and multiple co-morbidities, present a challenging clinical scenario. Addressing such high-risk cases has been a marked increase in the simultaneous support using microaxial flow pump devices, providing a crucial haemodynamic support during procedures. Case summary We report the case of a 58-year-old man, with a non-ST-segment elevation myocardial infarction in the context of a peripheral vascular surgery. Echocardiography revealed severely reduced left ventricular function and cardiac magnetic resonance imaging demonstrated transmural scars in all but left anterior descending artery area. The patient was of extreme high surgical risk due to the multiple co-morbidities, acute decompensation heart failure, and peripheral artery disease, and, therefore, the heart team preferred protected percutaneous coronary intervention (PCI) over coronary artery bypass graft for revascularization. The peripheral artery disease included severely calcified ascending aorta, occlusions of both femoral arteries, the left subclavian artery, and the right radial artery. Taken together, the heart team agreed on a hybrid approach with surgical implantation of Impella 5.0 via the left subclavian artery, by a single-access technique. Following the intervention procedure, haemostasis of the vascular prosthesis was achieved by an angio-seal technique without complications. The patient recovered satisfactorily, with improved left ventricular function, and discharged 10 days post-procedure. Discussion The single-access high-risk PCI technique offers a standardized approach for microaxial flow pump devices such as Impella 5.0 and PCI. The subclavian artery as a single-access route for high-risk PCI has demonstrated safety and efficacy.
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Affiliation(s)
- Marta Medina
- Department of Cardiac Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Philip Wenzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Bilel Fathallah
- Department of Cardiac Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Tobias Ruf
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Mehmet Oezkur
- Department of Cardiac Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstraße 1, Mainz 55131, Germany
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Park DY, An S, Kassab K, Jolly N, Attanasio S, Sawaqed R, Malhotra S, Doukky R, Vij A. Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression. Acta Cardiol 2023; 78:778-789. [PMID: 37294002 DOI: 10.1080/00015385.2023.2218025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 12/19/2022] [Accepted: 05/19/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks. METHODS We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time. RESULTS A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement. CONCLUSIONS TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, John H. Stroger Jr Hospital of Cook County, Chicago, IL, USA
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Kameel Kassab
- Division of Cardiology, Ascension Borgess Hospital/Michigan State University, Kalamazoo, MI, USA
| | - Neeraj Jolly
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Steve Attanasio
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Ray Sawaqed
- Division of Cardiothoracic Surgery, Cook County Health, Chicago, IL, USA
- Division of Cardiothoracic Surgery, Rush Medical College, Chicago, IL, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Aviral Vij
- Division of Cardiology, Cook County Health, Chicago, IL, USA
- Division of Cardiology, Rush Medical College, Chicago, IL, USA
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Kainuma S, Toda K, Daimon T, Miyagawa S, Yoshikawa Y, Hata H, Yoshioka D, Kawamura T, Kawamura A, Kashiyama N, Ueno T, Kuratani T, Funatsu T, Kondoh H, Masai T, Hiraoka A, Sakaguchi T, Yoshitaka H, Shirakawa Y, Takahashi T, Sakaki M, Taniguchi K, Sawa Y. Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes. Circ J 2021; 85:1991-2001. [PMID: 33828021 DOI: 10.1253/circj.cj-20-0907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024). CONCLUSIONS NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.
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Affiliation(s)
- Satoshi Kainuma
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | | | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Ai Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Noriyuki Kashiyama
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Toshihiro Funatsu
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety Osaka Rosai Hospital
| | - Haruhiko Kondoh
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety Osaka Rosai Hospital
| | - Takafumi Masai
- Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, Sakakibara Heart Institute of Okayama
| | | | | | - Masayuki Sakaki
- Department of Cardiovascular Surgery, National Hospital Organization Osaka National Hospital
| | - Kazuhiro Taniguchi
- Department of Cardiovascular Surgery, Japan Organization of Occupational Health and Safety Osaka Rosai Hospital
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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Maile MD, Mathis MR, Habib RH, Schwann TA, Engoren MC. Association of Both High and Low Left Ventricular Ejection Fraction With Increased Risk After Coronary Artery Bypass Grafting. Heart Lung Circ 2021; 30:1091-1099. [PMID: 33516659 DOI: 10.1016/j.hlc.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/20/2020] [Accepted: 11/05/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND While reduced left ventricular ejection fraction (LVEF) is a known risk factor for complications after coronary artery bypass grafting (CABG), the relevance of higher LVEF values has not been established. Currently, most risk stratification tools consider LVEF values above a certain point as normal. However, since this does not account for insufficient ventricular filling or increased adrenergic tone, higher values may have clinical significance. To improve our understanding of this situation, we investigated the relationship of preoperative LVEF values with short- and long-term outcomes after CABG using a strategy that allowed for the identification of nonlinear relationships. We hypothesised that both higher and lower values are independently associated with increased postoperative complications and death in this population. METHODS We performed a single-centre retrospective cohort study of patients undergoing isolated CABG surgery. All patients had a preoperative measurement of their LVEF. Surgery involving mitral valve repair was excluded in order to eliminate the impact of mitral regurgitation. The primary outcome was long-term mortality; secondary outcomes included atrial fibrillation, operative mortality, and a composite outcome including any postoperative adverse event. Fractional polynomial equations were used to model the relationship between LVEF and outcomes so we could account for nonlinear relationships if present. Adjustments for confounders were made using multivariable logistic regression and Cox models. RESULTS A total of 7,932 subjects were included in the study. After adjusting for patient and surgical characteristics, LVEF remained associated with the primary outcome as well as the composite outcome of any postoperative adverse event. Both these relationships were best described by a J-shaped curve given that higher LVEF values were associated with increased risk, albeit not as high has lower values. Regarding long-term mortality, individuals with a preoperative LVEF of 60% demonstrated the longest survival. A statistically significant relationship was not found between LVEF and operative mortality or atrial fibrillation after adjustment for confounders. CONCLUSIONS Higher preoperative LVEF values may be associated with increased risk for patients undergoing CABG surgery. Future studies are needed to better characterise this phenotype.
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Affiliation(s)
- Michael D Maile
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA. https://twitter.com/MikeMaile_MD
| | - Michael R Mathis
- Division of Adult Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, IL, USA
| | - Thomas A Schwann
- Division of Cardiac Surgery, Department of Surgery, University of Massachusetts, University of Massachusetts-Baystate, Springfield, MA, USA
| | - Milo C Engoren
- Division of Critical Care Medicine, Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
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Farkash A, Pevni D, Mohr R, Kramer A, Ziv-Baran T, Paz Y, Nesher N, Ben-Gal Y. Single versus bilateral internal thoracic artery grafting in patients with low ejection fraction. Medicine (Baltimore) 2020; 99:e22842. [PMID: 33126324 PMCID: PMC7598827 DOI: 10.1097/md.0000000000022842] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Coronary artery bypass grafting (CABG) is the standard of care for the treatment of complex coronary artery disease. However, the optimal surgical treatment for patients with reduced left ventricular function with low ejection fraction (EF) is inconclusive. In our center, left-sided coronary grafting with bilateral internal thoracic artery (BITA) is generally the preferred method for surgical revascularization, also for patients with low EF. We compared early and long-term outcomes between BITA grafting and single internal thoracic artery (SITA) grafting in patients with low EF.We evaluated short- and long-term outcomes of all patients who underwent surgical revascularization in our center during 1996 to 2011, according to EF ≥30% and <30%. Univariate and multivariate analyses were performed. In addition, patients who underwent BITA and SITA grafting were matched using propensity score matching.In total, 5337 patients with multivessel disease underwent surgical revascularization during the study period. Of them, 394 had low EF. Among these, 188 underwent SITA revascularization and 206 BITA grafting. Those who underwent SITA were more likely to have comorbidities such as chronic obstructive pulmonary disease, diabetes, congestive heart failure, chronic renal failure, and a critical preoperative condition including preoperative intra-aortic balloon pump insertion.Statistically significant differences were not observed between the SITA and BITA groups in 30-day mortality (8.5% vs 6.8%, P = .55), sternal wound infection (2.7% vs 1.0%, P = .27), stroke (3.7% vs 6.3%, P = .24), and perioperative myocardial infarction (5.9% vs 2.9%, P = .15). Long-term survival (median follow up of 14 years, interquartile range, 11.2-18.9) was also similar between the groups. Propensity score matching (129 matched pairs) yielded similar early and long-term outcomes for the groups.This study did not demonstrate any clinical benefit for BITA compared with SITA revascularization in individuals with low EF.
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Affiliation(s)
- Ariel Farkash
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Dmitri Pevni
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Rephael Mohr
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Amir Kramer
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Paz
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Nahum Nesher
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
| | - Yanai Ben-Gal
- Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center and Faculty of Medicine
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Revascularization in Patients With Left Main Coronary Artery Disease and Left Ventricular Dysfunction. J Am Coll Cardiol 2020; 76:1395-1406. [DOI: 10.1016/j.jacc.2020.07.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 01/10/2023]
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Risk of conventional cardiac surgery among patients with severe left ventricular dysfunction in the era of mechanical circulatory support. J Thorac Cardiovasc Surg 2018; 156:1530-1540.e2. [PMID: 30248795 DOI: 10.1016/j.jtcvs.2018.04.130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 02/25/2018] [Accepted: 04/11/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Despite suggestions that severe left ventricle dysfunction may warrant selection of durable mechanical circulatory support over conventional surgery, comparative studies are lacking due to incomplete characterization of patients at highest risk after conventional surgery. We sought to define subsets of patients with severe left ventricle dysfunction who are at greatest mortality risk following conventional cardiac surgery. METHODS We studied 892 patients aged ≥ 18 years who underwent conventional coronary or valve surgery from 1993 to 2014, with preoperative ejection fraction ≤ 25%. Exclusions were transcatheter interventions, major concomitant procedures, active endocarditis, and prior/concurrent durable mechanical circulatory support use. Logistic and Cox regression identified determinants of early and late mortality. RESULTS Median age was 70 years (interquartile range, 62-76 years), 46% (n = 411) had New York Heart Association (NYHA) functional class IV symptoms, and 16% (n = 142) had undergone prior surgery. Operative mortality was 7.5%. NYHA functional class IV (odds ratio [OR], 1.88; P = .033), prior cardiac surgery (OR, 2.13; P = .017), peripheral vascular disease (OR, 2.55; P = .001), emergency status (OR, 2.68; P = .024), and intra-aortic balloon pump use (OR, 4.95; P < .001) independently predicted operative death. Risk imparted by presence of both NYHA functional class IV symptoms and prior surgery was additive, with a 4-fold increase in early mortality risk (OR, 3.95; P = .003). Prior surgery increased the hazard of late death by 60% (P < .001). In patients without prior surgery, late mortality was greatest in those aged ≥ 70 years (hazard ratio, 1.86; P < .001), especially if NYHA functional class IV symptoms were concurrently present (hazard ratio, 2.25; P < .001). Surgery type (coronary artery bypass graft surgery, aortic valve surgery, or mitral valve surgery) did not predict long-term outcome. CONCLUSIONS In patients referred for conventional surgery with an ejection fraction ≤ 25%, prior cardiac surgery, and/or NYHA functional class IV symptoms-particularly in those aged ≥ 70 years-confer significant and sustained survival disadvantages. Such high-risk subsets may benefit from durable mechanical circulatory support consideration.
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10
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Lozonschi L, Kohmoto T, Osaki S, De Oliveira NC, Dhingra R, Akhter SA, Tang PC. Coronary bypass in left ventricular dysfunction and differential cardiac recovery. Asian Cardiovasc Thorac Ann 2017; 25:586-593. [DOI: 10.1177/0218492317744472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We aimed to examine the efficacy of surgical revascularization with respect to improvement in ventricular function and survival in patients with ischemic cardiomyopathy and poor left ventricular function. Methods We retrospectively analyzed the data of 429 patients (median age 64.6 years, 81.1% male) with ejection fractions <40% undergoing isolated primary coronary artery bypass grafting from 2000 to 2016. Techniques included on-pump cardioplegic arrest ( n = 312), off-pump ( n = 75), and on-pump beating heart ( n = 42). Propensity matching was performed to compare the cardioplegic arrest group ( n = 114) with the combined off-pump and beating heart groups ( n = 114). Results Postoperatively, ejection fraction increased by 10.1% ± 13.1% (from 31.4% ± 7.1% to 41.6% ± 13.6%; p < 0.001) and mitral regurgitation grade improved ( p < 0.001) but right ventricular function on echocardiographic assessment worsened over time ( p = 0.04). No difference in ejection fraction improvement was seen in the time periods <1 (9.8% ± 11.2%), 1–5 (11.6% ± 14.5%), and >5 (8.8% ± 14.2%) years ( p = 0.442). Following propensity matching, there was no significant difference between the combined off-pump/beating heart and cardioplegic arrest groups with respect to survival or postoperative complications. Conclusions Patients with moderate to severe left ventricular dysfunction experience long-term improvement in left ventricular ejection fraction after coronary artery bypass. However, right ventricular function often continues to decline, contributing to persistent or worsening heart failure symptoms and late mortality. No difference in survival was seen between the 2 techniques.
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Affiliation(s)
- Lucian Lozonschi
- Section of Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Takushi Kohmoto
- Section of Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Satoru Osaki
- Section of Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nilto C De Oliveira
- Section of Cardiac Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ravi Dhingra
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shahab A Akhter
- Department of Cardiovascular Sciences, Division of Cardiac Surgery, East Carolina Heart Institute at East Carolina University, Greenville, NC, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
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11
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Abstract
PURPOSE OF REVIEW The review explores the recent findings surrounding the evaluation and the treatment of patients with heart failure and coronary artery disease. It also shed the light on the gaps in this area. RECENT FINDINGS Surgical revascularization in patients with ischemic cardiomyopathy has the potential to offer symptomatic and survival benefits. SUMMARY Patients with heart failure and coronary artery disease should be considered candidates for revascularization on the basis of their symptoms, extent of the disease, and comorbidities. Surgical revascularization in these patients provides a symptomatic relief, and a survival benefit.
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Schwann TA. The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem. Surg Clin North Am 2017; 97:835-865. [PMID: 28728719 DOI: 10.1016/j.suc.2017.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Toledo College of Medicine & Life Sciences, 3000 Arlington Avenue, Toledo, OH 43614, USA.
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13
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Popovic B, Maureira P, Juilliere Y, Danchin N, Voilliot D, Vanhuyse F, Villemot JP. Bilateral vs unilateral internal mammary revascularization in patients with left ventricular dysfunction. World J Cardiol 2017; 9:339-346. [PMID: 28515852 PMCID: PMC5411968 DOI: 10.4330/wjc.v9.i4.339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/29/2016] [Accepted: 01/18/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the survival benefit of bilateral internal mammary artery (BIMA) grafts in patients with left ventricular dysfunction.
METHODS Between 1996 and 2009, we performed elective, isolated, primary, multiple cardiac arterial bypass grafting in 430 consecutive patients with left ventricular ejection fraction ≤ 40%. The early and long-term results were compared between 167 patients undergoing BIMA grafting and 263 patients using left internal mammary artery (LIMA)-saphenous venous grafting (SVG).
RESULTS The mean age of the overall population was 60.1 ± 15 years. In-hospital mortality was not different between the two groups (7.8% vs 10.3%, P = 0.49). Early postoperative morbidity included myocardial infarction (4.2% vs 3.8%, P = 0.80), stroke (1.2% vs 3.8%, P = 0.14), and mediastinitis (5.3% vs 2.3%, P = 0.11). At 8-year follow-up, Kaplan-Meier-estimated survival (74.2% vs 58.9%, P = 0.02) and Kaplan-Meier-estimated event-free survival (all cause deaths, myocardial infarction, stroke, target vessel revascularization, heart failure) (61.7% and 41.1%, P < 0.01) were significantly higher in the BIMA group compared with the LIMA-SVG group in univariate analysis. The propensity score matching analysis confirmed that BIMA grafting is a safe revascularization procedure but there was no long term survival (P = 0.40) and event-free survival (P = 0.13) in comparison with LIMA-SVG use.
CONCLUSION Our longitudinal analysis suggests that BIMA grafting can be performed with acceptable perioperative mortality in patients with left ventricular dysfunction.
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14
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Revascularización quirúrgica en pacientes con disfunción ventricular severa. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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15
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Mc Ardle B, Shukla T, Nichol G, deKemp RA, Bernick J, Guo A, Lim SP, Davies RA, Haddad H, Duchesne L, Hendry P, Masters R, Ross H, Freeman M, Gulenchyn K, Racine N, Humen D, Benard F, Ruddy TD, Chow BJ, Mielniczuk L, DaSilva JN, Garrard L, Wells GA, Beanlands RS, Higginson L, Mesana T, Ukkonen H, Yoshinaga K, Renaud J, Klein R, Aung M, Kostuk W, Wisenberg G, White M, Iwanochko R, Mickleborough L, Abramson B, Latter D, Lamy A, Fallen E, Coates G. Long-Term Follow-Up of Outcomes With F-18-Fluorodeoxyglucose Positron Emission Tomography Imaging–Assisted Management of Patients With Severe Left Ventricular Dysfunction Secondary to Coronary Disease. Circ Cardiovasc Imaging 2016; 9:CIRCIMAGING.115.004331. [DOI: 10.1161/circimaging.115.004331] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 07/21/2016] [Indexed: 11/16/2022]
Abstract
Background—
Whether viability imaging can impact long-term patient outcomes is uncertain. The PARR-2 study (Positron Emission Tomography and Recovery Following Revascularization) showed a nonsignificant trend toward improved outcomes at 1 year using an F-18-fluorodeoxyglucose positron emission tomography (PET)–assisted strategy in patients with suspected ischemic cardiomyopathy. When patients adhered to F-18-fluorodeoxyglucose PET recommendations, outcome benefit was observed. Long-term outcomes of viability imaging–assisted management have not previously been evaluated in a randomized controlled trial.
Methods and Results—
PARR-2 randomized patients with severe left ventricular dysfunction and suspected CAD being considered for revascularization or transplantation to standard care (n= 195) versus PET-assisted management (n=197) at sites participating in long-term follow-up. The predefined primary outcome was time to composite event (cardiac death, myocardial infarction, or cardiac hospitalization). After 5 years, 105 (53%) patients in the PET arm and 111 (57%) in the standard care arm experienced the composite event (hazard ratio for time to composite event =0.82 [95% confidence interval 0.62–1.07];
P
=0.15). When only patients who adhered to PET recommendations were included, the hazard ratio for the time to primary outcome was 0.73 (95% confidence interval 0.54–0.99;
P
=0.042).
Conclusions—
After a 5-year follow-up in patients with left ventricular dysfunction and suspected CAD, overall, PET-assisted management did not significantly reduce cardiac events compared with standard care. However, significant benefits were observed when there was adherence to PET recommendations. PET viability imaging may be best applied when there is likely to be adherence to imaging-based recommendations.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00385242.
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Affiliation(s)
- Brian Mc Ardle
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Tushar Shukla
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Graham Nichol
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Robert A. deKemp
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Jordan Bernick
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Ann Guo
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Siok Ping Lim
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Ross A. Davies
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Haissam Haddad
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Lloyd Duchesne
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Paul Hendry
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Roy Masters
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Heather Ross
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Michael Freeman
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Karen Gulenchyn
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Normand Racine
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Dennis Humen
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Francois Benard
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Terrence D. Ruddy
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Benjamin J. Chow
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Lisa Mielniczuk
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Jean N. DaSilva
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Linda Garrard
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - George A. Wells
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | - Rob S.B. Beanlands
- From the Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Division of Cardiac Surgery, Department of Surgery and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, Canada (B.M., T.S., R.A.D., J.B., A.G., S.P.L., R.A.D., H.H., L.D., P.H., R.M., T.D.R., B.J.C., L.M., J.N.D., L.G., G.A.W., R.S.B.B.); Department of Medicine, Division of General Internal Medicine, University of
| | | | - T. Mesana
- University of Ottawa Heart Institute
| | | | | | - J. Renaud
- University of Ottawa Heart Institute
| | - R. Klein
- University of Ottawa Heart Institute
| | - M. Aung
- University of Ottawa Heart Institute
| | | | | | | | | | | | | | | | - A. Lamy
- Hamilton Health Sciences Centre
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Romanov A, Goscinska-Bis K, Bis J, Chernyavskiy A, Prokhorova D, Syrtseva Y, Shabanov V, Alsov S, Karaskov A, Deja M, Krejca M, Pokushalov E. Cardiac resynchronization therapy combined with coronary artery bypass grafting in ischaemic heart failure patients: long-term results of the RESCUE study. Eur J Cardiothorac Surg 2015; 50:36-41. [DOI: 10.1093/ejcts/ezv448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/18/2015] [Indexed: 12/11/2022] Open
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Silvay G, Zafirova Z. Ten Years Experiences With Preoperative Evaluation Clinic for Day Admission Cardiac and Major Vascular Surgical Patients: Model for "Perioperative Anesthesia and Surgical Home". Semin Cardiothorac Vasc Anesth 2015; 20:120-32. [PMID: 26620138 DOI: 10.1177/1089253215619236] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Admission on the day of surgery for elective cardiac and noncardiac surgery is the prevalent practice in North America and Canada. This approach realizes medical, psychological and logistical benefits, and its success is predicated on an effective outpatient preoperative evaluation. The establishment of a highly functional preoperative clinic with a comprehensive set up and efficient logistical pathways is invaluable. This notion in recent years has included the entire perioperative period, and the concept of a perioperative anesthesia/surgical home (PASH) is gaining popularity. The anesthesiologists as perioperative physicians can organize and lead the entire process from the preoperative evaluation, through the hosptial discharge. The functions of the PASH include preoperative optimization of medical conditions and psychological preparation of the patients and their support system; the care in the operating room and intensive care unit; pain management; respiratory therapy; cardiac rehabilitation; and specialized nutrition. Along with oversight of the medical issues, the preoperative visit is an opportune time for counseling, clarification of expectations and discussion of research, as well as for utilization of various informatics systems to consolidate the pertinent information and distribute it to relevant health care providers. We review the scientific foundation and practical applications of a preoperative visit and share our experience with the development of the preoperative evaluation clinic, designed specifically for cardiac and major vascular patients scheduled for day admission surgery. The ultimate goal of preoperative evaluation clinic is to ensure a safe, efficient, and cost-effective perioperative care for patients undergoing a complex type of surgery.
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Affiliation(s)
- George Silvay
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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Abstract
Background The significance of right ventricular ejection fraction (RVEF), independent of left ventricular ejection fraction (LVEF), following isolated coronary artery bypass grafting (CABG) and valve procedures remains unknown. The aim of this study is to examine the significance of abnormal RVEF by cardiac magnetic resonance (CMR), independent of LVEF in predicting outcomes of patients undergoing isolated CABG and valve surgery. Methods From 2007 to 2009, 109 consecutive patients (mean age, 66 years; 38% female) were referred for pre-operative CMR. Abnormal RVEF and LVEF were considered <35% and <45%, respectively. Elective primary procedures include CABG (56%) and valve (44%). Thirty-day outcomes were perioperative complications, length of stay, cardiac re-hospitalizations and early mortaility; long-term (> 30 days) outcomes included, cardiac re-hospitalization, worsening congestive heart failure and mortality. Mean clinical follow up was 14 months. Findings Forty-eight patients had reduced RVEF (mean 25%) and 61 patients had normal RVEF (mean 50%) (p<0.001). Fifty-four patients had reduced LVEF (mean 30%) and 55 patients had normal LVEF (mean 59%) (p<0.001). Patients with reduced RVEF had a higher incidence of long-term cardiac re-hospitalization vs. patients with normal RVEF (31% vs.13%, p<0.05). Abnormal RVEF was a predictor for long-term cardiac re-hospitalization (HR 3.01 [CI 1.5-7.9], p<0.03). Reduced LVEF did not influence long-term cardiac re-hospitalization. Conclusion Abnormal RVEF is a stronger predictor for long-term cardiac re-hospitalization than abnormal LVEF in patients undergoing isolated CABG and valve procedures.
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Schwann TA, Al-Shaar L, Tranbaugh RF, Dimitrova KR, Hoffman DM, Geller CM, Engoren MC, Bonnell MR, Habib RH. Multi Versus Single Arterial Coronary Bypass Graft Surgery Across the Ejection Fraction Spectrum. Ann Thorac Surg 2015; 100:810-7; discussion 817-8. [PMID: 26116479 DOI: 10.1016/j.athoracsur.2015.02.111] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 02/11/2015] [Accepted: 02/18/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Left internal thoracic artery (LITA) and radial artery (RA) multi-arterial CABG (MABG) is generally associated with improved long-term survival compared with traditional LITA and saphenous vein single arterial CABG (SABG). We examined the hypothesis that this multi-arterial survival advantage persists irrespective of left ventricular ejection fraction (LVEF). METHODS We retrospectively analyzed the primary, non-salvage multi-graft CABG experience (n = 11,261; 64.4 ± 10.4 years, 70.4% men) from 2 institutions (1995 to 2011). Risk-adjusted 15-year survival was pairwise compared for the MABG versus SABG grafting approaches within 3 LVEF subcohorts (>0.50, n = 4,833 [44% MABG]; 0.36 to 0.50, n = 4,465 [39% MABG]; and ≤ 0.35, n = 1,963 [35% MABG]) using propensity-matched and covariate adjusted Cox regression (all patients) comparisons. RESULTS Propensity matching yielded 1,317 (LVEF > 0.50), 1,179 (LVEF, 0.36 to 0.50), and 470 (LVEF ≤ 0.35) well-matched grafting method pairs. Acute perioperative mortality was equivalent between MABG and SABG within each LVEF group, but increased with decreasing LVEF. MABG was uniformly associated with better 15-year survival compared with SABG for all LVEF categories. The associated matched-adjusted hazard ratios (95% confidence intervals) were consistent across EF groups at 0.79 (0.68 to 0.93), 0.80 (0.69 to 0.93), and 0.82 (0.66 to 1.0), respectively. Covariate adjusted HR in all patients concurred with matched results. CONCLUSIONS MABG results in significantly enhanced long-term survival compared with LITA/SVG SABG regardless of the degree of LV dysfunction. These results favor MABG as the therapy of choice in patients with LV dysfunction.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Laila Al-Shaar
- Vascular Medicine Program, American University of Beirut, Beirut, Lebanon
| | - Robert F Tranbaugh
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Darryl M Hoffman
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Charles M Geller
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Milo C Engoren
- Mercy Saint Vincent Medical Center, Toledo, Ohio; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Mark R Bonnell
- Department of Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Robert H Habib
- Vascular Medicine Program, American University of Beirut, Beirut, Lebanon; Department of Surgery, Mount Sinai Beth Israel Medical Center, New York, New York.
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Efird JT, O'Neal WT, Camargo GA, Davies SW, O'Neal JB, Kypson AP. Conditional survival of heart failure patients after coronary artery bypass grafting. J Cardiovasc Med (Hagerstown) 2015; 15:498-503. [PMID: 24983270 DOI: 10.2459/jcm.0b013e328365b615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIMS Conditional survival is defined as the probability of surviving an additional number of years beyond that already survived. The aim of this study was to estimate conditional survival in heart failure patients after coronary artery bypass grafting (CABG). METHODS Heart failure patients with multivessel coronary artery disease undergoing first-time, isolated CABG between 1992 and 2011 were included in this study. Conditional survival estimates were computed for 1, 5, and 10 years after already surviving 0.5, 1, 2, 3, 4, and 5 years. RESULTS Compared with traditional survival estimates, conditional survival was consistently higher at all time periods. The overall 2-year adjusted survival estimate was 84% compared with the 1-year conditional survival rate of 95% for 1-year survivors. Similarly, the overall 10-year adjusted survival rate was 36% from the time of surgery compared with the 5-year conditional survival of 54% for patients who had survived 5 years. CONCLUSION Conditional survival provides a more accurate estimate of long-term survival in heart failure patients who have already survived for a certain amount of time after CABG. This information is useful for patients and physicians who manage their long-term care.
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Affiliation(s)
- Jimmy T Efird
- aEast Carolina Heart Institute, Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University bCenter for Health Disparities, Brody School of Medicine, East Carolina University, Greenville cDepartment of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina dDepartment of General Surgery, University of Virginia School of Medicine, Charlottesville, Virginia eDepartment of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Ohira S, Doi K, Numata S, Yamazaki S, Yamamoto T, Fukuishi M, Fujita A, Yaku H. Does Age at Operation Influence the Short- and Long-Term Outcomes of Off-Pump Coronary Artery Bypass Grafting? Circ J 2015; 79:2177-2185. [DOI: 10.1253/circj.cj-15-0462] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Suguru Ohira
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Kiyoshi Doi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Sachiko Yamazaki
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Tsunehisa Yamamoto
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Megumi Fukuishi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Akie Fujita
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
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A multidisciplinary approach to unplanned conversion from off-pump to on-pump beating heart coronary artery revascularization in patients with compromised left ventricular function. Crit Care Res Pract 2014; 2014:348021. [PMID: 25478216 PMCID: PMC4244953 DOI: 10.1155/2014/348021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/09/2014] [Accepted: 10/23/2014] [Indexed: 11/17/2022] Open
Abstract
Aim. To comparably assess the perioperative risk factors that differentiate off-pump coronary artery bypass (OPCAB) grafting cases from those sustaining unplanned conversion to on-pump beating heart (ONCAB/BH) approach, in patients with left ventricular ejection fraction (LVEF) < 40%. Methods. Perioperative variables were retrospectively assessed in 216 patients with LVEF < 40%, who underwent myocardial revascularization with OPCAB (n = 171) or ONCAB/BH (n = 45) approach. The study endpoints were operative mortality (30-day) and morbidity assessed by length of intensive care unit stay (LOS-ICU), using 2 days as cut-off point. Results. Poor LVEF, increased EuroSCORE II, acute presentation, congestive heart failure, cerebrovascular disease, perioperative renal impairment, clinical status deterioration upon admission and during ICU stay, acute myocardial infarction, and low cardiac output syndrome supported by inotropes and/or balloon-pump counterpulsation were significantly related to ONCAB/BH group (P < 0.05). EuroSCORE II (P = 0.01) and LVEF (P = 0.03) were the most powerful discriminative predictors of intraoperative conversion to ONCAB/BH. Operative mortality was 2.9% in OPCAB and 6.6% in ONCAB/BH group (P = 0.224), while 23.4% participants in OPCAB and 42.2% in ONCAB/BH approach had a LOS-ICU > 2 days (P = 0.007). Conclusions. Patients with LVEF < 40% undergoing ONCAB/BH are subjected to more preoperative comorbidities and implicated ICU stay than their OPCAB counterparts, which influences adversely short-term morbidity, while operative mortality remains unaffected.
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Marui A, Kimura T, Nishiwaki N, Mitsudo K, Komiya T, Hanyu M, Shiomi H, Tanaka S, Sakata R. Comparison of five-year outcomes of coronary artery bypass grafting versus percutaneous coronary intervention in patients with left ventricular ejection fractions≤50% versus >50% (from the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol 2014; 114:988-96. [PMID: 25124184 DOI: 10.1016/j.amjcard.2014.07.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/02/2014] [Accepted: 07/02/2014] [Indexed: 10/25/2022]
Abstract
Coronary heart disease is a major risk factor for left ventricular (LV) systolic dysfunction. However, limited data are available regarding long-term benefits of percutaneous coronary intervention (PCI) in the era of drug-eluting stent or coronary artery bypass grafting (CABG) in patients with LV systolic dysfunction with severe coronary artery disease. We identified 3,584 patients with 3-vessel and/or left main disease of 15,939 patients undergoing first myocardial revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2. Of them, 2,676 patients had preserved LV systolic function, defined as an LV ejection fraction (LVEF) of >50% and 908 had impaired LV systolic function (LVEF≤50%). In patients with preserved LV function, 5-year outcomes were not different between PCI and CABG regarding propensity score-adjusted risk of all-cause and cardiac deaths. In contrast, in patients with impaired LV systolic function, the risks of all-cause and cardiac deaths after PCI were significantly greater than those after CABG (hazard ratio 1.49, 95% confidence interval 1.04 to 2.14, p=0.03 and hazard ratio 2.39, 95% confidence interval 1.43 to 3.98, p<0.01). In both patients with moderate (35%<LVEF≤50%) and severe (LVEF≤35%) LV systolic dysfunction, the risk of cardiac death after PCI was significantly greater than that after CABG (hazard ratio 2.25, 95% confidence interval 1.15 to 4.40, p=0.02 and hazard ratio 4.42, 95% confidence interval 1.48 to 13.24, p=0.01). Similarly, the risk of all-cause death tended to be greater after PCI than after CABG in both patients with moderate and severe LV systolic dysfunction without significant interaction (hazard ratio 1.57, 95% confidence interval 0.96 to 2.56, p=0.07 and hazard ratio 1.42, 95% confidence interval 0.71 to 2.82, p=0.32; interaction p=0.91). CABG was associated with better 5-year survival outcomes than PCI in patients with impaired LV systolic function (LVEF≤50%) with complex coronary disease in the era of drug-eluting stents. In both patients with moderate (35%<LVEF≤50%) and severe (LVEF≤35%) LV systolic dysfunction, CABG tended to have better survival outcomes than PCI.
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Marui A, Kimura T, Nishiwaki N, Komiya T, Hanyu M, Shiomi H, Tanaka S, Sakata R. Three-year outcomes after percutaneous coronary intervention and coronary artery bypass grafting in patients with heart failure: from the CREDO-Kyoto percutaneous coronary intervention/coronary artery bypass graft registry cohort-2†. Eur J Cardiothorac Surg 2014; 47:316-21; discussion 321. [PMID: 24662243 DOI: 10.1093/ejcts/ezu131] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Ischaemic heart disease is a major risk factor for heart failure. However, long-term benefit of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in those patients has not been well elucidated. METHODS Of the 15 939 patients undergoing first myocardial revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2, we identified 1064 patients with multivessel and/or left main disease with a history of heart failure (ACC/AHA Stage C or D). RESULTS There were 672 patients undergoing PCI and 392 CABG. Preprocedural left ventricular ejection fraction was not different between PCI and CABG (46.6 ± 15.1 vs 46.6 ± 14.6%, P = 0.89), but the CABG group included more patients with triple-vessel and left main disease (P < 0.01 each). Three-year outcomes revealed that the risk of hospital readmission for heart failure was higher after PCI than after CABG (hazard ratio [95% confidence interval]; 1.90 [1.18-3.05], P = 0.01). More importantly, adjusted mortality after PCI was significantly higher than after CABG (1.79 [1.13-2.82], P = 0.01). The risk of cardiac death after PCI was also higher than after CABG (1.98 [1.10-3.55], P = 0.02). Stratified analysis using the SYNTAX score demonstrated that risk of death was not different between PCI and CABG in patients with low (<23) and intermediate (23-32) SYNTAX scores (2.10 [0.57-7.68], P = 0.26 and 1.43 [0.63-3.21], P = 0.39, respectively), whereas those with a high (≥ 33) SYNTAX score, the risk of death was far higher after PCI than after CABG (4.83 [1.46-16.0], P = 0.01). CONCLUSIONS In patients with heart failure with advanced coronary artery disease, CABG was a better option than PCI because CABG was associated with better survival benefit, particularly in more complex coronary lesions stratified by the SYNTAX score.
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Affiliation(s)
- Akira Marui
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Noboru Nishiwaki
- Department of Cardiovascular Surgery, Nara Hospital Kinki University Faculty of Medicine, Ikoma, Japan
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Michiya Hanyu
- Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shiro Tanaka
- Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Mohammadi S, Kalavrouziotis D, Cresce G, Dagenais F, Dumont E, Charbonneau E, Voisine P. Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term benefit? Eur J Cardiothorac Surg 2014; 46:425-31; discussion 431. [PMID: 24554069 DOI: 10.1093/ejcts/ezu023] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The use of bilateral internal thoracic arteries (BITA) has been associated with improved long-term outcomes following coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the impact of BITA use on long-term survival among patients with low ejection fraction (EF) undergoing CABG. METHODS Between April 1991 and October 2011, 2035 consecutive patients underwent primary BITA grafting. Among them, there were 129 patients with left ventricular EF ≤40%. During the same time period, 1666 primary CABGs were performed using a single internal thoracic artery (SITA) in patients with EF ≤40%. A propensity score optimal matching algorithm was used to create the matched SITA and BITA groups (n = 111 in each group). Also, Cox regression multivariable analyses were performed to determine the independent risk factors for long-term mortality. The date of death was obtained from provincial vital statistics. RESULTS There was no difference in operative mortality between matched BITA and SITA (n = 2, 1.8% vs n = 1, 0.9%, respectively, P = 0.6) groups. The mean follow-up was 8.6 ± 5.1 and 7.7 ± 5.5 years for BITA and SITA groups, respectively (P = 0.2). Five-, 10- and 15-year survival rates were 93.7, 77.5 and 59.0% in the matched BITA patients vs 82.8, 68.1 and 65.2% in the matched SITA patients (P = 0.3). In multivariate analysis, the independent risk factors for late mortality among hospital survivors were: insulin-dependent diabetes [adjusted hazard ratio (HR): 3.4, 95% confidence interval (CI): 1.4-8.4, P = 0.008], perioperative intra-aortic balloon pump insertion (HR: 3.2, 95% CI: 1.5-6.9, P = 0.004), postoperative deep sternal wound infection (HR: 7.4, 95% CI: 2.2-24.1, P = 0.001) and neurological complications (HR: 3.5, 95% CI: 1.4-8.4, P = 0.006). Choice of BITA versus SITA was not an independent predictor of long-term mortality (P = 0.3). CONCLUSIONS The use of a second internal thoracic artery (ITA) does not prolong late survival in patients with low EF undergoing CABG compared with a propensity-matched group of SITA graft patients.
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Affiliation(s)
- Siamak Mohammadi
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Giovanni Cresce
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - François Dagenais
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Eric Dumont
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Eric Charbonneau
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
| | - Pierre Voisine
- Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada
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Chung S, Kim WS, Jeong DS, Lee J, Lee YT. Outcomes of off-pump coronary bypass grafting with the bilateral internal thoracic artery for left ventricular dysfunction. J Korean Med Sci 2014; 29:69-75. [PMID: 24431908 PMCID: PMC3890479 DOI: 10.3346/jkms.2014.29.1.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 11/12/2013] [Indexed: 11/30/2022] Open
Abstract
This study evaluated the outcomes of off-pump coronary artery bypass surgery (OPCAB) with severe left ventricular dysfunction using composite bilateral internal thoracic artery grafting. From January 2001 to December 2008, 1,842 patients underwent primary isolated OPCAB with composite bilateral internal thoracic artery grafting. A total of 131 of these patients were diagnosed with a severely depressed preoperative left ventricle ejection fraction (LVEF) (≤ 0.35). These patient outcomes were compared with the outcomes of 830 patients that had mildly or moderately depressed LVEF (0.36 to 0.59) and 881 patients with normal LVEF (>0.6). The early mortality for patients with severe LVEF was 2.3%. The 3-yr and 7-yr survival rate for patients with severe LV dysfunction was 86.0% and 82.8%, respectively. Multivariate analysis showed that severe LV dysfunction EF increased the risk of all-cause death (P=0.012; hazard ratio [HR],2.14; 95% confidence interval [CI],1.19-3.88) and the risk of cardiac-related death (P=0.008; HR,3.38; 95% CI, 1.37-8.341). The study identified positive surgical outcomes of OPCAB, although severe LVEF was associated with two-fold increase in mortality risk compared with patients who had normal LVEF.
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Affiliation(s)
- Suryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaejin Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul Adventist Hospital, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Nagendran J, Norris CM, Graham MM, Ross DB, MacArthur RG, Kieser TM, Maitland AM, Southern D, Meyer SR. Coronary Revascularization for Patients With Severe Left Ventricular Dysfunction. Ann Thorac Surg 2013; 96:2038-44. [DOI: 10.1016/j.athoracsur.2013.06.052] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/27/2013] [Accepted: 06/03/2013] [Indexed: 01/23/2023]
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Coronary artery bypass grafting in patients with left ventricular dysfunction: predictors of long-term survival and impact of surgical strategies. Int J Cardiol 2013; 168:5316-22. [PMID: 23978366 DOI: 10.1016/j.ijcard.2013.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/01/2013] [Accepted: 08/03/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND In the surgical management of ischemic cardiomyopathy, factors associated with long-term prognosis after coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) dysfunction are poorly understood. This study aimed to determine predictors of clinical outcomes in patients with severe LV dysfunction undergoing CABG. METHODS Out of 6084 patients who underwent CABG between 1997 and 2011, 476 patients (aged 62.6 ± 9.3 years, 100 females) were identified as having severe LV dysfunction (ejection fraction ≤ 35%), preoperatively. All-cause mortality and adverse cardiac events (myocardial infarction, repeat revascularization, stroke and hospitalization due to cardiovascular causes) were evaluated during a median follow-up period of 55.2 months (inter-quartile range: 26.4-94.8 months). RESULTS During the follow-up, 187 patients (39.3%) died and 126 cardiac events occurred in 104 patients (21.8%). Five-year survival and event-free survival rates were 72.1 ± 2.2% and 61.3 ± 2.4%, respectively. On Cox-regression analysis, old age (P < 0.001), recent MI (P < 0.001), history of coronary stenting (P = 0.023), decreased glomerular filtration rate (P < 0.001), and presence of mitral regurgitation (≥moderate) (P = 0.012) or LV wall thinning (P = 0.007) emerged as significant and independent predictors of death. After adjustment for important covariates affecting outcomes, none of the pump strategy (off-pump vs. on-pump), concomitant mitral surgery or surgical ventricular reconstruction (SVR) affected survival or event-free survival (P = 0.082 to >0.99). CONCLUSIONS Long-term survival following CABG in patients with severe LV dysfunction was affected by age, renal function, recent MI, prior coronary stenting, and presence of mitral regurgitation or LV wall thinning. Neither concomitant mitral surgery nor SVR, however, had significant influence on clinical outcomes.
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Shirani J. Is ischemia the most powerful indicator of myocardial viability? Curr Cardiol Rep 2013; 15:354. [PMID: 23512623 DOI: 10.1007/s11886-013-0354-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Chronic symptomatic ischemic heart failure remains a major cause of morbidity and mortality in the adult. Recently, the utility of coronary revascularization in early management of patients with stable ischemic heart failure has come into question by several randomized clinical trials. Some of these studies have also challenged the notion that determination of the predominant state of the dysfunctional left ventricular myocardium (viable or scarred) may facilitate identification of patients who would benefit the most from revascularization. These prospective, randomized, multi-center trials have also exposed many of the practical impediments to conducting an ideal clinical investigation particularly in the context of increasingly recognized need for goal-directed and personalized approaches to management of ischemic heart disease. This review summarizes the present evidence for an ischemia-guided approach to evaluation and treatment of chronic ischemic heart disease with left ventricular systolic dysfunction.
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Affiliation(s)
- Jamshid Shirani
- Department of Cardiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, 18015, USA.
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Lopes RD, Williams JB, Mehta RH, Reyes EM, Hafley GE, Allen KB, Mack MJ, Peterson ED, Harrington RA, Gibson CM, Califf RM, Kouchoukos NT, Ferguson TB, Lorenz TJ, Alexander JH. Edifoligide and long-term outcomes after coronary artery bypass grafting: PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT IV) 5-year results. Am Heart J 2012; 164:379-386.e1. [PMID: 22980305 DOI: 10.1016/j.ahj.2012.05.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 05/30/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Edifoligide, an E2F transcription factor decoy, does not prevent vein graft failure or adverse clinical outcomes at 1 year in patients undergoing coronary artery bypass grafting (CABG). We compared the 5-year clinical outcomes of patients in PREVENT IV treated with edifoligide and placebo to identify predictors of long-term clinical outcomes. METHODS A total of 3,014 patients undergoing CABG with at least 2 planned vein grafts were enrolled. Kaplan-Meier curves were generated to compare the long-term effects of edifoligide and placebo. A Cox proportional hazards model was constructed to identify factors associated with 5-year post-CABG outcomes. The main outcome measures were death, myocardial infarction (MI), repeat revascularization, and rehospitalization through 5 years. RESULTS Five-year follow-up was complete in 2,865 patients (95.1%). At 5 years, patients randomized to edifoligide and placebo had similar rates of death (11.7% and 10.7%, respectively), MI (2.3% and 3.2%), revascularization (14.1% and 13.9%), and rehospitalization (61.6% and 62.5%). The composite outcome of death, MI, or revascularization occurred at similar frequency in patients assigned to edifoligide and placebo (26.3% and 25.5%, respectively; hazard ratio 1.03 [95% CI 0.89-1.18], P = .721). Factors associated with death, MI, or revascularization at 5 years included peripheral and/or cerebrovascular disease, time on cardiopulmonary bypass, lung disease, diabetes mellitus, and congestive heart failure. CONCLUSIONS Up to a quarter of patients undergoing CABG will have a major cardiac event or repeat revascularization procedure within 5 years of surgery. Edifoligide does not affect outcomes after CABG; however, common identifiable baseline and procedural risk factors are associated with long-term outcomes after CABG.
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Khanna P, Stilp E, Pfau S. Recovery of left ventricular function after percutaneous revascularization of a left main chronic total occlusion. Catheter Cardiovasc Interv 2012; 80:310-5. [PMID: 22553190 DOI: 10.1002/ccd.24322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 01/03/2012] [Indexed: 11/05/2022]
Abstract
Surgical revascularization of left main and/or three-vessel coronary artery disease (CAD) is associated with improved survival in patients with left ventricular dysfunction when compared to medical therapy and can result in improved left ventricular ejection fraction (LVEF) [1]. Multivessel percutaneous coronary intervention (PCI) is equivalent to surgery regarding short and intermediate term mortality, and left main PCI has emerged as a safe and effective alternate to surgical revascularization [2]. However, outcomes of unprotected left main PCI in patients with severely depressed LVEF have not been examined. We report a patient with left main chronic total occlusion, multivessel CAD, and dilated cardiomyopathy, in whom complete revascularization via PCI resulted in decreased left ventricular size and improved LVEF.
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Affiliation(s)
- Pravien Khanna
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: a propensity-matched study with 30-year follow-up. J Thorac Cardiovasc Surg 2012; 143:844-853.e4. [PMID: 22245240 DOI: 10.1016/j.jtcvs.2011.12.026] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Revised: 11/17/2011] [Accepted: 12/14/2011] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied. METHODS Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm. RESULTS There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001). CONCLUSIONS Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.
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Kunadian V, Zaman A, Qiu W. Revascularization among patients with severe left ventricular dysfunction: a meta-analysis of observational studies. Eur J Heart Fail 2011; 13:773-84. [PMID: 21478241 DOI: 10.1093/eurjhf/hfr037] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AIMS Coronary artery bypass graft (CABG) surgery is the standard of care for the management of patients with severe three-vessel and left main coronary artery disease (CAD). However, the optimal strategy for management of patients with CAD and severe left ventricular (LV) dysfunction [ejection fraction (EF) ≤35%] is not clear. A meta-analysis of observational studies was performed to determine the operative mortality and long-term (5-year actuarial survival) outcomes among patients with severe LV dysfunction undergoing CABG. METHODS AND RESULTS A systematic computerized literature search was performed and observational studies consisting of patients undergoing isolated CABG for CAD and severe LV dysfunction were included. Studies that did not report operative mortality, long-term (≥1 year) survival data, or pre-operative EF and multiple studies from the same group were excluded. In total, 4119 patients from 26 observational clinical studies were included. The estimated mean age was 63.9 years and 82.4% of patients were men. The mean (estimate) pre-operative EF was 24.7% (95% CI 22.5-27.0%). The operative mortality among patients (26 studies, n= 3621) who underwent on-pump CABG was 5.4%, n= 189 (95% CI 4.5-6.4%). The 5-year actuarial survival among patients (13 studies, n= 1980) who underwent on-pump CABG was 73.4%, n= 1483 (95% CI 68.7-77.7%). Patients who underwent off-pump CABG (7 studies, n= 498) tended to have reduced operative mortality of 4.4%, n= 20 (95% CI 2.8-6.4%). The mean (estimate) post-operative EF was 35.19% (95% CI 31.95-38.43%). CONCLUSION The present meta-analysis demonstrates that based on data from available observational clinical studies, CABG can be performed with acceptable operative mortality and 5-year actuarial survival in patients with severe LV dysfunction.
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Mutch WAC, Fransoo RR, Campbell BI, Chateau DG, Sirski M, Warrian RK. Dementia and depression with ischemic heart disease: a population-based longitudinal study comparing interventional approaches to medical management. PLoS One 2011; 6:e17457. [PMID: 21387018 PMCID: PMC3046165 DOI: 10.1371/journal.pone.0017457] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 02/04/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We compared the proportion of ischemic heart disease (IHD) patients newly diagnosed with dementia and depression across three treatment groups: percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical management alone (IHD-medical). METHODS AND FINDINGS De-identified, individual-level administrative records of health service use for the population of Manitoba, Canada (approximately 1.1 million) were examined. From April 1, 1993 to March 31, 1998, patients were identified with a diagnosis of IHD (ICD-9-CM codes). Index events of CABG or PCI were identified from April 1, 1998 to March 31, 2003. Outcomes were depression or dementia after the index event. Patients were followed forward to March 31, 2006 or until censored. Proportional hazards regression analysis was undertaken. Independent variables examined were age, sex, diabetes, hypertension and income quintile, medical management alone for IHD, or intervention by PCI or CABG. Age, sex, diabetes, and presence of hypertension were all strongly associated with the diagnosis of depression and dementia. There was no association with income quintile. Dementia was less frequent with PCI compared to medical management; (HR = 0.65; p = 0.017). CABG did not provide the same protective effect compared to medical management (HR = 0.90; p = 0.372). New diagnosis depression was more frequent with interventional approaches: PCI (n = 626; hazard ratio = 1.25; p = 0.028) and CABG (n = 1124, HR = 1.32; p = 0.0001) than non-interventional patients (n = 34,508). Subsequent CABG was nearly 16-fold higher (p<0.0001) and subsequent PCI was 22-fold higher (p<0.0001) for PCI-managed than CABG-managed patients. CONCLUSIONS Patients managed with PCI had the lowest likelihood of dementia-only 65% of the risk for medical management alone. Both interventional approaches were associated with a higher risk of new diagnosed depression compared to medical management. Long-term myocardial revascularization was superior with CABG. These findings suggest that PCI may confer a long-term protective effect from dementia. The mechanism(s) of dementia protection requires elucidation.
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Affiliation(s)
- W Alan C Mutch
- Department of Anesthesia and Peri-operative Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada.
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Hage FG, Venkataraman R, Aljaroudi W, Bravo PE, McLarry J, Faulkner M, Heo J, Iskandrian AE. The impact of viability assessment using myocardial perfusion imaging on patient management and outcome. J Nucl Cardiol 2010; 17:378-89. [PMID: 20186583 DOI: 10.1007/s12350-010-9199-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 02/04/2010] [Indexed: 01/25/2023]
Abstract
BACKGROUND Prior studies show that ischemic cardiomyopathy (ICM) patients with substantial viable myocardium have better survival with coronary revascularization (CR) than medical therapy (MT). When myocardial perfusion imaging (MPI) is used, the analysis is often based on visual scoring. We sought to determine the value of automated quantitative viability analysis in guiding management and predicting outcome. METHODS We identified 246 consecutive ICM patients who had rest-redistribution gated SPECT thallium-201 MPI. Size and severity of perfusion defects were assessed by automated method. Regions with <50% activity vs normal were considered nonviable. Mortality was verified against the social security death index database. RESULTS Of the 246 patients, 37% underwent CR within 3 months of MPI. The initial images showed a total perfusion defect size of 32 +/- 17%, redistribution of 3.5 +/- 4.6% and nonviable myocardium of 13 +/- 14%LV. Using multivariate logistic regression analysis, independent predictors of CR included chest pains (OR 2.74) and rest-delayed transient ischemic dilatation (OR 4.49), while a prior history of CR or ventricular arrhythmias favored MT. The cohort was followed-up for 41 +/- 30 m during which 111 patients (45%) died. Survival was better with CR than MT (P < .0001). For CR, survival was better for those with a smaller area of nonviable myocardium (risk of death increased by 5%/1% increase in size of nonviable myocardium, P = .009) but this was not seen in MT. CR had a mortality advantage over MT when the area of nonviable myocardium was CONCLUSIONS Automated quantitative analysis of MPI is useful in predicting survival in ICM, but the decision for or against CR is a complex one as it depends on multiple other factors and "viability testing" is just one variable that needs to be incorporated in the decision-making process.
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Affiliation(s)
- Fadi G Hage
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Zeigler Research Building 1024, 1530 3rd AVE S, Birmingham, AL 35294, USA.
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Sezai A, Hata M, Niino T, Yoshitake I, Unosawa S, Wakui S, Fujita K, Takayama T, Kasamaki Y, Hirayama A, Minami K. Continuous Low-Dose Infusion of Human Atrial Natriuretic Peptide in Patients With Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Grafting. J Am Coll Cardiol 2010; 55:1844-51. [DOI: 10.1016/j.jacc.2009.11.085] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Revised: 10/30/2009] [Accepted: 11/02/2009] [Indexed: 11/24/2022]
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Boehm J, Haas F, Bauernschmitt R, Wagenpfeil S, Voss B, Schwaiger M, Lange R. Impact of preoperative positron emission tomography in patients with severely impaired LV-function undergoing surgical revascularization. Int J Cardiovasc Imaging 2010; 26:423-32. [PMID: 20091350 PMCID: PMC2852592 DOI: 10.1007/s10554-010-9585-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2009] [Accepted: 01/07/2010] [Indexed: 12/03/2022]
Abstract
In patients with ischemic cardiomyopathy, coronary artery bypass grafting (CABG) offers an important therapeutic option but is still associated with high perioperative mortality. Although previous studies suggest a benefit from revascularization for patients with defined viability by a non-invasive technique, the role of viability assessment to determine suitability for revascularization in patients with ischemic cardiomyopathy has not yet been defined. This study evaluates the hypothesis that the use of PET imaging in the decision-making process for CABG will improve postoperative patient survival. We reviewed 476 patients with ischemic cardiomyopathy (LV ejection fraction ≤0.35) who were considered candidates for CABG between 1994 and 2004 on the basis of clinical presentation and angiographic data. In a Standard Care Group, 298 patients underwent CABG. In a second PET-assisted management group of 178 patients, 152 patients underwent CABG (PET-CABG) and 26 patients were excluded from CABG because of lack of viability (PET-Alternatives). Primary endpoint was postoperative survival. There were two in hospital deaths in the PET-CABG (1.3%) and 30 (10.1%) in the Standard Care Group (P = 0.018). The survival rate after 1, 5 and 9.3 years was 92.0, 73.3 and 54.2% in the PET-CABG and 88.9, 62.2 and 35.5% in the Standard Care Group, respectively (P = 0.005). Cox-regression analysis revealed a significant influence on long-term survival of patient selection by viability assessment via PET (P = 0.008), of LV-function (P = 0.017), and age >70 (P = 0.016). Preoperative assessment of myocardial viability via PET identifies patients, who will benefit most from CABG.
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Affiliation(s)
- Johannes Boehm
- Klinik fuer Herz- und Gefaesschirurgie, Deutsches Herzzentrum Muenchen, Technische Universitaet Muenchen, Lazarettstrasse 36, 80636, Munich, Germany.
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Tang GH, Fremes S. Invited Commentary. Ann Thorac Surg 2009; 87:1407-8. [DOI: 10.1016/j.athoracsur.2009.03.045] [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: 03/15/2009] [Revised: 03/15/2009] [Accepted: 03/18/2009] [Indexed: 11/26/2022]
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