Does Prior Percutaneous Coronary Intervention Adversely Affect Early and Mid-Term Survival After Coronary Artery Surgery?

Late Myocardial Infarction and Repeat Revascularization after Coronary Artery Bypass Grafting in Patients with Prior Percutaneous Coronary Intervention

Objectives: The aim of the present study was to evaluate the risk of late mortality and major adverse cardiovascular and cerebral events after coronary artery bypass grafting (CABG) in patients with prior percutaneous coronary intervention (PCI). Methods: A total of 2948 patients undergoing isolated CABGs were included in a prospective multicenter registry. Outcomes were adjusted for multiple covariates in logistic regression, Cox proportional hazards analysis and competing risk analysis. Results: In all, 2619 patients fulfilled the inclusion criteria of this analysis. Of them, 2199 (79.1%) had no history of PCI and 420 (20.9%) had a prior PCI. An adjusted analysis showed that a single prior PCI and multiple prior PCIs did not increase the risk of 30-day and 5-year mortality. Patients with multiple prior PCIs had a significantly higher risk of 5-year myocardial infarction (SHR 2.566, 95%CI 1.379–4.312) and repeat revascularization (SHR 1.774, 95%CI 1.140–2.763). Similarly, 30-day and 5-year mortality were not significantly increased in patients with prior PCI treatment of single or multiple vessels. Patients with multiple vessels treated with PCI had a significantly higher risk of 5-year myocardial infarction (SHR 2.640, 95%CI 1.497–4.658), repeat revascularization (SHR 1.648, 95%CI 1.029–2.638) and stroke (SHR 2.215, 95%CI 1.056–4.646) at 5-year. The risk for repeat revascularization was also increased with a prior single vessel PCI, but not for other outcomes. Conclusions: Among patients undergoing CABGs, multiple prior PCIs seem to increase the risk of late myocardial infarction and the need for repeat revascularization, but not the risk of mortality.

Нospital outcomes of coronary artery bypass grafting in patients with coronary heart disease with previous percutaneous coronary intervention

Aim. Evaluation of the frequency hospital cardiovascular events in groups of patients with stable angina who underwent percutaneous coronary interventions (PCI) with stenting of the arteries before coronary bypass surgery, or who did not have previous myocardial revascularization. Materials and methods. The 120 patients with stable angina who underwent routine coronary artery bypass grafting were examined. Group composition: Men 80.8%, age 587.6, duration of coronary heart disease 65.7 years, history of myocardial infarction (MI) 77.5%. Arterial hypertension was present in 92.5%, diabetes mellitus in 12.5% of patients. Multivessel coronary artery disease in 72.5% of patients. 28 (23.4%) patients had previously undergone PCI with stenting of the coronary arteries. The period from PCI to coronary bypass surgery was 2032.6 months. Coronary bypass surgery on-pump was performed in 88.3%, coronary bypass surgery on off-pump in 11.7%. The number of distal anastomoses ranged from 1 to 4. Results. There were no differences in clinical and angiographic indicators, pharmacotherapy, and operation characteristics between the groups of patients who were subjected to or did not have PCI before coronary bypass surgery. There were no differences between the analyzed groups of patients in the frequency of cardiac death (0 and 1.1%, p=0.58), non-fatal MI (3.6% and 9.8%, p=0.29), stroke (0 and 1.1%, p=0.58), acute heart failure (11.7% and 34.8%, p=0.06), the number of patients with paroxysms of atrial fibrillation (28.6% and 17.4%, p=0.94), the proportion of patients with resternotomies (3.6% and 3.3%, p=0.94) and gastrointestinal bleeding (3.6% and 4.3%, p=0.86). Conclusion. PCI with coronary artery stenting, prior to coronary bypass surgery, does not affect the frequency of post-operative hospital cardiovascular and hemorrhagic complications.

Prior percutaneous coronary intervention and outcomes in patients after coronary artery bypass grafting: a meta-analysis of 308,284 patients

Background:

The association between prior percutaneous coronary intervention (PCI) and prognosis after coronary artery bypass grafting (CABG) remains uncertain. We aimed to evaluate the aforementioned association in a meta-analysis.

Methods:

PubMed, Cochrane’s Library, and Embase databases were searched for potential studies. A random-effects model was used for the meta-analysis. Meta-regression was performed to evaluate the influence of study characteristics on the outcomes.

Results:

Thirty-six follow-up studies with 308,284 patients were included, and 40,892 (13.3%) patients had prior PCI. Pooled results showed that prior PCI was associated with higher risks of early (in-hospital or within 1 month) all-cause mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 1.11–1.44, p = 0.003; I² = 64%] and major adverse cardiovascular events (MACEs; OR: 1.36, 95% CI: 1.12–1.66, p = 0.002, I² = 79%), but not with late (follow-up durations from 1 to 13 years) mortality (OR: 1.03, 95% CI: 0.95–1.13, p = 0.44, I² = 46%) or MACEs (OR: 1.03, 95% CI: 0.97–1.09, p = 0.38, I² = 0%). Meta-regression showed that the study characteristics of patient number, age, sex, diabetic status, and proportion of patients with prior PCI did not affect the outcomes. Sensitivity analyses limited to multivariate studies excluding patients with acute PCI failure showed similar results (early mortality, OR: 1.25, p = 0.003; early MACE, OR: 1.50, p = 0.001; late mortality, OR: 1.03, p = 0.70).

Conclusion:

The current evidence, mostly from retrospective observational studies, suggests that prior PCI is related to poor early clinical outcomes, but not to late clinical outcomes, after CABG.

Multiple percutaneous coronary interventions may negatively impact cardiac remodelling after bypass surgery

OBJECTIVES

Many patients undergo percutaneous coronary intervention (PCI) multiple times before being referred for coronary artery bypass grafting (CABG), in which bypass grafts are often anastomosed to small distal targets with higher risk of graft failure. We aimed to assess whether multiple PCIs adversely affect the long-term outcomes of patients who undergo CABG subsequently.

METHODS

A cohort of 368 patients with no history of PCI underwent initial isolated CABG between 2003 and 2013 (no PCI group). Ninety-seven patients who had undergone PCI 2 or more times preoperatively during the same period constituted the multiple PCI group. After propensity score matching, the group outcomes were compared.

RESULTS

There were no significant differences in the 10-year all-cause mortality and major adverse cardiac and cerebrovascular event rates in both groups. Although the left ventricular end-diastolic dimension in the multiple PCI group did not change markedly (from 48.0 ± 6.0 to 47.2 ± 7.9 mm; P = 0.25), it decreased significantly in the no PCI group (from 48.3 ± 6.1 to 44.9 ± 9.1 mm; P < 0.001). The left ventricular end-systolic dimension in the no PCI group decreased significantly (from 34.1 ± 8.7 to 31.4 ± 8.6 mm; P = 0.024), while it in the multiple PCI group did not (from 33.6 ± 8.3 to 32.7 ± 8.6 mm; P = 0.21).

CONCLUSIONS

For complex coronary artery disease, early surgical intervention could be considered with respect to postoperative left ventricular remodelling during the long-term follow-up.

Long-term survival in patients who had CABG with or without prior coronary artery stenting

Objective

To conduct a large-scale, single-centre retrospective cohort study to understand the impact of prior percutaneous coronary intervention (PCI) on long-term survival of patients who then undergo coronary artery bypass graft (CABG).

Methods

Between 1999 and 2017, a total of 11 332 patients underwent CABG at a hospital in the UK. The patients were stratified into those who received PCI (n=1090) or no PCI (n=10 242) prior to CABG. A total of 1058 patients from each group were matched using propensity score matching. Kaplan-Meier estimates were used to assess risk-adjusted survival in patients with prior PCI. Cox proportional hazards (CoxPH) model was then used to assess the effect of prior PCI and other variables in patients undergoing CABG.

Results

The immediate postoperative outcome showed no difference in number of grafts per patients, blood transfusion, hospital stay or 30 days mortality between the groups. There was no significant difference in 5 years (90.8% vs 87.9), 10-year (76.5% vs 74.6%) and 15-year (64.4% vs 64.7%) survival between the non-PCI versus PCI groups. The Cox proportional hazards model further supports the null hypothesis as the PCI variable was found to be non-significant (CoxPH=1.03, p=0.75, CI=0.87–1.22) implying there was no difference in hazard of death for CABG patients with or without previous PCI. However, the model did yield information on the covariates that do affect the hazard of death.

Conclusion

There is no difference in 5-year, 10-year and 15-year survival between patients undergoing CABG with or without prior PCI. However, certain patient, preoperative and intraoperative risk factors were identified with high hazard of death which needs to be investigated further.

Effect of previous coronary stenting on subsequent coronary artery bypass grafting outcomes

OBJECTIVES

The effect of previous coronary stenting on subsequent coronary artery bypass graft is inconclusive.

METHODS

We used Taiwan's National Health Insurance Database to retrospectively evaluate patients with multivessel coronary artery bypass graft between January 2000 and December 2013. Overall, 32,335 patients who received coronary artery bypass graft were included, of whom 3028 had previous coronary stenting. Propensity-score matching yielded 2977 cases each for evaluation under the previous stenting and no stenting groups. The 30-day mortality and major adverse cardiac events, including all-cause mortality, acute myocardial infarction, and revascularization, were considered primary outcomes.

RESULTS

The number of coronary artery bypass grafts decreased per year. However, the percentage of patients who had previous coronary stent implantation before coronary artery bypass graft increased steadily (P for trend <.001), and the average number of stents implanted in a patient also increased per year (P for trend <.001). The previous stent group had a significantly greater 30-day mortality rate than did the no-stent group (7.2% vs 5.0%; odds ratio, 1.47; 95% confidence interval, 1.19-1.82). The previous stent group had a greater rate of revascularization (14.4% and 10.0%; subdistribution hazard ratio, 1.50; 95% confidence interval, 1.30-1.74) in the last follow-up at year 13.

CONCLUSIONS

Previous coronary stenting before coronary artery bypass graft for multivessel coronary artery disease significantly increased 30-day mortality but did not affect late survival. However, patients who had coronary stenting before coronary artery bypass graft experienced more revascularization events during late follow-up.

Full Metal Jacket Endarterectomy of Left Anterior Descending Coronary Artery is Safe With Good Midterm Outcomes

BACKGROUND

Multiple overlapping stents (Full metal jacket, FMJ) from percutaneous coronary artery intervention (PCI) renders coronary artery bypass modus operandi unmanageable. We report our surgical revascularisation in patients with failed full metal jacket of left anterior descending coronary artery (FMJ-LAD).

METHODS

We reviewed 22 patients who presented with FMJ-LAD From 2006 to 2019. Extensive endarterectomy involving almost the whole length of the left anterior descending (LAD) was performed, the arteriotomy patched up with a saphenous vein. All reconstructed LADs were grafted with the left internal mammary artery. We compared the group to propensity-matched patients with single proximal LAD lesions requiring coronary artery bypass graft (CABG).

RESULTS

The mean age was 54±3.5 years. Twenty-one (21) patients (95%) were in angina class III or IV despite maximum medical therapy. Fourteen (14) patients (63.6%) presented with MI within 1 month. All patients had a preoperative positive test for ischaemia. Cross-clamp and bypass times were significantly shorter (25.5±7 mins and 65±5 mins, versus 52±3 mins and 77.2±4 mins) in the CABG group compared to FMJ-LAD group, the mean hospital stay of 6±1.5 days was not different between the groups. Postoperative electrocardiograms showed non-specific changes in 75% (n=16) with no enzyme rise. Early postoperative angiography was performed in 10 patients because of the new electrocardiograph (ECG) changes; all FMJ-LAD patients had an angiogram at 1 year, two late angiograms (2 and 3 years postoperatively), and one computed tomography (CT)-angiogram for readmission with angina. All patients in the FMJ-LAD group had 12 months follow-up angiogram or cardiac CT scan. All the endarterectomies' LADs were patent. There was no mortality within the 30 days. Patients' follow-up time was between 1-13 years.

CONCLUSIONS

Open stent endarterectomy is a valuable alternative option for patients with "full metal jacket" diseased LAD that is not graftable using standard techniques with acceptable midterm results.

Patients over 70 years of age with moderate ischemic mitral regurgitation undergoing surgical revascularization plus mitral valve repair: insights from a single-center study of propensity-matched data

Background

Elderly patients, compared with the young, have a higher burden of surgical risk factors with reduced functional capacity and increased comorbidities conditions, and may have worse clinical outcomes. So far, few reports have focused on clinical outcomes of patients over 70 years of age with moderate chronic ischemic mitral regurgitation (IMR) undergoing mitral valve repair at the time of coronary artery bypass grafting (CABG). This single-center study of propensity-matched data attempts to answer a question: compared with patients with age of 70 or less, whether patients over 70 years of age with moderate IMR undergoing CABG plus mitral valve repair receive poor outcomes.

Methods

All eligible patients were included in this study and were entered into either an elderly group (n=142) or a control group (n=182) according to patients' age. In-hospital outcomes (consisting of surgical mortality and major postoperative morbidity) and midterm clinical outcomes (including all-cause mortality and recurrent mitral regurgitation) were compared after propensity score matching (1:1).

Results

Using propensity-score matching, 103 pairs of patients were successfully established in a 1:1 ratio. No significant differences between the two matched groups were found with regard to surgical mortality (5.8% vs. 3.9%, P=0.754) and major postoperative morbidity. A total of 184 patients (91 in the elderly group and 93 in the control group) received regular follow-up visit with the median duration of 38 months [interquartile range (IQR), 27-56 months]. There were not any significant differences between the two matched groups regarding overall survival and recurrent IMR-free survival (stratified log-rank P=0.185 and stratified log-rank P=0.453, respectively). The elderly group as compared to the control group did not affect midterm mortality via cox proportional hazard regression (propensity score adjusted hazard ratio, 1.143; 95% confidence interval, 0.761-1.943; P=0.285).

Conclusions

Patients over 70 years of age with moderate chronic IMR undergoing combined CABG and mitral valve repair may receive favorable in-hospital and midterm clinical outcomes.

Does Prior Percutaneous Coronary Intervention Influence the Outcomes of Coronary Artery Bypass Surgery?

Introduction

Percutaneous coronary intervention (PCI) has been increasingly performed to treat coronary artery disease. The performance of multiple PCI has also been increasing. Consequently, the percentage of patients presenting for coronary artery bypass graft (CABG) surgery is reported to vary from 13 to 40%. The influence of previous PCI on CABG outcomes has been studied in single center, regional studies, registries and meta-analyses. Some reports showed a negative effect on mortality and morbidity in early or long-term follow-up, but others did not find this influence.

Methods and Results

A cohort of 3007 patients consecutively operated for CABG, 261 of them with previous PCI, were included in this analysis. Comparison of the groups "previous PCI" and "primary CABG" was made in the original cohort and in a propensity score matched cohort of 261 patients. There were some differences in preoperative clinical characteristics in both types of cohort, even in the matched one. Outcomes were compared at 30 days, 1 year and 5 years of follow-up. There were no statistically significant differences in mortality in any period or cohort. There were some differences in other outcomes as readmission and composite events, including cardiovascular death at 1 and 5 years of follow-up. These differences, neverthless, were not confirmed in comparison with the matched cohort.

Conclusion

Although there are some limitations in this study, it was not found consistent negative influence of previous PCI on CABG.

Elderly Patients with Moderate Chronic Ischemic Mitral Regurgitation: Coronary Artery Bypass Grafting Alone or Concomitant Mitral Annuloplasty?

Background

An increasing number of elderly patients with ischemic mitral regurgitation (IMR) are referred for coronary artery bypass grafting (CABG). However, data about the management of elderly patients with moderate IMR are scanty. This study evaluates the impacts of two surgical approaches (CABG alone or concomitant mitral annuloplasty (MAP)) on in-hospital and midterm outcomes, to attempt to determine an appropriate treatment option for elderly patients with moderate chronic IMR.

Methods

All eligible patients over 65 years of age were included and were entered into either a MAP group (patients undergoing CABG plus MAP, n = 96) or a CABG group (patients receiving CABG alone, n = 104). Baseline and surgical characteristics were analyzed, and in-hospital and midterm outcomes between groups were compared after propensity score-matching (1 : 1).

Results

Using propensity score-matching, 82 pairs of patients were successfully established in a 1 : 1 ratio. No significant differences between the two matched groups were found regarding surgical mortality (4.9% vs. 1.2%, p=0.173) and major postoperative morbidity. 150 patients (76 in the MAP group and 74 in the CABG group) received regular follow-up visit with the median duration of 37 months. Compared with the CABG group, the MAP group received a similar overall survival but a better recurrent MR-free survival (stratified log-rank p, 0.492 and < 0.001, respectively). Using Cox regression, the MAP group as compared with the CABG group did not affect midterm survival probability (propensity score-adjusted hazard ratio, 0.854; 95% confidence interval, 0.571–2.729, p=0.630). Additionally, patients in the MAP group had a significantly lower ratio of NYHA class III-IV at the latest follow-up by comparison with patients in the CABG group (19.7% vs. 35.5%, p=0.033).

Conclusion

Compared with CABG alone, concomitant mitral annuloplasty is associated with improved midterm outcomes (including reduced IMR recurrence and improved cardiac functional class) but shares similar surgical mortality and major postoperative morbidity and may be a promising treatment option for elderly patients with moderate chronic IMR.

Prior Percutaneous Coronary Interventions May Be Associated With Increased Mortality After Coronary Bypass Grafting: A Meta-Analysis

There is conflicting evidence for adverse outcomes after coronary artery bypass surgery (CABG) with prior percutaneous intervention (PCI). A literature search was performed from 1998 to 2017 and articles with primary or secondary outcomes of survival, major adverse cardiovascular events (MACE), and myocardial infarction in CABG patients with prior PCI were included. Forest plots were generated from odds ratios for survival, MACE, and myocardial infarction for unmatched and propensity-matched data. Heterogeneity between studies was assessed for all outcomes using I². Funnel plots were generated for early survival, survival at 5 years, survival at >5 years, and MACE. Thirty-one studies were included over 18 years with 194,544 patients without PCI prior to CABG and 23,519 patients (12.09%) with prior PCI. Prior PCI did not adversely affect survival among the included studies (inverse rate ratio: 1.12, 95% confidence interval: 0.98-1.27, P = 0.110. MACE was significantly worse for those with prior PCI (odds ratio: 1.26, confidence interval: 1.02-1.55, P = 0.03). The relative risk of mortality associated with prior PCI has decreased significantly over the last 2 decades. Studies with higher percentage of prior PCI patients had higher relative mortalities. There was significant heterogeneity between studies for the treatment effects. PCI prior to CABG in recent times does not adversely affect survival despite adverse early and late MACE rates. However, high institutional rates of prior PCI may be associated with increasing mortality after CABG.

Persistent Inflammatory Activity in Blood Cells and Artery Tissue from Patients with Previous Bare Metal Stent

BACKGROUND

Studies have pointed out a higher mortality after coronary artery bypass surgery (CABG) in patients with stent.

OBJECTIVE

To evaluate inflammatory markers in peripheral blood cells and in coronary artery tissue samples obtained during CABG in patients with stent compared to controls.

METHODS

The case series consisted of two groups, one with previous stent implantation (n = 41) and one control (n = 26). The expression of the LIGHT, IL-6, ICAM, VCAM, CD40, NFKB, TNF, IFNG genes was analyzed in peripheral blood cells collected preoperatively. The coronary artery was evaluated for: interleukin-6, ICAM, VCAM, CD40, NFKB, TNF-alpha and IFN-gamma by immunohistochemistry. A total of 176 tissue samples were grouped for analysis in: A1- arteries with stent (n = 38); A2- native arteries from patients with stent in another artery (n = 68); and A3- arteries without stent from controls undergoing routinely CABG surgery (n = 70). A significance level of 0.05 was adopted.

RESULTS

Patients with stent showed higher TNF (p = 0.03) and lower CD40 gene expression (p = 0.01) in peripheral blood cells than controls without stent. In coronary artery samples, the TNF-alpha protein staining was higher in the group A1, not only in the intima-media layer (5.16 ± 5.05 vs 1.90 ± 2.27; p = 0.02), but also in the adipose tissue (6.69 ± 3.87 vs 2.27 ± 4.00; p < 0.001). Furthermore, group A1 had a higher interleukin-6 protein staining in adipose tissue than group A3 (p = 0.04).

CONCLUSION

We observed a persistently higher systemic TNF expression associated with exacerbated TNF-alpha and interleukin-6 local production in patients with stents. This finding may contribute to a worse clinical outcome.

Coronary Endarterectomy: Recent Trends

Coronary Endarterectomy (CE) assures complete revascularization of the myocardium in case of diffusely diseased vessels and prevents residual ischemia. Recently cardiac surgeons are performing increasing number of coronary endarterectomy and it has evolved as an important adjuvant procedure in Coronary Artery Bypass Grafting (CABG). There are controversies regarding the efficiency of CE. CE is criticised for its higher rates of morbidity and mortality. At present the available evidence supports CE in Off Pump Coronary Artery Bypass surgery (OPCAB) and along with valvular procedures. Graft patency is better with open technique. Postoperative anticoagulation regimen though not uniform, the overall outcome remains the same. Therefore, it is important to focus on the current results to accept CE as a routine procedure like CABG.

Impact of prior coronary stenting on the outcome of subsequent coronary artery bypass grafting

BACKGROUND

The percentage of patients referred for coronary artery bypass grafting (CABG) who have previously undergone percutaneous coronary interventions (PCIs) is increasing. The purpose of this study was to review the outcomes of patients who had received coronary stenting before CABG, and to examine the validity of a mortality risk stratification system in this patient group.

METHODS

From 2010 to 2012, 439 patients who underwent isolated CABG at our medical center were reviewed. The patients were divided into two study groups: those who had previously received coronary artery stenting (97 patients, 24.7%), and those who had not (342 patients, 75.3%). The patients who received balloon angioplasty were excluded.

RESULTS

There were no significant differences in baseline characteristics. The prior stenting group had a lower risk of mortality, although the difference was not significant. The prior stenting group had fewer graft anastomoses (p = 0.005), and hence a significantly shorter cardiopulmonary bypass time (p = 0.045) and shorter aortic cross-clamping time. Surgical mortality was similar between the two groups. The durations of intensive care unit stay and hospitalization were also similar. The discriminatory power of the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was lower in both group.

CONCLUSIONS

Prior coronary stenting does not affect short-term mortality in patients subsequently undergoing CABG surgery. The EuroSCORE does not predict perioperative mortality well for the patients who undergo coronary stenting before CABG.

Repeated Target Vessel Revascularization After Coronary Artery Bypass for In-Stent Restenosis

BACKGROUND

The purpose of this study was to examine the impact of previous percutaneous coronary intervention with stent on long-term outcomes after off-pump coronary artery bypass grafting (OPCAB).

METHODS

Between January 2001 and December 2014, 1,668 patients with triple-vessel disease undergoing OPCAB were reviewed and divided into 2 groups. The no-stent group (n = 1,409) included patients who underwent OPCAB as a primary revascularization procedure and the stent group (n = 259) included patients with a history of percutaneous coronary intervention with stent. The mean follow-up duration was 5.32 ± 3.39 years.

RESULTS

After propensity score matching, characteristics of both groups were comparable (n = 259 in each group). In-hospital mortality (n = 3 [1.2%] in both groups; p > 0.999) was similar. The 14-year overall survival rate (75.6% ± 6.6% in the no-stent group versus 71.9% ± 8.5% in the stent group; p = 0.917) and freedom from major adverse cardiac and cerebrovascular events (MACCEs) rate (68.3% ± 6.6% versus 54.6% ± 8.5%; p = 0.239) were also similar. However, freedom from target vessel revascularization (TVR) rate at 14 years was significantly higher in the no-stent group (97.2% ± 1.7% versus 76.9% ± 6.5%; p < 0.001). The independent risk factor for late TVR was in-stent restenosis (hazard ratio, 3.355; 95% confidence interval, 1.925 to 5.848; p < 0.001) and it also was a risk factor for MACCEs (hazard ratio, 1.645; 95% CI, 1.105 to 2.448; p = 0.014).

CONCLUSIONS

Previous intracoronary stenting does not increase long-term mortality, but grafting to previously stented target vessels with in-stent restenosis increases the risk of repeat TVR and MACCEs.

Factors Associated with Early Adverse Events after Coronary Artery Bypass Grafting Subsequent to Percutaneous Coronary Intervention

BACKGROUND

A previous percutaneous coronary intervention (PCI) may affect the outcomes of patients who undergo coronary artery bypass grafting (CABG). The objective of this study was to compare the early in-hospital postoperative outcomes between patients who underwent CABG with or without previous PCI.

METHODS

The present study included 160 patients who underwent isolated elective on-pump CABG at the department of cardiothoracic surgery, Minia University Hospital from January 2010 to December 2014. Patients who previously underwent PCI (n=38) were compared to patients who did not (n=122). Preoperative, operative, and early in-hospital postoperative data were analyzed. The end points of the study were in-hospital mortality and postoperative major adverse events.

RESULTS

Non-significant differences were found between the study groups regarding preoperative demographic data, risk factors, left ventricular ejection fraction, New York Heart Association class, EuroSCORE, the presence of left main disease, reoperation for bleeding, postoperative acute myocardial infarction, a neurological deficit, need for renal dialysis, hospital stay, and in-hospital mortality. The average time from PCI to CABG was 13.9±5.4 years. The previous PCI group exhibited a significantly larger proportion of patients who experienced in-hospital major adverse events (15.8% vs. 2.5%, p=0.002). On multivariate analysis, only previous PCI was found to be a significant predictor of major adverse events (odds ratio, 0.16; 95% confidence interval, 0.03 to 0.71; p=0.01).

CONCLUSION

Previous PCI was found to have a significant effect on the incidence of early major adverse events after CABG. Further large-scale and long-term studies are recommended.

Coronary Artery Bypass Grafting After Percutaneous Intervention Has Higher Early Mortality: A Meta-Analysis

BACKGROUND

We compared early adverse events and midterm survival between primary coronary artery bypass grafting (pCABG) and CABG in patients with percutaneous intervention (secondary CABG, sCABG) because data on this topic are very limited.

METHODS

A systematic review of published literature was done to obtain original studies fulfilling the search criteria. The end points studied were early mortality, stroke, renal failure, myocardial infarction, and the need for an intra-aortic balloon pump. A random-effect inverse variance weighted analysis was performed. The results are presented as risk ratios (RR) (95% confidence interval); p < 0.05 was considered statistically significant.

RESULTS

Fourteen studies (84,983 pCABG patients and 14,775 sCABG patients) were included in the systematic review. Early mortality was lower with primary CABG (RR 1.54 [1.19-2]; p = 0.007). The incidence of myocardial infarction was also less with pCABG than with sCABG. (RR 1.46 [1.04-2.06]; p = 0.06). Patients undergoing pCABG were 14% (0% to 55%; p = 0.04). Less likely to need an intra-aortic balloon pump. Although renal failure was lower with pCABG (RR 1.254 [1.047-1.502]; p = 0.014), the stroke rates were comparable in both cohorts (p = 0.95). Renal failure was favorable in the primary CABG cohort. Early stroke was comparable between the two cohorts (p = 0.95). The pooled hazard ratios demonstrated comparable survival at the end of 3 years (p = 0.36).

CONCLUSIONS

Patients undergoing CABG after prior percutaneous therapy have a higher incidence of myocardial infarction and mortality in the postoperative period. However, midterm survival is comparable in both cohorts.

Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease

OBJECTIVE

Recent studies have indicated that coronary artery bypass grafting (CABG) outcomes in patients with prior stents are suboptimal. We aimed to study the impact of prior percutaneous coronary intervention (PCI) with stenting (PCI-S) on late CABG mortality in diabetic patients with triple-vessel disease.

METHODS

We reviewed the primary nonemergency CABG experience from a single U.S. institution (n = 7005; 1996-2007, Toledo, Ohio). Diabetics with triple-vessel disease (n = 1583) were identified and divided into 2 groups: (1) prior PCI-S (n = 202); and (2) no prior PCI (No-PCI [n = 1381]). Hierarchic Cox proportional hazards models were used to assess the effect of prior PCI-S on 5-year mortality after CABG. A propensity score for PCI-S and No-PCI patients was derived using a nonparsimonious logistic regression and used to generate a 1:1 (PCI-S to No-PCI) matched cohort.

RESULTS

In model 1, after adjusting for preoperative clinical characteristics, medications, off-pump surgery, and isolated CABG surgery status, prior PCI-S was associated with a 39% increased risk of mortality (hazard ratio [HR] = 1.39, with 95% confidence interval [CI; 1.02, 1.90]; P = .04). Further adjustment for date of surgery (model 2) (HR = 1.39, with 95% CI [1.02, 1.91]; P = .04) or operative parameters (model 3) (HR = 1.38, with 95% CI [1.01, 1.88]; P = .046) did not alter the association. The 1:1 matched-cohort analysis confirmed the increased risk associated with PCI-S (HR = 1.61, with 95% CI [1.03, 2.51]; P = .037).

CONCLUSIONS

Patients who have both diabetes and triple-vessel disease, and have undergone prior PCI-S, have poorer long-term outcomes after CABG compared with those who have had no prior PCI-S.

Immediate Postoperative Complications in Patients Undergoing CABG; Investigating the Role of Prior Coronary Stenting

Introduction: Approximately 15 to 30% of patients undergoing percutaneous coronary intervention (PCI) will require repeated revascularization. There is an ongoing debate concerning the impact of prior PCI on subsequent coronary artery bypass graft (CABG) surgery. This study sought to compare immediate post-CABG complications between patients with and without previous coronary stenting.

Methods: A total of 556 CABG candidates including 73 patients with previous coronary stenting and 483 patients without prior stenting were enrolled in this retrospective-prospective study. Demographic information, cardiac markers (CK-MB, Troponin T), and postoperative data including inotrope administration, intra-aortic balloon pump (IABP) use, bleeding, pathological electrocardiography (ECG) changes, and overall complications were compared between the two groups.

Results: The mean age of the patients in stented group was significantly higher than that in unstented group (63.49±7.71 vs. 61.37±9.80 years, p=0.05). The mean serum level of Troponin T 12 h postoperation was significantly higher in the same group (323.26±33.16 vs. 243.30±11.52 ng/dL; p=0.03). Comparing the stented and unstented groups, the rates of inotrope use (17.8% vs. 7.2%; p=0.003), significant bleeding (15.1% vs. 4.3%; p=0.001), and overall complications (32.9% vs. 11.6%; odds ratio: 3.74 with 95% confidence interval of 2.13-6.55, p<0.001) were significantly higher in the former group. The association between overall complications and prior stenting was independent (odd ratio: 3.06). No significant connections were found between postoperative complications and stent number or type.

Conclusion: A positive history of previous coronary stenting significantly increases the risk of immediate post-CABG complications.

CABG mortality is not influenced by prior PCI in low risk patients

BACKGROUND AND AIMS

An increasing number of patients referred for coronary artery bypass grafting (CABG) have had prior percutaneous coronary intervention (PCI). We sought to determine whether a relationship exists between increased postoperative mortality and morbidity following CABG procedure in patients with prior PCI.

METHODS

Over an 18-month period, 950 patients having first-time isolated CABG were divided into two groups based on absence (Group A, 819 patients--86.21%) or presence of a prior PCI (Group B, 131 patients--13.79%).

RESULTS

In the prior PCI population, 74 patients (56.4%) had only one stent, and only 6.8% had multiple admissions for PCI. The overall incidence of three vessel disease in the entire patient population was only 65% and the average ejection fraction was 52%. Multivariate analysis demonstrated age (OR 1.080; 95% CI: 1.020 to 1.145; p = 0.009), left ventricular ejection fraction (OR 0.939; 95% CI: 0.901 to 0.978; p = 0.002), and emergency surgery (OR 0.138; 95% CI: 0.0.045 to 0.424; p = 0.001) as risk factors for 30-day mortality, while age (OR 1.059; 95% CI: 1.016 to 1.104; p = 0.007) and emergency surgery (OR 0.205; 95% CI: 0.078 to 0.537; p = 0.001) predicted major adverse cardiac events (MACE). Prior PCI did not influence mortality or MACE at 30 days.

CONCLUSION

In this study involving low risk patients, a PCI prior to CABG did not increase morbidity or mortality.

[Correlation between previous coronary artery stenting and early mortality in patients undergoing coronary artery bypass graft surgery]

BACKGROUND

In this study, we examine the effect of previous percutaneous intervention on the rate of adverse perioperative outcome in patients undergoing coronary artery bypass graft surgery (CABG).

METHODS

Outcomes of 240 CABG patients, collected consecutively in an observational study, were compared. Gp A (n=35) had prior PCI before CABG and Gp B (n=205) underwent primary CABG.

RESULTS

Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 48.6% vs 36.6% (P=0.003), distribution of CAD (P=0.0001), unstable angina: 45.7% vs 39% (P=0.04). For intraoperative data, the total number of established bypasses was 2.6 (GpA) vs 2.07 (Gp B) (P=0.017), with the number of arterial bypass grafts being: 20% vs 13% (P=ns). Regarding the postoperative course, no significant difference in troponine I rate, 24-hour bleeding: 962 ml (Gp A) vs 798 ml (Gp B) (P=0.004), transfusion (PRBC unit): 3.63 (Gp A) vs 2.5 (Gp B) (P=0.006). Previous PCI emerged as an independent predictor of postoperative in-hospital mortality (OR 2.24, 95% CI [1.52-2.75], P<0.01).

CONCLUSION

Patients with prior PCI presented for CABG with more severe CAD. Thirty-day mortality and morbidity were significantly higher in patients with prior PCI.

Previous percutaneous coronary intervention increases morbidity after coronary artery bypass grafting

BACKGROUND

We hypothesized that the incidence of previous percutaneous coronary intervention (PCI) is increasing and that prior PCI influences patient morbidity and mortality after coronary artery bypass grafting (CABG).

METHODS

A total of 34,316 patients underwent isolated CABG operations at 16 different statewide, institutions from 2001 to 2008. Patients were stratified into prior PCI (n = 4346; 12.7%) and no prior PCI (n = 29,970). Patient risk factors, intraoperative variables, and outcomes were compared by univariate and multivariate analyses.

RESULTS

The incidence of prior PCI in CABG has risen from <1% to 22.0% from 2001 to 2008 (P < .001). Prior PCI patients were younger (P < .001) and more commonly had previous myocardial infarction (P < .001), but less commonly had heart failure (P < .001). The operative mortality was similar between groups (2.3% vs 1.9%; P = .13). Prior PCI patients had more major complications (15.0% vs 12.0%; P < .001), longer hospitalization (P = .01), and higher readmission rates (P = .01). Importantly, by multivariate analyses, prior PCI was not associated with mortality, but was an independent predictor of major complications after CABG (odds ratio, 1.15; P = .01).

CONCLUSION

The incidence of prior PCI in patients undergoing CABG is increasing. Previous PCI is associated with a higher risk of major complications, greater hospital length of stay, and higher readmission rates after CABG.

Mid-term outcomes after off-pump coronary surgery in patients with prior intracoronary stent

OBJECTIVE

An increasing number of patients undergoing heart surgery have had a prior coronary stent placement. This study was designed to examine the effect of this situation on the mid-term outcomes of off-pump coronary artery bypass graft (OP-CABG) surgery.

METHODS

A comparative retrospective non-randomized comparison was performed as follows: all patients undergoing OP-CABG from January 2005 to December 2009 at our centre were divided into two groups: those who did or did not have stents at the time of surgery. We compared the incidences of the following events: (i) death and (ii) combined major adverse cardiac events (MACEs): death, myocardial infarction (MI) and repeat revascularization. Cox's proportional hazards analysis adjusted by a propensity score (n:m) were performed to determine the effects of prior stent placement on the risks of such events.

RESULTS

A total of 1020 patients were included, of which 156 (15.6%) had at least one stent. The median follow-up was 32.32 months (interquartile rank 18.08-48). The overall 1, 3 and 5-year survival rates were 95, 92 and 91% for the without-stent group vs. 82, 77 and 74% for the with-stent group, respectively. The 1, 3 and 5-year survival rates free from MACEs were: 92, 87 and 76% for patients without stent vs. 77, 66 and 56% for those with stents. Patients with stent showed an increased risk of death [hazard ratio (HR) 3.631, 95% confidence interval (CI) 2.29-5.756] and MACEs (HR 2.784, 95% CI 1.962-3.951). When adjusted by the propensity score, prior stent placement continued to increase the risks of death (HR 3.795, 95% CI 2.319-6.21) and MACEs (HR 2.89, 95% CI 2.008-4.158).

CONCLUSIONS

Patients with intracoronary stents have a lower survival rate and a greater risk of death, MI or need for repeat revascularization during the mid-term follow-up after OP-CABG.

The impact of coronary artery endarterectomy on outcomes during coronary artery bypass grafting

BACKGROUND

The impact of coronary artery endarterectomy during coronary artery bypass grafting (CABG) has been debated. We examined the early and late outcomes of CABG with endarterectomy (CE) compared to CABG alone.

METHODS

Patients undergoing isolated CABG operations from 2003 to 2008 were retrospectively reviewed. We identified 99 patients who underwent CE and 3:1 propensity matched them to 297 CABG-alone patients based upon clinical factors: Society of Thoracic Surgeons (STS) predicted risk of mortality, age, gender, year of surgery, and ejection fraction. Patient risk factors as well as short- and long-term outcomes were compared by univariate and Kaplan-Meier analysis.

RESULTS

Preoperative risk factors were similar between patients undergoing CE or CABG alone. Cross-clamp times (95.6 vs. 71.8 minutes, p = 0.0001) and perfusion times (121.8 vs. 92.7 minutes, p = 0.0001) were longer in patients undergoing CE. Operative mortality (4.0% vs. 1.3%, p = 0.112) and postoperative complications were not significantly different between groups. Patients undergoing coronary endarterectomy incurred longer ICU (75.06 vs. 48.64 hours, p = 0.001) and hospital stays (9.01 vs. 7.7 days, p = 0.034). Long-term mortality (mean follow-up = 27.7 ± 17.7 months) was equivalent despite revascularization technique (p = 0.13); however, patients undergoing CE encountered worse overall freedom from myocardial infarction (MI) (p = 0.03).

CONCLUSION

Patients undergoing CABG with coronary CE required longer ventilatory support and ICU stay yet have comparable operative mortality, major complication rates, and long-term survival to isolated CABG. Coronary endarterectomy should be considered an acceptable adjunct to CABG for patients with extensive coronary artery disease to achieve complete revascularization.