2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Interhospital variability in cardiac rehabilitation use after cardiac surgery among Medicare beneficiaries

OBJECTIVE

Despite guideline recommendation, cardiac rehabilitation (CR) after cardiac surgery remains underused, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes.

METHODS

This retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between July 1, 2016, and December 31, 2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use.

RESULTS

Overall, 90,171 (54.1%) participated in at least 1 CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included nonteaching status and lower-hospital volume. Before adjustment for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had greater adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, P < .001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, P < .001).

CONCLUSIONS

Identifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

Skeletonized versus Pedicled harvesting of internal mammary artery: A systematic review and Meta-analysis

There are two recognized internal mammary artery (IMA) harvesting techniques during coronary artery bypass grafting (CABG): pedicled and skeletonized. This systematic review and meta-analysis sought to compare the clinical outcomes of the two harvesting techniques. A comprehensive electronic literature search of PubMed, Scopus, and Embase was conducted from inception till June 2023. Thirty-one studies with a total of 13005 patients met our inclusion criteria. The results from the included studies were presented as weighted mean difference (WMD) with its relevant standard deviation (SD) for continuous variables, while Odds Ratio (OR) was used for dichotomous variables. A 95% confidence interval (CI) was used, and the results were pooled using a random effects model. The skeletonized IMA demonstrated a significantly reduced risk of sternal wound infection (SWI) compared to the pedicled IMA (OR = 0.45 [95% CI, 0.32-0.66]; p = 0.0001). The conduit length used was significantly longer in the skeletonized IMA (WMD -2.48, 95% CI, [-3.75, -1.20], P = 0.0001) and a significantly higher postoperative flow rate was observed while using skeletonization compared to the pedicled harvesting (WMD -13.11, 95% CI, [-22.52, -3.70], P = 0.006). However, no significant difference was seen in mortality between the two techniques (OR = 1.19 [95% CI, 1.00-1.41]; p = 0.05). Pedicled harvesting demonstrated significantly reduced incidents of MI (OR = 1.38 [95% CI, 1.13-1.69]; p = 0.002), while significant results in graft patency were observed favoring pedicled harvesting over skeletonization (OR = 0.63 [95% CI, 0.40-0.98]; p = 0.04).

External stenting for saphenous vein grafts in coronary artery bypass grafting: A meta-analysis

OBJECTIVES

Autologous saphenous vein grafts (SVGs) are the most commonly used bypass conduits in coronary artery bypass grafting (CABG) with multivessel coronary artery disease. Although external support devices for SVGs have shown promising outcomes, the overall efficacy and safety remains controversial. We aimed to evaluate external stenting for SVGs in CABG versus non-stented SVGs.

METHODS

MEDLINE, EMBASE, Cochrane Library and clinicaltrails.gov were searched for randomized controlled trials (RCTs) to evaluate external-stented SVGs versus non-stented SVGs in CABG up to 31 August 2022. The risk ratio and mean difference with 95% confidence interval were analysed. The primary efficacy outcomes included intimal hyperplasia area and thickness. The secondary efficacy outcomes were graft failure (≥50% stenosis) and lumen diameter uniformity.

RESULTS

We pooled 438 patients from three RCTs. The external stented SVGs group showed significant reductions in intimal hyperplasia area (MD: -0.78, p < 0.001, I2  = 0%) and thickness (MD: -0.06, p < 0.001, I2  = 0%) compared to the non-stented SVGs group. Meanwhile, external support devices improved lumen uniformity with Fitzgibbon I classification (risk ratio (RR):1.1595, p = 0.05, I2  = 0%). SVG failure rates were not increased in the external stented SVGs group during the short follow-up period (RR: 1.14, p = 0.38, I2  = 0%). Furthermore, the incidences of mortality and major cardiac and cerebrovascular events were consistent with previous reports.

CONCLUSIONS

External support devices for SVGs significantly reduced the intimal hyperplasia area and thickness, and improved the lumen uniformity, assessed with the Fitzgibbon I classification. Meanwhile, they did not increase the overall SVG failure rate.

Coronary steal: how many thieves are out there?

The colorful term "coronary steal" arose in 1967 to parallel "subclavian steal" coined in an anonymous 1961 editorial. In both instances, the word "steal" described flow reversal in the setting of an interconnected but abnormal vascular network-in one case a left subclavian stenosis proximal to the origin of the vertebral artery and in the other case a coronary fistula. Over time, the term has morphed to include a larger set of pathophysiology without explicit flow reversal but rather with a decrease in stress flow due to other mechanisms. This review aims to shed light on this phenomenon from a clinical and a pathophysiological perspective, detailing the anatomical and physiological conditions that allow so-called steal to appear and offering treatment options for six distinct scenarios.

Inspiratory muscle training to reduce risk of pulmonary complications after coronary artery bypass grafting: a systematic review and meta-analysis

BACKGROUND

Pulmonary complications occur in a substantial proportion of patients who undergo coronary artery bypass grafting. Inspiratory muscle training (IMT), a simple, well-tolerated physical therapy, has been proposed to reduce the risk of complications, but its efficacy remains controversial.

METHOD

Randomized controlled trials (RCTs) examining the influence of IMT on the risk of pulmonary complications after coronary artery bypass grafting were identified from PubMed, Embase, CENTRAL, CINAL, and Web of Science through March 2023. Data were meta-analyzed for the primary outcomes of pulmonary complications, defined as pneumonia, pleural effusion, and atelectasis; and in terms of the secondary outcomes of maximum inspiratory pressure, maximum expiratory pressure, length of hospitalization, 6 min walk test, and peak expiratory flow and other outcomes. Risk of bias and quality of evidence assessments were carried out using the RoB 2.0 and Grading of Recommendations Assessment, Development and Evaluation (GRADE) applied to primary outcomes of pulmonary complications.

RESULTS

Data from eight RCTs involving 755 patients were meta-analyzed. IMT was associated with a significantly lower risk of postoperative pneumonia [relative risk (RR) 0.39, 95% confidence interval (CI) 0.25-0.62, P < 0.0001] and atelectasis (RR 0.43, 95% CI 0.27-0.67, P = 0.0002), but not pleural effusion (RR 1.09, 95% CI 0.62-1.93, P = 0.76). IMT was associated with significantly better maximum inspiratory pressure (preoperative: mean difference (MD) 16.55 cmH2O, 95% CI 13.86-19.24, P < 0.00001; postoperative: mean difference (MD) 8.99 cmH2O, 95% CI 2.39-15.60, P = 0.008) and maximum expiratory pressure (MD 7.15 cmH2O, 95% CI: 1.52-12.79, P = 0.01), and with significantly shorter hospitalization (MD -1.71 days, 95% CI -2.56 to -0.87, P < 0.001). IMT did not significantly affect peak expiratory flow or distance traveled during the 6 min walk test.

CONCLUSIONS

The available evidence from medium and high quality trials suggests that IMT can significantly decrease the risk of pneumonia and atelectasis after coronary artery bypass grafting while shortening hospitalization and improving the strength of respiratory muscles.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42023415817.

Changes in Controllable Coronary Artery Bypass Grafting Practice for White and Black Americans

BACKGROUND

Racial disparities in outcomes after cardiac surgery are well reported. We sought to determine whether variation by race exists in controllable practices during coronary artery bypass graft surgery (CABG). We hypothesized that racial disparities exist in CABG quality metrics, but have improved over time.

METHODS

All patients undergoing isolated CABG (2000 to 2019) in a multiple state database were stratified into three eras by race. Analysis included propensity matched White Americans and Black Americans. Primary outcomes included left internal mammary artery use, multiple arterial grafting, revascularization completeness, and guideline-directed medication prescription.

RESULTS

Of 72 248 patients undergoing CABG, Black American patients (n = 10 270, 15%) had higher rates of diabetes mellitus, hypertension, prior stroke, and myocardial infarction. After matching, 19 806 patients (n = 9903 per group) were well balanced. Left internal mammary artery use was significantly different early (era 1, Black Americans 84.7% vs White Americans 86.6%; P = .03), but equalized over time. Importantly, multiarterial grafting differed between Black Americans and White Americans over the entire study (9.1% vs 11.5%, P < .001) and within each era. Black Americans had more incomplete revascularization during the study period (14% vs 12.8%, P = .02) driven by a large disparity in era 1 (9.5% vs 7.2%, P < .001). Despite similar rates of preoperative use, Black Americans were more often discharged on a regimen of β-blockers (91.8% vs 89.6%, P < .001).

CONCLUSIONS

Coronary artery bypass graft surgery metrics of left internal mammary artery use and optimal medical therapy have improved over time and are similar despite patient race. Black Americans undergo less frequent multiarterial grafting and greater discharge β-blocker prescription. Identifying changes in controllable CABG quality practices across races supports a continued focus on standardizing such efforts.

Coronary-subclavian steal syndrome: a case report of a rare entity that can become a deadly threat

Background

In patients who underwent coronary artery bypass graft (CABG), the coronary-subclavian steal syndrome (CSSS) is characterized by a subclavian artery stenosis proximal to the origin of the internal mammary artery resulting in functional graft failure.

Case summary

A 62-year-old gentleman underwent CABG following a non-ST elevation myocardial infarction and an angiogram showing left main stem and three-vessel disease. Forty-eight hours later he developed cardiogenic shock that improved with inotropic support and intra-aortic balloon pump insertion. However, 7 days later, he deteriorated again and even though the myocardial injury markers and echocardiogram were normal, an angiography was performed showing significant CSSS. Due to the chronic nature of his subclavian stenosis and the severity of the cardiogenic shock, the heart team decided to treated his epicardial disease percutaneously and occlude the left internal mammary artery in its mid-segment with coils. The patient was discharged home 28 days after CABG and has remained since asymptomatic with improvement in his functional class.

Discussion

Coronary-subclavian steal syndrome is a rare but fatal complication with increased morbidity and mortality due to reduced awareness amongst medical professionals. Subclavian artery stenosis stenting is the gold standard treatment; herein we present a new approach for complex and very sick patients in whom it is not possible to open the subclavian artery percutaneously. Increased awareness and prompt diagnosis of this pathology in CABG patients are essential for successful outcomes.

Health Techequity: Opportunities for Digital Health Innovations to Improve Equity and Diversity in Cardiovascular Care

Purpose of Review

In this review, we define health equity, disparities, and social determinants of health; the different components of digital health; the barriers to digital health equity; and cardiovascular digital health trials and possible solutions to improve health equity through digital health.

Recent Findings

Digital health interventions show incredible potential to improve cardiovascular diseases by obtaining longitudinal, continuous, and actionable patient data; increasing access to care; and by decreasing delivery barriers and cost. However, certain populations have experienced decreased access to digital health innovations and decreased representation in cardiovascular digital health trials.

Summary

Special efforts will need to be made to expand access to the different elements of digital health, ensuring that the digital divide does not exacerbate health disparities. As the expansion of digital health technologies continues, it is vital to increase representation of minoritized groups in all stages of the process: product development (needs findings and screening, concept generation, product creation, and testing), clinical research (pilot studies, feasibility studies, and randomized control trials), and finally health services deployment.

Surgical Site Infection in Cardiac Surgery

Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.

Microfluidic bioprinting of tough hydrogel-based vascular conduits for functional blood vessels

Three-dimensional (3D) bioprinting of vascular tissues that are mechanically and functionally comparable to their native counterparts is an unmet challenge. Here, we developed a tough double-network hydrogel (bio)ink for microfluidic (bio)printing of mono- and dual-layered hollow conduits to recreate vein- and artery-like tissues, respectively. The tough hydrogel consisted of energy-dissipative ionically cross-linked alginate and elastic enzyme-cross-linked gelatin. The 3D bioprinted venous and arterial conduits exhibited key functionalities of respective vessels including relevant mechanical properties, perfusability, barrier performance, expressions of specific markers, and susceptibility to severe acute respiratory syndrome coronavirus 2 pseudo-viral infection. Notably, the arterial conduits revealed physiological vasoconstriction and vasodilatation responses. We further explored the feasibility of these conduits for vascular anastomosis. Together, our study presents biofabrication of mechanically and functionally relevant vascular conduits, showcasing their potentials as vascular models for disease studies in vitro and as grafts for vascular surgeries in vivo, possibly serving broad biomedical applications in the future.

Basement Membrane of Tissue Engineered Extracellular Matrix Scaffolds Modulates Rapid Human Endothelial Cell Recellularization and Promote Quiescent Behavior After Monolayer Formation

Off-the-shelf small diameter vascular grafts are an attractive alternative to eliminate the shortcomings of autologous tissues for vascular grafting. Bovine saphenous vein (SV) extracellular matrix (ECM) scaffolds are potentially ideal small diameter vascular grafts, due to their inherent architecture and signaling molecules capable of driving repopulating cell behavior and regeneration. However, harnessing this potential is predicated on the ability of the scaffold generation technique to maintain the delicate structure, composition, and associated functions of native vascular ECM. Previous de-cellularization methods have been uniformly demonstrated to disrupt the delicate basement membrane components of native vascular ECM. The antigen removal (AR) tissue processing method utilizes the protein chemistry principle of differential solubility to achieve a step-wise removal of antigens with similar physiochemical properties. Briefly, the cellular components of SV are permeabilized and the actomyosin crossbridges are relaxed, followed by lipophilic antigen removal, sarcomeric disassembly, hydrophilic antigen removal, nuclease digestion, and washout. Here, we demonstrate that bovine SV ECM scaffolds generated using the novel AR approach results in the retention of native basement membrane protein structure, composition (e.g., Collagen IV and laminin), and associated cell modulatory function. Presence of basement membrane proteins in AR vascular ECM scaffolds increases the rate of endothelial cell monolayer formation by enhancing cell migration and proliferation. Following monolayer formation, basement membrane proteins promote appropriate formation of adherence junction and apicobasal polarization, increasing the secretion of nitric oxide, and driving repopulating endothelial cells toward a quiescent phenotype. We conclude that the presence of an intact native vascular basement membrane in the AR SV ECM scaffolds modulates human endothelial cell quiescent monolayer formation which is essential for vessel homeostasis.

Thromboelastography in guiding preventive platelet transfusion in patients with haematologic diseases

OBJECTIVE

This study analysed the relationships between the main thromboelastography (TEG) parameters, the platelet (PLT) count and clinical bleeding in patients with blood diseases. We explored the threshold of the relevant parameters in the pathological condition of bleeding, aiming to scientifically guide clinical prophylactic PLT transfusion.

METHODS

In total, 268 patients with clear diagnoses of blood diseases and thrombocytopenia were enrolled and divided into five groups, A, B, C, D and E, corresponding to PLT counts of 0-10 × 10⁹ /L, 11-20 × 10⁹ /L, 21-30 × 10⁹ /L, 31-50 × 10⁹ /L and 51-100 × 10⁹ /L, respectively. TEG and routine blood testing were performed simultaneously, the main TEG parameters and the PLT count were analysed, and the thresholds of the main TEG parameters in each group when the patient had bleeding were obtained.

RESULTS

The maximum amplitude (MA) in groups A, B and C increased gradually, with a significant difference between each pair of these groups (P < 0.05). In groups A, B, C, D and E, the corresponding MA at the time of bleeding was 43.5 mm, 39.6 mm, 38.0 mm, 35.2 mm and 50.5 mm, respectively, with statistically significant differences (P < 0.05).

CONCLUSIONS

The MA can be used as a reference indicator for preventive PLT transfusion to a certain extent. When the PLT count is within different ranges, the MA threshold for preventive PLT transfusion also differs. It is recommended that different PLT counts be correlated with different MA thresholds to guide clinical prophylactic PLT transfusion.

Platelet function assessed by ROTEM® platelet in patients receiving antiplatelet therapy during cardiac and vascular surgery

Patients undergoing coronary artery bypass graft (CABG) surgery or carotid endarterectomy (CEA) continue antiplatelet therapy perioperatively, which may increase bleeding risk. We aimed to investigate whether Rotational thromboelastometry (ROTEM^®) platelet, a newly marketed platelet function analysis, would detect antiplatelet therapy in CABG and CEA patients; whether detection of reduced platelet function was associated with increased bleeding; and whether ex vivo desmopressin increased platelet function. We included 20 CABG patients continuing aspirin and 20 CEA patients continuing clopidogrel (n = 1) or clopidogrel and aspirin (n = 19). Platelet function was analyzed with ROTEM^® platelet and light transmission aggregometry (LTA). According to the lower reference limit, ROTEM^® platelet managed to detect aspirin, but clopidogrel detection was inadequate compared to LTA. Using a previously published cut-off for bleeding risk, 6 (30%) patients receiving aspirin and 4 (21%) patients receiving both clopidogrel and aspirin demonstrated platelet function below this cut-off. One of the four CEA patients below the cut-off died from intracerebral hemorrhage postoperatively. CABG patients below (n = 6) and above (n = 14) the cut-off did not differ in chest tube output (median [range]: 373 ml [250-900] vs. 368 ml [195-820]). Ex vivo addition of desmopressin did not increase platelet function. In conclusion, ROTEM^® platelet does reveal aspirin treatment whereas clopidogrel treatment is most often overlooked. Due to low bleeding in the study population, it was not possible to conclude on the association with bleeding risk.

How to Handle Arterial Conduits in Liver Transplantation? Evidence From the First Multicenter Risk Analysis

OBJECTIVE

The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective.

BACKGROUND

Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature.

STUDY DESIGN

This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival.

RESULTS

The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT.

CONCLUSION

When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.

Tissue engineered bovine saphenous vein extracellular matrix scaffolds produced via antigen removal achieve high in vivo patency rates

Diseases of small diameter blood vessels encompass the largest portion of cardiovascular diseases, with over 4.2 million people undergoing autologous vascular grafting every year. However, approximately one third of patients are ineligible for autologous vascular grafting due to lack of suitable donor vasculature. Acellular extracellular matrix (ECM) scaffolds derived from xenogeneic vascular tissue have potential to serve as ideal biomaterials for production of off-the-shelf vascular grafts capable of eliminating the need for autologous vessel harvest. A modified antigen removal (AR) tissue process, employing aminosulfabetaine-16 (ASB-16) was used to create off-the-shelf small diameter (< 3 mm) vascular graft from bovine saphenous vein ECM scaffolds with significantly reduced antigenic content, while retaining native vascular ECM protein structure and function. Elimination of native tissue antigen content conferred graft-specific adaptive immune avoidance, while retention of native ECM protein macromolecular structure resulted in pro-regenerative cellular infiltration, ECM turnover and innate immune self-recognition in a rabbit subpannicular model. Finally, retention of the delicate vascular basement membrane protein integrity conferred endothelial cell repopulation and 100% patency rate in a rabbit jugular interposition model, comparable only to Autograft implants. Alternatively, the lack of these important basement membrane proteins in otherwise identical scaffolds yielded a patency rate of only 20%. We conclude that acellular antigen removed bovine saphenous vein ECM scaffolds have potential to serve as ideal off-the-shelf small diameter vascular scaffolds with high in vivo patency rates due to their low antigen content, retained native tissue basement membrane integrity and preserved native ECM structure, composition and functional properties. STATEMENT OF SIGNIFICANCE: The use of autologous vessels for the treatment of small diameter vascular diseases is common practice. However, the use of autologous tissue poses significant complications due to tissue harvest and limited availability. Developing an alternative vessel for use for the treatment of small diameter vessel diseases can potentially increase the success rate of autologous vascular grafting by eliminating complications related to the use of autologous vessel and increased availability. This manuscript demonstrates the potential of non-antigenic extracellular matrix (ECM) scaffolds derived from xenogeneic vascular tissue as off-the-shelf vascular grafts for the treatment of small diameter vascular diseases.

Catheter-related thrombosis after cardiac surgery in patients with both central venous and pulmonary artery catheters inserted into the right internal jugular vein: a single-center, prospective, observational study

Central venous catheters (CVCs) and pulmonary artery catheters (PACs) are widely used in intensive care and perioperative management. The detection and prevention of catheter-related thrombosis (CRT) are important because CRT is a complication of catheter use and can cause pulmonary embolism and bloodstream infection. Currently, there is no evidence for CRT in patients using both CVC and PAC. We conducted a single-center, prospective, observational study to identify the incidence, timing, and risk factors for CRT in patients undergoing cardiovascular surgery and using a combination of CVC and PAC through the right internal jugular vein (RIJV). Out of 50 patients, CRT was observed using ultrasonography in 39 patients (78%), and the median time of CRT formation was 1 day (interquartile range: 1-1.5) after catheter insertion. The mean duration of PAC placement was 3 days (interquartile range: 2-5), and the maximum diameter of CRT was 12 mm (interquartile range: 10-15). In short-axis images, CRT occupied more than half of the cross-sectional area of the RIJV in five patients (10%), and CRT completely occluded the RIJV in one patient (2%). Platelet count, duration of PAC placement, and intraoperative bleeding amount were found to be high-risk indicators of CRT. In conclusion, patients who underwent cardiovascular surgery and using both CVC and PAC had a high incidence of CRT. Avoiding unnecessary PAC placement and early removal of catheters in patients at high risk of developing CRT may prevent the development of CRT.

Commentary: When will the robots come marching in?

Minimally invasive techniques for coronary artery bypass grafting (CABG), specifically robotic-assisted CABG has increased in popularity despite conflicting evidence. Here, we review a report by Yokoyama and colleagues to the Journal of Cardiac Surgery investigating outcomes of robotic versus nonrobotic CABG utilizing the National Inpatient Sample (NIS).

Molecular Action of Hydroxytyrosol in Attenuation of Intimal Hyperplasia: A Scoping Review

Objective: Hydroxytyrosol (HT), a polyphenol of olive plant is well known for its antioxidant, anti-inflammatory and anti-atherogenic properties. The aim of this systematic search is to highlight the scientific evidence evaluating molecular efficiency of HT in halting the progression of intimal hyperplasia (IH), which is a clinical condition arises from endothelial inflammation.

Methods: A systematic search was performed through PubMed, Web of Science and Scopus, based on pre-set keywords which are Hydroxytyrosol OR 3,4-dihydroxyphenylethanol, AND Intimal hyperplasia OR Neointimal hyperplasia OR Endothelial OR Smooth muscles. Eighteen in vitro and three in vitro and in vivo studies were selected based on a pre-set inclusion and exclusion criteria.

Results: Based on evidence gathered, HT was found to upregulate PI3K/AKT/mTOR pathways and supresses inflammatory factors and mediators such as IL-1β, IL-6, E-selectin, P-selectin, VCAM-1, and ICAM-1 in endothelial vascularization and functioning. Two studies revealed HT disrupted vascular smooth muscle cells (SMC) cell cycle by dephosphorylating ERK1/2 and AKT pathways. Therefore, HT was proven to promote endothelization and inhibit vascular SMCs migration thus hampering IH development. However, none of these studies described the effect of HT collectively in both vascular endothelial cells (EC) and SMCs in IH ex vivo model.

Conclusions: Evidence from this concise review provides an insight on HT regulation of molecular pathways in reendothelization and inhibition of VSMCs migration. Henceforth, we propose effect of HT on IH prevention could be further elucidated through in vivo and ex vivo model.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1

BACKGROUND

Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

METHODS

The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

RESULTS

Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

CONCLUSIONS

These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

Impact of Renin-Angiotensin System Blockers on Mortality in Veterans Undergoing Cardiac Surgery

Background

Renin‐angiotensin system blockers (RASBs) have well‐validated benefit in patients with hypertension, coronary artery disease, and left ventricular systolic dysfunction. Their use in the perioperative period, however, has been controversial, including in patients undergoing cardiac surgery, who often have a strong indication for their use. In the current study, we explore the impact of RASB use with 30‐day and 1‐year mortality after cardiac surgery.

Methods and Results

The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse were data sources for this retrospective cohort study. A total of 37 197 veterans undergoing elective coronary artery bypass grafting and or valve repair or replacement over a 10‐year period met inclusion criteria and were stratified into 4 groups by preoperative exposure (preoperative exposure versus no preoperative exposure) and postoperative continuing exposure (current exposure versus no current exposure) to RASBs. After adjusting for all baseline covariates, the preoperative exposure/current exposure group had lower 30‐day and 1‐year mortality than the preoperative exposure/no current exposure (30‐day hazard ratio [HR], 0.25; 95% CI, 0.19–0.33 [P<0.001] and 1‐year HR, 0.40; 95% CI, 0.33–0.48 [P<0.001] or no preoperative exposure/no current exposure (30‐day HR, 0.44; 95% CI, 0.32–0.60 [P<0.001] and 1‐year HR, 0.72; 95% CI, 0.62–0.84 [P<0.001] groups. The no preoperative exposure/current exposure group had significantly lower 30‐day (HR, 0.31; 95% CI, 0.14–0.71 [P=0.006]) and 1‐year (HR, 0.64; 95% CI, 0.53–0.77 [P<0.001]) mortality than the no preoperative exposure/no current exposure group.

Conclusions

Continuation of preoperative RASBs and initiation before discharge is associated with decreased mortality in veterans undergoing cardiac surgery. Given these findings, continuation of preoperative RASBs or initiation in the early postoperative period should be considered in patients undergoing cardiac surgery.

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

Development and Psychometric Properties Evaluation of a Care Needs Questionnaire in Phase 1 Cardiac Rehabilitation for Patients with Coronary Artery Disease: CNCR-Q

Introduction: Cardiovascular diseases (CVDs) are one of the most common chronic illnesses and the leading cause of mortality worldwide. This study aimed to design and assess the psychometric properties of questionnaire to examine the care needs of patients with coronary artery disease (CAD) in phase 1 of cardiac rehabilitation (CR).

Methods: This sequential exploratory study used a mixed method with two phases. In the first phase, qualitative study was performed by analyzing the concept of Schwartz-Barcott-Kim hybrid model; and in the second phase, quantitative data were obtained and analyzed for the psychometric parameters of the designed tool.

Results: The questionnaire for care needs was based on the indicators of measurement, which was identified in the qualitative phase of the study, as a tool with 40 items. After conducting face validity qualitatively, all tool items were considered important and were retained for the next steps. After completing the steps for determining the content validity ratio (CVR) and content validity index (CVI) of 40 items, they were preserved for decision making at a later stage. The results of exploratory factor analysis revealed four factors; the factor analysis of three items was eliminated and the final version of the questionnaire CNCR-Q (Care Needs Cardiac Rehabilitation-Questionnaire) with 37 items remained.

Conclusion: The findings indicated that the questionnaire with properties, such as simple scoring, reliability and validity, is an appropriate tool for assessing care needs in Iranian patients with CAD. Moreover, the CNCR-Q is an effective instrument for assessing patient needs before discharge.

Measures to Increase Use of Multiple Arterial Grafts for Isolated Coronary Artery Bypass Grafting

BACKGROUND

Use of multiple arterial grafts (MAGs) provides superior patency and long-term survival benefit compared with venous grafts during coronary artery bypass grafting (CABG). However, MAGs are used infrequently for CABG. We hypothesized that specific measures introduced at our institution would lead to an increase in the use of MAGs.

STUDY DESIGN

Use of MAGs before and after introduction of bundled measures was compared. Measures included increased education in arterial graft harvesting, inclusion as a quality metric, and hiring of surgeon champions. Patients younger than 70 years who underwent first time, isolated CABG using at least 1 arterial graft were included. Number and type of grafts used were compared between time periods using chi-square test. Secondary outcomes included postoperative complications. Complications were compared between time periods, as well as between MAG and non-MAG recipients before and after propensity score matching using Fisher exact test and univariate logistic regression. Multivariable logistic regression was used to determine patient characteristics associated with MAG use.

RESULTS

There were 2,169 patients included from 2012 to 2019. MAG use increased significantly after introduction of measures (21.1% to 41.9%; p < 0.001). Radial artery use with an internal mammary artery (0.3% to 16%; p < 0.001) and the use of triple arterial grafts increased significantly (0% to 2.4%; p < 0.001). MAG use in the entire cohort was associated with decreased 30-day mortality and postoperative cardiac arrest that was not significant after propensity matching.

CONCLUSIONS

A programmatic emphasis on the use of MAGs for CABG is an effective method to increase its use.

The enigmatic immunoglobulin G4-related disease and its varied cardiovascular manifestations

Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterised by multiorgan lymphoplasmacytic infiltration, obliterative phlebitis and storiform fibrosis. It can be associated with cardiovascular pathology. The objective of this narrative review is to summarise the published literature on cardiovascular manifestations of IgG4-RD and to provide a basis for diagnosis and management of the condition by the practising cardiologist.We propose the following categorisations of cardiovascular IgG4-RD: aortitis, medium-vessel arteritis, pulmonary vascular disease, phlebitis, valvulopathy, pericarditis, myocardial disease and antineutrophilic cytoplasmic antibody-associated vasculitis. We also review herein developments in radiological diagnosis and reported medical and surgical therapies. Cardiovascular lesions frequently require procedural and/or surgical interventions, such as aortic aneurysm repair and valve replacement. IgG4-RD of the cardiovascular system results in serious complications that can be missed if not evaluated aggressively. These are likely underdiagnosed, as clinical presentations frequently mimic cardiovascular disease due to more common aetiologies (myocardial infarction, abdominal aortic aneurysm and so on). While systemic corticosteroids are the mainstay of IgG4-RD treatment, biological and disease-modifying agents are becoming more widely used. Cardiologists should be aware of cardiovascular IgG4-RD as a differential diagnosis, and understand the roles of corticosteroids, disease-modifying agents and biologicals, as well as their integration with surgical approaches. There are several knowledge gaps, including diagnosis, risk factors, pathogenesis and appropriate management in Ig4-RD of the cardiovascular system. Areas lacking well-conducted randomized trials include safety of steroids in the setting of vascular aneurysms and the role of disease-modifying drugs and biological agents in patients with established cardiovascular complications of this multifaceted enigmatic disease.

Second best conduit-is it the tag or patency that counts?

The Radial Artery Patency and Clinical Outcomes (RAPCO) trial compared radial artery (RA) with free right internal thoracic artery (RITA) and saphenous vein grafts (SVG). This was a prospective, randomized, single-center trial with two separate arms (RA-RITA and RA-SVG). The study showed that RA was superior to free RITA in terms of 10-year angiographic patency and provided a survival advantage as well. In contrast, RA-SVG comparison suggested a trend towards better outcomes with RA but no statistically significant difference in patency or survival. In this appraisal of the RAPCO trial, both the conduct and the findings have been critically evaluated. The concerns over using free RITA as aorto-coronary grafts as opposed to composite grafts and the insufficient sample size for the RA-SVG comparison have been highlighted. In the RAPCO trial that spanned almost quarter of a century, patency of all three conduits studied in the trial appears satisfactory.

Intensive care outcome of left main stem disease surgery: A single center three years’ experience

BACKGROUND

Left main coronary artery (LMCA) supplies more than 80% of the left ventricle, and significant disease of this artery carries a high mortality unless intervened surgically. However, the influence of coronary artery bypass grafting (CABG) surgery on patients with LMCA disease on morbidity intensive care unit (ICU) outcomes needs to be explored. However, the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring.

AIM

To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome.

METHODS

Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG. Patients were divided into 2 groups; those with LMCA disease as group 1 (75 patients) and those without LMCA disease as group 2 (324 patients). We correlated ICU outcome parameters including ICU length of stay, post-operative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post-operative bleeding in both groups.

RESULTS

Patients with LMCA disease had a significantly higher prevalence of diabetes (43.3% vs 29%, P = 0.001). However, we did not find a statistically significant difference with regards to ICU stay, or other morbidity and mortality outcome measures.

CONCLUSION

Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement. Diabetes was more prevalent in patients with LMCA disease. These findings may help in guiding decision making for future practice and stratifying the patients’ care.

Coronary subclavian steal syndrome causing myocardial Infarction

Coronary subclavian steal syndrome (CSSS) is a rare complication of the internal mammary artery (IMA) grafting in coronary artery bypass surgery. The technical definition is myocardial ischemia due to the reduced flow of blood, or flow reversal in the IMA graft. This in most cases results from hemodynamically significant proximal subclavian artery stenosis. The clinical presentation is variable and ranges from unstable angina to myocardial infarction, and in some cases, sudden cardiac arrest. CSSS is an entity that is hard to diagnose if one is not actively looking for it. The clinical diagnosis is often complicated, and the prevalence of the disorder is frequently underestimated. In this case presentation, we report a case of myocardial infarction that resulted from significant proximal subclavian artery stenosis.

Neurologic complications of heart surgery

Cardiac surgeries are commonly associated with neurologic complications. The type and complexity of the surgery, as well as patients' comorbidities, determine the risk for these complications. Awareness and swift recognition of these complications may have significant implications on management and prognosis. Recent trials resulted in an expansion of the time window to treat patients with acute ischemic stroke with intravenous thrombolysis and/or mechanical thrombectomy using advanced neuroimaging for screening. The expanded time window increases the reperfusion treatment options for patients that suffer a periprocedural ischemic stroke. Moreover, there is now limited data available to help guide management of intracerebral hemorrhage in patients undergoing treatment with anticoagulation for highly thrombogenic conditions, such as left ventricular assist devices and mechanical valves. In addition to cerebrovascular complications patients undergoing heart surgery are at increased risk for seizures, contrast toxicity, cognitive changes, psychological complications, and peripheral nerve injuries. We review the neurological complications associated with the most common cardiac surgeries and discuss clinical presentation, diagnosis and management strategies.

The Effects of Volatile Anesthetics on Lung Ischemia-Reperfusion Injury: Basic to Clinical Studies

Case reports from as early as the 1970s have shown that intravenous injection of even a small dose of volatile anesthetics result in fatal lung injury. Direct contact between volatile anesthetics and pulmonary vasculature triggers chemical damage in the vessel walls. A wide variety of factors are involved in lung ischemia-reperfusion injury (LIRI), such as pulmonary endothelial cells, alveolar epithelial cells, alveolar macrophages, neutrophils, mast cells, platelets, proinflammatory cytokines, and surfactant. With a constellation of factors involved, the assessment of the protective effect of volatile anesthetics in LIRI is difficult. Multiple animal studies have reported that with regards to LIRI, sevoflurane demonstrates an anti-inflammatory effect in immunocompetent cells and an anti-apoptotic effect on lung tissue. Scattered studies have dismissed a protective effect of desflurane against LIRI. While a single-center randomized controlled trial (RCT) found that volatile anesthetics including desflurane demonstrated a lung-protective effect in thoracic surgery, a multicenter RCT did not demonstrate a lung-protective effect of desflurane. LIRI is common in lung transplantation. One study, although limited due to its small sample size, found that the use of volatile anesthetics in organ procurement surgery involving "death by neurologic criteria" donors did not improve lung graft survival. Future studies on the protective effect of volatile anesthetics against LIRI must examine not only the mechanism of the protective effect but also differences in the effects of different types of volatile anesthetics, their optimal dosage, and the appropriateness of their use in the event of marked alveolar capillary barrier damage.

Use of native Y-saphenous vein graft in multi-vessel coronary bypass surgery

Objective. Demonstration of the advantages of using the natural Y shaped form of saphenous vein graft, which is the most preferred coronary bypass graft after internal thoracic artery (ITA). Methods. 32 patients with coronary artery disease who underwent coronary bypass grafting (CABG) with 3 or more distal anastomoses between January 2014 and January 2018 were included in the study. The natural Y saphenous vein grafts were used in these operations beside of LİMA-LAD anastomosis. Patients have been evaluated in terms of early and short-term survival, early cardiac events, the need for reoperation, and the need for percutaneous transluminal coronary angioplasty (PTCA). All patients were followed up directly by outpatient examination or telephone consultation. Results. New cardiac events, reoperation and death were not seen in the early postoperative period. Coronary angiography performed in 3 patients due to angina in the second and third years revealed that all anastomoses of y-saphenous grafts were open. No mortality was observed in the patients who were followed remotely. The duration of operation and the duration of cardiopulmonary bypass resulted in a reduction in the number of proximal anastomoses and the time by about 10 to 15 minutes. The incision in the saphenous leg was about 10 cm shorter for each anastomosis. Conclusion. The natural shaped Y saphenous vein can be used safely in multi vessel coronary artery disease (CAD) patients for reducing the surgical trauma.

[Infectious and inflammatory complications occurring after cardiac surgery in cardiac rehabilitation centres]

Patients undergoing cardiac surgery are older, have complex pathologies and several comorbidities, but need to leave the hospital quickly! Therefore, the mission of cardiac rehabilitation centres has substantially changed. Indeed, if 15 to 25% of patients undergoing cardiac surgery will have a postoperative complication requiring a hospital management (infectious, pericardial, rhythmic, neurologic, pulmonary, digestive, etc.), more than 2/3 of these acute events could be managed by cardiac rehabilitation centres for a lower cost. Therefore, the quickest the patient is transferred to a cardiac rehabilitation centre, the easier the cardiac surgery centre could manage his beds. Infectious complications are the most dreadful, particularly mediastinitis.

Secondary prevention after CABG: do new agents change the paradigm?

PURPOSE OF REVIEW

Coronary artery bypass graft (CABG) surgery remains the gold-standard treatment for multivessel and left main coronary artery disease. Despite significant improvement in cardiovascular outcomes, patients undergoing CABG remain at risk for recurrent adverse ischemic events and other cardiovascular outcomes (coronary revascularisation, stroke, cardiac death, etc.). The purpose of this review is to summarize the most recent evidence in pharmacological preventive therapies addressing the residual cardiovascular risk in patients who have undergone CABG.

RECENT FINDINGS

Novel cardiovascular pharmacological preventive strategies targeting inflammatory, metabolic and prothrombotic (antiplatelet and anticoagulation) pathways have been recently assessed, with promising results for secondary prevention after CABG.

SUMMARY

Secondary prevention is an essential part of postoperative care after CABG. Novel lipid-lowering and glucose-controlling agents suggest a strong and consistent benefit on native coronary artery disease and overall cardiovascular outcomes. The role and the choice of enhanced antiplatelet/anticoagulation/lipid/glucose-modulating therapies following CABG should be better defined and deserves further investigation. Additional studies are required to identify new therapeutic target addressing the specific multifactorial nature of the graft CV disease and identifying the best preventive strategies for long-term graft patency.

Is carotid screening redundant for patients undergoing coronary artery bypass grafting?

OBJECTIVES

Stroke is a devastating complication following coronary artery bypass grafting, which thankfully occurs with low incidence. The role of preoperative carotid ultrasound remains unclear. Whilst it is a cheap and reliable way of diagnosing carotid stenosis (CS), it is unclear if and how this knowledge should impact on subsequent patient management.

METHODS

A systematic review of the literature was performed using the PRISMA guideline. A literature search was conducted on the MEDLINE database from 1950 to May 2020 using the OVID interface. Fifteen papers out of a total of 5931 were identified for inclusion.

RESULTS

The evidence overall suggests that patients with severe CS are likely to have an increased incidence of postoperative stroke-however, the prevalence of severe CS is low, and even in this cohort of patients, the incidence is not particularly high.

CONCLUSION

In screened patients identified to have severe CS, there appears to be a generally low appetite for undertaking carotid intervention internationally either before or concurrently with the coronary artery bypass grafting. Putting this all together, the widespread screening of asymptomatic patients would appear to not be justified.

Association Between β-Blockers and Outcome of Coronary Artery Bypass Grafting: Before and After 1 Year

BACKGROUND

We evaluated the long-term outcomes of coronary artery bypass grafting (CABG) according to β-blocker therapy using landmark analysis. Although β-blockers have been shown to improve outcomes for ischemic heart disease, the long-term effects and optimal treatment duration of use after CABG remain unknown.

METHODS

From January 2001 to December 2014, 5382 CABG patients were stratified into 2 groups according to β-blocker therapy at discharge (β-blocker group: 3677 [68.3%], no β-blocker group: 1705 [31.7%]).

RESULTS

The primary outcome was all-cause death during 48 months of follow-up. Using propensity score-matched analysis, β-blocker therapy was associated with all-cause death during the 48-month follow-up (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.41-0.95; P = .03). The landmark analysis demonstrated that the effect of β-blockers on all-cause death was particularly significant within the first 12 months of therapy (HR, 0.37; 95% CI, 0.19-0.80; P = .01) but not after 12 months (HR, 0.92; 95% CI, 0.56-1.53; P = .77).

CONCLUSIONS

The benefits of postdischarge β-blockers may be limited to 1 year after CABG, but further studies are required to confirm this finding.

Synchronous versus staged carotid artery stenting and coronary artery bypass graft for patients with concomitant severe coronary and carotid artery stenosis: A systematic review and meta-analysis

BACKGROUND

Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable.

OBJECTIVE

The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes.

METHODS

This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity.

RESULTS

Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00-13.69; I² = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88-23.01; I² = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18- 13.09; I² = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02-3.12; I² = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04- 9.20; I² = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03-4.03; I² = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02-3.12; I² = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50-27.94; I² = 0.0%), MI (OR: 0.33; 95% CI: 0.01-12.03; I² = 0.0%) and stroke (OR:3.58; 95% CI:0.84-15.20; I² = 0.0%) after a mean follow-up of 47 months.

CONCLUSION

The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results.

The Relation between Volume and Outcome of Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are standard procedures for dealing with severe aortic stenosis patients. Researchers have not carried out a systematic review of the volume-outcome relationship in TAVR and SAVR. Our study is intended to address this problem. We systemically searched databases through MEDLINE, EMBASE, PUBMED, and the Cochrane Library up to September 2019. Two reviewers independently screened for the studies and evaluated bias. We used short-term mortality (in-hospital or 30-day mortality) as an outcome. A meta-analysis of TAVR with 115,596 patients ranging from 2005 to 2016 showed a result significantly in favor of high-volume hospitals (OR 0.43 (CI 0.36-0.51)). The subgroup of population period, region, data type, and cut-off value did not show any difference. A meta-analysis of SAVR comprising 418,384 patients ranging from 1994 to 2011 revealed that the OR of short-term mortality for a high-volume hospital compared with that of a low-volume hospital was 0.73 (CI 0.71, 0.74). No difference was observed in subgroups based on population period and cut-off. In conclusion, we found that short-term mortality was lower in high-volume hospitals for both TAVR and SAVR.

Antigen removal process preserves function of small diameter venous valved conduits, whereas SDS-decellularization results in significant valvular insufficiency

Chronic venous disease (CVD) is the most common reported chronic condition in the United States, affecting more than 25 million Americans. Regardless of its high occurrence, current therapeutic options are far from ideal due to their palliative nature. For best treatment outcomes, challenging cases of chronic venous insufficiency (CVI) are treated by repair or replacement of venous valves. Regrettably, the success of venous valve transplant is dependent on the availability of autologous venous valves and hindered by the possibility of donor site complications and increased patient morbidity. Therefore, the use of alternative tissue sources to provide off-the-shelf venous valve replacements has potential to be extremely beneficial to the field of CVI. This manuscript demonstrates the capability of producing off-the-shelf fully functional venous valved extracellular matrix (ECM) scaffold conduits from bovine saphenous vein (SV), using an antigen removal (AR) method. AR ECM scaffolds maintained native SV structure-function relationships and associated venous valves function. Conversely, SDS decellularization caused significant changes to the collagen and elastin macromolecular structures, resulting in collagen fibril merging, elimination of fibril crimp, amalgaming collagen fibers and fragmentation of the inner elastic lamina. ECM changes induced by SDS decellularization resulted in significant venous valve dysfunction. Venous valved conduits generated using the AR approach have potential to serve as off-the-shelf venous valve replacements for CVI. STATEMENT OF SIGNIFICANCE: Retention of the structure and composition of extracellular matrix (ECM) proteins within xenogeneic scaffolds for tissue engineering is of crucial importance, due to the undeniable effect ECM proteins can impose on repopulating cells and function of the resultant biomaterial. This manuscript demonstrates that alteration or elimination of ECM proteins via commonly utilized decellularization approach results in complete disruption of venous valve function. Conversely, retention of the delicate ECM structure and composition of native venous tissue, using an antigen removal tissue processing method, results in preservation of native venous valve function.

Coronary artery bypass grafting in children for atheromatous and non-atheromatous lesions

Coronary artery involvement in children is an uncommon but well-recognized clinical entity. It is an important cause for sudden cardiac death in children. Diagnosis requires a high index of suspicion since it has serious consequences when missed. Presentation of coronary artery abnormality is very variable due to congenital as well as acquired aetiology. In this review, we have described the different causes that require coronary artery bypass grafting in children and their pathogenesis. The nuances of conduit selection, graft behaviour in children, patency rates and long-term outcomes in children undergoing coronary artery bypass have also been discussed.

Annual case volume on mortality after coronary artery bypass grafting: a dose-response meta-analysis

OBJECTIVES

This study evaluated the effect of both hospital and surgeon annual case volumes on patient mortality following coronary artery bypass grafting (CABG).

METHODS

PubMed and Embase databases were searched for clinical studies on CABG. The outcome was mortality, including operative mortality, in-hospital mortality and 30-day mortality.

RESULTS

Twenty-five studies involving 3 492 101 participants and 143 951 deaths were included for hospital volume, and 4 studies involving 108 356 participants and 2811 deaths were included for surgeon volume. The pooled estimate revealed that both hospital and surgeon annual case volumes were inversely associated with mortality in patients after CABG [odds ratio (OR) for hospital: 0.62, 95% confidence interval (CI) 0.56-0.69; P < 0.001; OR for surgeon: 0.51, 95% CI 0.31- 0.83; P < 0.001] with high heterogeneity (hospital: I2 = 90.6%, Pheterogeneity < 0.001; surgeon: I2 = 86.8%, Pheterogeneity < 0.001). The relationship remained consistent and robust in most subgroup and sensitivity analyses. Our meta-regression analysis of time suggested that the strength of the negative associations between volume and mortality for both hospitals and surgeons remained unattenuated over time even though the CABG mortality gradually decreased over time. The dose-response analysis suggested a non-linear relationship between both hospital and surgeon annual case volumes and mortality (both Pnon-linearity = 0.001).

CONCLUSIONS

Both higher hospital and surgeon annual case volumes are associated with lower mortality in patients undergoing CABG, and the negative associations remain unattenuated over time.

CLINICAL REGISTRATION NUMBER

The study was registered at PROSPERO as CRD42017067912.

Central Diabetes Insipidus in an Off-pump Coronary Artery Bypass Grafting Surgery

Polyuria in perioperative coronary artery bypass grafting (CABG) surgery is common and mostly benign. Diabetes insipidus (DI) post-CABG is however very rare and mostly have been related with use of cardiopulmonary bypass (CPB) pump. The patient recovered completely with transient requirement of exogenous vasopressin. The central DI may be considered as a differential diagnosis in case of polyuria in the perioperative period of CABG surgery.

How to cite this article

Nasa P, Varma G, Kulkarni A, Chaudhary S, Sagar P. Central Diabetes Insipidus in an Off-pump Coronary Artery Bypass Grafting Surgery. IJCCM 2019;23(11):523-525.

Central Diabetes Insipidus in an Off-pump Coronary Artery Bypass Grafting Surgery

Polyuria in perioperative coronary artery bypass grafting (CABG) surgery is common and mostly benign. Diabetes insipidus (DI) post-CABG is however very rare and mostly have been related with use of cardiopulmonary bypass (CPB) pump. The patient recovered completely with transient requirement of exogenous vasopressin. The central DI may be considered as a differential diagnosis in case of polyuria in the perioperative period of CABG surgery.

HOW TO CITE THIS ARTICLE

Nasa P, Varma G, Kulkarni A, Chaudhary S, Sagar P. Central Diabetes Insipidus in an Off-pump Coronary Artery Bypass Grafting Surgery. IJCCM 2019;23(11):523-525.

Coronary artery bypass surgery plus medical therapy versus medical therapy alone for ischaemic heart disease: a protocol for a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Despite increasing survival, cardiovascular disease remains the primary cause of death worldwide with an estimated 7.4 million annual deaths. The main symptom of ischaemic heart disease is chest pain (angina pectoris) most often caused by blockage of a coronary artery. The aim of coronary artery bypass surgery is revascularisation achieved by surgically grafting harvested arteries or veins distal to the coronary lesion restoring blood flow to the heart muscle. Older evidence suggested a clear survival benefit of coronary artery bypass graft surgery, but more recent trials yield less clear evidence. We want to assess the benefits and harms of coronary artery bypass surgery combined with different medical therapies versus medical therapy alone in patients with ischaemic heart disease.

METHODS

This protocol for a systematic review follows the recommendations of Cochrane and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all randomised clinical trials assessing coronary artery bypass surgery combined with different medical therapies versus medical therapy alone in patients with ischaemic heart disease. We plan to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, Science Citation Index Expanded on Web of Science, and BIOSIS to identify relevant trials. Any eligible trial will be assessed as high risk or low risk of bias, and our conclusions will primarily be based on trials at low risk of bias. The analyses of the extracted data will be performed using Review Manager 5, STATA 16 and trial sequential analysis. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table and use GRADE to assess the certainty of the evidence.

DISCUSSION

Coronary artery bypass surgery is invasive and can cause death, which is why its use must be thoroughly studied to determine if it yields a large enough long-term benefit for the thousands of patients receiving it every year.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 131924.