Completeness of coronary revascularization and survival: Impact of age and off-pump surgery

Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents

Objective

Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention.

Methods

From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8 years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization.

Results

The mean age of patients was 65 ± 10 years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26 ± 1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311 ± 54 minutes, and the mean hospital length of stay was 2.7 ± 1.1 days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14 ± 0.4, and the mean number of vessels stented was 1.23 ± 0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39 ± 26 months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%.

Conclusions

In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.

Off-Pump Coronary Artery Bypass Grafting; is it Still Relevant?

Off-pump Coronary Artery Bypass Grafting (OPCAB) experienced a resurgence in the 1980s -2000s and developed steadily with improvement of the instrumentation and techniques. However questions about graft patency and long-term survival of OPCAB patients still exist. This review attempts to explore the current relevance of OPCAB.

Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events

OBJECTIVE

Complete revascularization literature is limited by variance in patient cohorts and inconsistent definitions. The objective of the current study was to provide risk-adjusted outcomes for complete revascularization of significant nonmain-branch and main-branch vessel stenoses.

METHODS

All patients that underwent first-time isolated coronary artery bypass grafting procedures were included. Kaplan-Meier survival estimates, cumulative incidence function, and Cox regression were used to analyze outcomes.

RESULTS

The total population consisted of 3356 patients that underwent first-time isolated coronary artery bypass grafting. Eight hundred eighty-nine (26.5%) patients had incomplete and 2467 (73.5%) had complete revascularization. For main-branch vessels, 677 (20.2%) patients had incomplete revascularization and 2679 (79.8%) were completely revascularized. Following risk adjustment with inverse probability treatment weighting, all baseline characteristics were balanced (standardized mean difference, ≤ 0.10). On Kaplan-Meier estimates, survival at 1 year (94.6% vs 92.5%) and 5 years (86.5% vs 82.1%) (P = .05) was significantly better for patients who received complete revascularization. Freedom from major adverse cardiac and cerebrovascular events was significantly higher for the complete revascularization cohort at both 1 year (89.2% vs 84.2%) and 5 years (72.5% vs 66.7%) (P < .001). Complete revascularization (hazard ratio, 0.82; 95% confidence interval, 0.70-0.95; P = .01) was independently associated with a significant reduction in major adverse cardiac and cerebrovascular events. Incomplete revascularization of nonmain-branch vessels was not associated with mortality (hazard ratio, 1.14; 95% confidence interval, 0.74-1.8; P = .55) or major adverse cardiac and cerebrovascular events (hazard ratio, 0.90; 95% confidence interval, 0.66-1.24; P = .52).

CONCLUSIONS

Complete surgical revascularization of all angiographically stenotic vessels in patients with multivessel coronary artery disease is associated with fewer major adverse events. Incomplete revascularization of nonmain-branch vessels is not associated with survival or major adverse cardiac and cerebrovascular events.

Rate of Incomplete Revascularization Following Coronary Artery Bypass Grafting at a Single Institution Between 2007 and 2017

Incomplete revascularization following coronary artery bypass grafting (CABG) is associated with increased repeat revascularization, myocardial infarction and death. Whether the rate of incomplete revascularization is increasing over time has not been previously described. All patients with multivessel coronary artery disease who underwent isolated and elective CABG at our Institution in 2007 (n = 291) were compared to patients who underwent CABG in 2017 (n = 290). A Revascularization Index Score was created to compare rates of incomplete revascularization between the 2 years based on the coronary anatomy and degree of stenosis. Comparison of the 2 years disclose that the rate of incomplete revascularization increased from 17.9% in 2007 to 28.3% in 2017 (p = 0.003) and was accompanied by a decline in the Revascularization Index Score from 0.73 to 0.67 (p = 0.005). Left ventricular function improved in both groups following CABG. Two-year cardiovascular mortality was significantly higher in the 2017 cohort compared to the 2007 cohort. These differences may be attributable to patient factors including more severe coronary artery disease associated with older age, greater incidence of smoking and previous percutaneous coronary intervention. In conclusion, the rate of incomplete revascularization following CABG significantly increased in 2017 compared to 2007 and was associated with higher cardiovascular mortality.

Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: Early outcomes and angiographic patency

OBJECTIVE

Multivessel minimally invasive coronary artery bypass grafting, performed chiefly with left internal thoracic artery and saphenous vein grafts through a left anterolateral thoracotomy, has recently emerged as an alternative to conventional coronary artery bypass grafting. The present study involves our initial experience with respect to early postoperative and angiographic outcomes after total arterial multivessel off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries.

METHODS

A total of 88 consecutive patients undergoing total arterial off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries without ascending aortic manipulation were included in this study. Bilateral internal thoracic arteries were harvested under direct vision through a left anterolateral thoracotomy and used as Y or in situ grafts. Multivessel grafting was performed off pump. Postoperative graft assessment was performed in 51 patients.

RESULTS

The mean age of patients was 67.1 ± 7.2 years, and 79 patients (89.8%) were male. The mean body mass index and ejection fraction were 26.7 ± 2.7 kg/m² and 57.6% ± 6.6%, respectively, and 40 patients (45.5%) had left main disease. No intraoperative conversions to cardiopulmonary bypass or sternotomy occurred. A total of 209 distal anastomoses (mean 2.4 ± 0.5) were performed, with 57 patients undergoing double, 29 patients undergoing triple, and 2 patients undergoing quadruple coronary artery bypass grafting. There was no in-hospital mortality, and 5 patients underwent reexploration for bleeding. No patient had stroke or chest wound infections. Predischarge coronary angiography revealed an overall graft patency rate of 96.8%.

CONCLUSIONS

Off-pump minimally invasive coronary artery bypass grafting using total arterial revascularization with bilateral internal thoracic arteries is a feasible and safe operation that is associated with excellent short-term outcomes and early graft patency. Future studies should focus on improving the generalizability and reproducibility of this technique.

Impacts of incomplete revascularization following off-pump coronary artery bypass grafting on clinical outcomes of patients with triple-vessel lesions: insights from a single-center study of propensity-matched data

Background

Although complete revascularization (CR) has been a goal of surgical revascularization, comorbidities and anatomical variables often conspire against a successful surgical CR. Currently, incomplete revascularization (IR) has been also considered as an acceptable strategy of surgical revascularization in some categories of patients. In the past decade, off-pump coronary artery bypass grafting (CABG) became one of the mainstream procedures of CABG due to its low incidence of perioperative complications. However, the magnitude of the impacts of off-pump IR on clinical outcomes of patients with triple-vessel disease remained unclear.

Methods

Eligible patients who received isolated off-pump CABG with left internal mammary artery (LIMA) grafting to the left anterior descending coronary artery (LAD) in our institute from January 2011 to December 2013 were entered into an IR group or a CR group. The incidence of off-pump IR was investigated. In-hospital and follow-up outcomes were also evaluated by adjusting baseline characteristics using propensity score matching (1:1).

Results

A total of 1,349 patients (268 in the IR group and 1,081 in the CR group) were analyzed. The off-pump IR rate was 19.9%. Using matching propensity scores, 234 pairs were successfully established in a 1:1 manner. The two matched groups had similar surgical mortality and major postoperative morbidity. Multivariate Cox regression analysis showed that IR was not an independent predictor of cardiac death at follow-up (HR =1.215; 95% CI, 0.883-2.164; P=0.371). The two matched groups received a similar cumulative survival freedom from repeat revascularization in Kaplan-Meier curves (χ²=2.120, log-rank P=0.145).

Conclusions

CR can be achieved in the majority of off-pump CABG cases. Compared with off-pump CR, off-pump IR with the LIMA grafting to the LAD was associated with acceptable clinical outcomes.

The impact of the radial artery or the saphenous vein in addition to the bilateral internal mammary arteries on late survival: A propensity score analysis

BACKGROUND

Long-term survival benefits of full arterial revascularization with radial artery (RA) used in addition to bilateral internal mammary arteries (BIMA) compared with saphenous vein (SV) used in addition to BIMA has not been clearly defined.

METHODS

We retrospectively analyzed 660 3-vessel coronary artery disease subjects who received BIMA in addition to either RA (n = 206) or SV (n = 454) grafting in a period between June 1999 and November 2017. After propensity score matching, we obtained 190 matched pairs for analysis.

RESULTS

In the matched population, in-hospital mortality occurred in 4 patients (1%), with 2 deaths (1.1%) in the BIMA + RA group and 2 deaths (1.1%) in BIMA + SV group (P > .99). The median follow-up time was 9.2 years (interquartile range, 5.6-13 years) with a maximum follow-up time of 18.5 years. There was not a significant difference in long-term survival between the 2 groups over the follow-up period. Survival at 5, 10, and 15 years were 94.8 ± 1.7%, 83.7 ± 3.1%, and 78.6 ± 3.9% in the BIMA + RA group and 96.2 ± 1.4%, 85.1 ± 2.9%, and 80.4 ± 3.6% in the BIMA + SV group (stratified log-rank P = .78). Cox proportional hazard regression model was used to estimate that the use of RA in addition to BIMA did not affect the late mortality (propensity score adjusted hazard ratio, 1.05; 95% confidence interval, 0.62-1.79; P = .83).

CONCLUSIONS

In a relatively small population of triple-vessel coronary artery disease, the use of RA as a third arterial conduit with BIMA did not confer a long-term survival benefit.

Incomplete revascularization and long-term survival after coronary artery bypass surgery

BACKGROUND

We sought to investigate the impact of incomplete revascularization (IR) on long-term survival after isolated coronary artery bypass grafting (CABG). The possible interaction between IR and off-pump surgery was also explored.

METHODS

A total of 13,701 patients with multivessel disease undergoing CABG were included in the analysis. All patients received left internal thoracic artery (LITA) to the left anterior descending artery (LAD) territory. IR was defined as at least one diseased arterial territory (right coronary artery [RCA] and/or circumflex [CX] artery) incompletely revascularized.

RESULTS

Overall, 3107 (22.7%) patients received IR. After propensity score matching, IR did not increase all-cause death in the overall group (HR 1.09; 95%CI 0.96-1.22; P=0.17). However, when both RCA and CX artery were incompletely revascularized, late survival was significantly lower (HR 2.15; 95%CI 1.57-2.93). IR was associated with a higher risk of death after off-pump (HR 1.26; 95%CI 1.05-1.49) regardless the extent of IR. After on-pump, IR significantly affected survival only when both RCA and CX artery only were incompletely revascularized (HR 2.32; 95%CI 1.27-4.22).

CONCLUSIONS

The present analysis shows that in patients with LITA-LAD graft the impact of IR on survival is marginal when only one coronary territory is left ungrafted. When both the RCA and CX territory remain unrevascularized the survival rate is significantly reduced. IR after off-pump CABG is associated with significantly lower survival and affects long-term outcome even when only one coronary territory is not revascularized.

Off-pump coronary artery bypass: past, present and future of a controversial technology

PURPOSE OF REVIEW

This review will examine the current role of off-pump coronary artery bypass (OPCAB) surgery compared with on-pump coronary artery bypass (ONCAB) surgery for the revascularization of ischemic myocardium.

RECENT FINDINGS

Recent studies have confirmed earlier findings that OPCAB is associated with less grafts per patient and less complete revascularization, and increased incidence of recurrent angina and need for repeat revascularization procedures, and more frequent rehospitalization for cardiac-related issues. OPCAB does not prevent postoperative renal dysfunction and is associated with worse long-term outcomes. Hospital costs are not reduced and are increased in those OPCAB patients who require intraoperative conversion to ONCAB procedures; however, when multiple arterial grafts are used and a complete revascularization is performed, OPCAB outcomes are equivalent to those of ONCAB procedures.

SUMMARY

OPCAB should only be performed by surgeons experienced in this technique in patients in whom a complete revascularization can be achieved; preferably with multiple arterial grafts.

Off-pump coronary artery bypass reduces early stroke in octogenarians: a meta-analysis of 18,000 patients

BACKGROUND

Data comparing results of off-pump and conventional operations in octogenarians is very limited. Thus we chose to compare early adverse events between off-pump coronary artery bypass grafting (OPCABG) and on-pump CABG (ONCABG) in patients older than 80 years.

METHODS

Systematic review of multiple databases was performed to obtain original studies fulfilling search criteria. End points--early mortality, stroke, respiratory failure, atrial fibrillation, and myocardial infarction--were compared between these cohorts. A random-effects weighted analysis was performed using the trim-fill adjustment when necessary. Results are presented as risk ratios (RRs) with 95% confidence intervals (CIs); p < 0.05 is considered statistically significant.

RESULTS

Sixteen retrospective studies (9,744 ONCABG and 8,566 OPCABG patients) were included in the systematic review. OPCAGB patients received significantly fewer grafts (2.54 ± 0.16) compared with ONCABG patients (3.22 ± 0.41). Early mortality was comparable at 4.6% and 5.2% in the OPCABG and ONCABG cohorts, respectively (risk ratio [RR], 0.91; 95% CI, 0.64-1.28; p = 0.598). Stroke rates were higher in the ONCABG cohort (RR, 0.65; 95% CI, 0.49- 0.87; p < 0.01). Respiratory failure was higher with ONCABG (RR, 0.74; 95% CI, 0.57-0.97; p = 0.03). New-onset renal failure (p = 0.99), atrial fibrillation (p = 0.27), and myocardial infarction (p = 0.99) were comparable.

CONCLUSIONS

Coronary artery bypass in octogenarians can be performed safely with low early mortality. Although off-pump operations reduce the risk of early stroke, all other adverse events are comparable in on- and off-pump coronary artery bypass operations. Data regarding late mortality is at present limited; however, both on- and off-pump procedures appear to produce comparable survival.