What constitutes optimal surgical revascularization? Answers from the Bypass Angioplasty Revascularization Investigation (BARI)

Does Timing of Coronary Artery Bypass Grafting after ST-Elevation Myocardial Infarction Impact Early- and Long-Term Outcomes?

BACKGROUND

 The optimal timing of surgical revascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-term outcomes in these patients.

METHODS

 Retrospective single-center analysis of patients with STEMI undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptom onset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and 10-year survival.

RESULTS

 During the study period, 437 consecutive patients underwent surgical revascularization in the setting of STEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality including patients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 (p = 0.31), whereas 10-year survival was 48.5, 57.3, and 54.9% (log-rank: p = 0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing of surgery had no influence on early- and long-term survival.

CONCLUSION

 In patients with STEMI, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularization strategy. Hence, when indicated, an early CABG strategy has no disadvantages in comparison to a delayed strategy.

Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry

BACKGROUND

Surgical ablation for atrial fibrillation at the time of isolated coronary artery bypass grafting is reluctantly attempted. Meanwhile, complete revascularization is not always possible in these patients. We attempted to counterbalance the long-term benefits of surgical ablation against the risks of incomplete revascularization.

METHODS

Atrial fibrillation patients undergoing isolated coronary artery bypass grafting for multivessel disease between 2012 to 2022 and included in the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry were divided into complete revascularization, complete revascularization with additional grafts, and incomplete revascularization cohorts; these were further split into surgical ablation and non-surgical ablation subgroups.

RESULTS

A total of 8,405 patients (78% men; age 69.3 ± 7.9) were included; of those, 5,918 (70.4%) had complete revascularization, and 556 (6.6%) had surgical ablation performed. Number of anastomoses was 2.7 ± 1.2. The median follow-up was 5.1 [interquartile range 2.1-8.8] years. In patients in whom complete revascularization was achieved, surgical ablation was associated with long-term survival benefit: hazard ratio 0.69; 95% confidence intervals (0.50-0.94); P = .020 compared with grafting additional lesions. Similarly, in patients in whom complete revascularization was not achieved, surgical ablation was associated with a long-term survival benefit of 0.68 (0.49-0.94); P = .019. When comparing surgical ablation on top of incomplete revascularization against complete revascularization without additional grafts or surgical ablation, there was no difference between the 2: 0.84 (0.61-1.17); P = .307, which was also consistent in the propensity score-matched analysis: 0.75 (0.39-1.43); P = .379.

CONCLUSION

To achieve complete revascularization is of utmost importance. However, when facing incomplete revascularization at the time of coronary artery bypass grafting in a patient with underlying atrial fibrillation, concomitant surgical ablation on top of incomplete revascularization is associated with similar long-term survival as complete revascularization without surgical ablation.

The heart team: the multidisciplinary approach to coronary artery disease

The recommendation to employ a heart team to guide revascularization has persisted for over a decade. Despite evidence for improved adherence to guidelines, widespread adoption of the heart team approach has been limited. This review delves into the history of the guidelines endorsing the use of a heart team and the supporting data. Additionally, it outlines some attributes of a successful heart team, and how the heart team has been run at several large academic centers. Finally, it reviews some of the barriers to a heart team and future considerations.

Clinical Insights to Complete and Incomplete Surgical Revascularization in Atrial Fibrillation and Multivessel Coronary Disease

Objectives

Although endorsed by international guidelines, complete revascularization (CR) with Coronary Artery Bypass Grafting (CABG) remains underused. In higher-risk patients such as those with pre-operative atrial fibrillation (AF), the effects of CR are not well studied.

Methods

We analyzed patients' data from the HEIST (HEart surgery In AF and Supraventricular Tachycardia) registry. Between 2012 and 2020 we identified 4770 patients with pre-operative AF and multivessel coronary artery disease who underwent isolated CABG. We divided the cohort according to the completeness of the revascularization and used propensity score matching (PSM) to minimize differences between baseline characteristics. The primary endpoint was all-cause mortality.

Results

Median follow-up was 4.7 years [interquartile range (IQR) 2.3-6.9]. PSM resulted in 1,009 pairs of complete and incomplete revascularization. Number of distal anastomoses varied, accounting for 3.0 + -0.6 vs. 1.7 + -0.6, respectively. Although early (< 24 h) and 30-day post-operative mortalities were not statistically different between non-CR and CR patients [Odds Ratio (OR) and 95% Confidence Intervals (CIs): 1.34 (0.46-3.86); P = 0.593, Hazard Ratio (HR) and 95% CIs: 0.88 (0.59-1.32); P = 0.542, respectively] the long term mortality was nearly 20% lower in the CR cohort [HR (95% CIs) 0.83 (0.71-0.96); P = 0.011]. This benefit was sustained throughout subgroup analyses, yet most accentuated in low-risk patients (younger i.e., < 70 year old, with a EuroSCORE II < 2%, non-diabetic) and when off-pump CABG was performed.

Conclusion

Complete revascularization in patients with pre-operative AF is safe and associated with improved survival. Particular survival benefit with CR was observed in low-risk patients undergoing off-pump CABG.

Non-invasive Ischaemia Testing in Patients With Prior Coronary Artery Bypass Graft Surgery: Technical Challenges, Limitations, and Future Directions

Coronary artery bypass graft (CABG) surgery effectively relieves symptoms and improves outcomes. However, patients undergoing CABG surgery typically have advanced coronary atherosclerotic disease and remain at high risk for symptom recurrence and adverse events. Functional non-invasive testing for ischaemia is commonly used as a gatekeeper for invasive coronary and graft angiography, and for guiding subsequent revascularisation decisions. However, performing and interpreting non-invasive ischaemia testing in patients post CABG is challenging, irrespective of the imaging modality used. Multiple factors including advanced multi-vessel native vessel disease, variability in coronary hemodynamics post-surgery, differences in graft lengths and vasomotor properties, and complex myocardial scar morphology are only some of the pathophysiological mechanisms that complicate ischaemia evaluation in this patient population. Systematic assessment of the impact of these challenges in relation to each imaging modality may help optimize diagnostic test selection by incorporating clinical information and individual patient characteristics. At the same time, recent technological advances in cardiac imaging including improvements in image quality, wider availability of quantitative techniques for measuring myocardial blood flow and the introduction of artificial intelligence-based approaches for image analysis offer the opportunity to re-evaluate the value of ischaemia testing, providing new insights into the pathophysiological processes that determine outcomes in this patient population.

Off-pump coronary artery bypass grafting is safe and effective in patients with severe left ventricular dysfunction

OBJECTIVES

Severe left ventricular dysfunction (LVD) is associated with increased risk following coronary artery bypass grafting (CABG). Due to a dearth of reports on the choice of CABG technique in patients with LVD, this study aims to compare the outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) in such patients.

METHODS

Retrospective single-centre propensity-matched analysis comparing early- and long-term outcomes of OPCAB and ONCAB in patients with severe LVD. Primary outcome was long-term all-cause mortality.

RESULTS

Between 2002 and 2014, a total of 1161 consecutive patients with severe LVD underwent isolated CABG [442 patients underwent OPCAB and 719 ONCAB (430 matched pairs)]. Incomplete revascularization was observed more frequently among OPCAB than ONCAB patients (35.3% vs 21.6%; P < 0.01). The overall 30-day mortality was 5% and was comparable between the matched groups [OR 0.64 (0.34-1.22); P = 0.18]. OPCAB patients had shorter median hospital stay (11 vs 12 days; P = 0.02) and lower packed red blood cell transfusion rates [2.7 (2.21-3.19) vs 4.4 (3.56-5.24); P < 0.01]. Estimated adjusted survival was 86.0% vs 85.8%, 69.1% vs 65.5% and 59.9% vs 49.1% at 1, 5 and 10 years for OPCAB and ONCAB patients, respectively (P = 0.99). Long-term risk of mortality was similar between groups [hazard ratio (HR) 0.94 (0.66-1.32); P = 0.7]. Incomplete revascularization was weakly associated with increased risk of long-term all-cause mortality [HR 1.33 (0.99-1.77); P = 0.05].

CONCLUSIONS

OPCAB is safe and effective in patients with severe LVD. Although incomplete revascularization is more commonly observed in patients undergoing OPCAB, it is not associated with increased late mortality.

Multiarterial coronary grafting using the radial artery as a second arterial graft: how far does the survival benefit extend?

OBJECTIVES

Despite the 10-year results of the Arterial Revascularization Trial, the controversy regarding the survival benefit of multiarterial grafting (MAG) remains. Our goal was to present our long-term survival data in this propensity-matched observational study.

METHODS

A primary unmatched population of 4303 patients with first-time isolated coronary artery bypass grafts operated on between 2000 and 2018 were included. A total of 1187 post-matched patients were compared with matched controls. Multivariate logistic regression and Cox proportional hazard analyses were undertaken to assess the contribution of MAG and other covariates to the long-term survival of unmatched and propensity-matched populations.

RESULTS

MAG was associated with increased median survival in both the unmatched and the matched groups; difference: 962 and 1459 days, log-rank tests; P = 0.029 and 0.0004, respectively. MAG was associated with a reduced hazard of death in the unmatched as well as in the matched groups: hazard ratio [95% confidence interval (CI)]: 0.72 (0.62-0.83); P < 0.0001 and 0.75 (0.64-0.88); P ≤ 0.0001, respectively. In the matched group, the prosurvival factors were low logistic EuroSCORE, obesity, no intra-aortic balloon pump, an ejection fraction >30%, age 50-69 years, operation by an experienced surgeon, with and without diabetes, on-pump surgery and 3 distal anastomoses. In a cohort of 242 late-presenting patients with reinfarction or recurrent angina, both MAG and control populations were associated with reduced median survival; median (95% CI): MAG: 3026 (1138-3503); control: 3035 (2134-3991), log-rank P = 0.217 with superior patency of the left internal mammary artery but no difference between radial artery and saphenous vein grafts.

CONCLUSIONS

Multiarterial revascularization, especially using the radial artery as a second arterial conduit, is associated with a significant survival benefit and a lack of in-hospital morbidity.

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.

Ten-Year All-Cause Death According to Completeness of Revascularization in Patients With Three-Vessel Disease or Left Main Coronary Artery Disease: Insights From the SYNTAX Extended Survival Study

BACKGROUND

Ten-year all-cause death according to incomplete (IR) versus complete revascularization (CR) has not been fully investigated in patients with 3-vessel disease and left main coronary artery disease undergoing percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG).

METHODS

The SYNTAX Extended Survival study (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]) evaluated vital status up to 10 years in patients who were originally enrolled in the SYNTAX trial. In the present substudy, outcomes of the CABG CR group were compared with the CABG IR, PCI CR, and PCI IR groups. In addition, in the PCI cohort, the residual SYNTAX score (rSS) was used to quantify the extent of IR and to assess its association with fatal late outcome. The rSS of 0 suggests CR, whereas a rSS>0 identifies the degree of IR.

RESULTS

IR was more frequently observed in patients with PCI versus CABG (56.6% versus 36.8%) and more common in those with 3-vessel disease than left main coronary artery disease in both the PCI arm (58.5% versus 53.8%) and the CABG arm (42.8% versus 27.5%). Patients undergoing PCI with CR had no significant difference in 10-year all-cause death compared with those undergoing CABG (22.2% for PCI with CR versus 24.3% for CABG with IR versus 23.8% for CABG with CR). In contrast, those with PCI and IR had a significantly higher risk of all-cause death at 10 years compared with CABG and CR (33.5% versus 23.7%; adjusted hazard ratio, 1.48 [95% CI, 1.15-1.91]). When patients with PCI were stratified according to the rSS, those with a rSS≤8 had no significant difference in all-cause death at 10 years as the other terciles (22.2% for rSS=0 versus 23.9% for rSS>0-4 versus 28.9% for rSS>4-8), whereas a rSS>8 had a significantly higher risk of 10-year all-cause death than those undergoing PCI with CR (50.1% versus 22.2%; adjusted hazard ratio, 3.40 [95% CI, 2.13-5.43]).

CONCLUSIONS

IR is common after PCI, and the degree of incompleteness was associated with 10-year mortality. If it is unlikely that complete (or nearly complete; rSS<8) revascularization can be achieved with PCI in patients with 3-vessel disease, CABG should be considered. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00114972. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03417050.

Complete versus incomplete coronary revascularization: definitions, assessment and outcomes

Coronary artery disease is the leading cause of morbidity and mortality worldwide. Selected patients with obstructive coronary artery disease benefit from revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Many (but not all) studies have demonstrated increased survival and greater freedom from adverse cardiovascular events after complete revascularization (CR) than after incomplete revascularization (ICR) in patients with multivessel disease. However, achieving CR after PCI or CABG surgery might not be feasible owing to patient comorbidities, anatomical factors, and technical or procedural considerations. These factors also mean that comparisons between CR and ICR are subject to multiple confounders and are difficult to understand or apply to real-world clinical practice. In this Review, we summarize and critically appraise the evidence linking various types of ICR to adverse outcomes in patients with multivessel disease and stable ischaemic heart disease, non-ST-segment elevation acute coronary syndrome or ST-segment elevation myocardial infarction, with or without cardiogenic shock. In addition, we provide practical recommendations for revascularization in patients with high-risk multivessel disease to optimize their long-term clinical outcomes and identify areas requiring future clinical investigation.

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.

Impact of Complete Revascularization on Long-Term Outcomes After Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction

BACKGROUND

The long-term outcomes of complete revascularization (CR) in patients with left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) remain unclear.

METHODS AND RESULTS

We evaluated a consecutive series of 111 patients with LV ejection fraction ≤35% who underwent isolated first-time CABG: 63 underwent CR and 48 underwent incomplete revascularization (IR). At a median follow-up of 10.1 years, the rates of death from any cause, cardiac death, and major adverse cardiac and cerebrovascular events (MACCE) were significantly greater in the IR group. After adjusting for propensity score, no significant difference was found between the CR and IR groups regarding death from any cause (hazard ratio [HR], 1.45; 95% CI: 0.75-2.81; P=0.271) and cardiac death (HR, 1.45; 95% CI: 0.68-3.10; P=0.337). In contrast, IR increased the risk of MACCE (HR, 1.92; 95% CI: 1.08-3.41; P=0.027), which was principally attributed to an increased risk of repeat revascularization (HR, 3.92; 95% CI: 1.34-11.44; P=0.013).

CONCLUSIONS

Although IR was not significantly associated with an increased risk of long-term mortality in patients with LV dysfunction who underwent CABG, CR might reduce the risks of repeat revascularization and subsequent MACCE.

The effect of completeness of revascularization during CABG with single versus multiple arterial grafts

INTRODUCTION

Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG).

METHODS

We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression.

RESULTS

Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]).

CONCLUSIONS

Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.

Incomplete revascularization: what the surgeon needs to know

For many years, the concept of "complete revascularization" (CR) was considered an absolute truth in coronary surgery with improved long-term survival and a lower rate of reintervention. This was derived from early publications which showed a survival benefit for patients undergoing coronary artery bypass grafting (CABG) who received CR. Many advances in the field of coronary revascularization have been made in the years that passed since those publications, including more frequent use of percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). This has led some to question the importance of CR and raise the option of "reasonable incomplete revascularization" (IR) for selected patients. The definition of CR is variable in the literature with the two most common definitions being an anatomical (revascularization of all coronary segments with stenosis and larger than a predefined size) and a functional definition (where revascularization is considered complete if all ischemic and viable territories are reperfused). No randomized control trials have been conducted to compare complete versus IR, and a significant proportion of data is based on post hoc analysis of data from randomized control trials and registries. Multiple studies have proven that CR is achieved more frequently with CABG then with PCI. A review of the available data from the past three to four decades shows a trend toward improved results with CR, regardless of the reperfusion strategy chosen. This should impact the heart team discussion when choosing a revascularization strategy and impact the surgical decision making while preforming CABG. IR can be part of a hybrid revascularization strategy or be reserved for rare cases where the cost of achieving CR much outweighs the benefit.

Validation of the Coronary Artery Bypass Graft SYNTAX Score (Synergy Between Percutaneous Coronary Intervention With Taxus) as a Prognostic Marker for Patients With Previous Coronary Artery Bypass Graft Surgery After Percutaneous Coronary Intervention

BACKGROUND

The efficacy and prognosis of percutaneous coronary intervention (PCI) as secondary revascularization in patients with previous coronary artery bypass graft surgery remain uncertain.

METHODS AND RESULTS

We retrospectively evaluated 434 consecutive patients with previous coronary artery bypass graft surgery hospitalized for PCI between 2004 and 2011 (men 84%, age 71 (interquartile range, 66-76) years) and calculated the coronary artery bypass graft Synergy Between Percutaneous Coronary Intervention With Taxus score (CSS) before (baseline CSS) and after PCI (post-PCI CSS). Patients were divided into 2 groups based on median post-PCI CSS: low-score (≤23; n=217) and high-score groups (>23; n=217). Major adverse cardiovascular events (MACE) were defined as the composite of cardiovascular death, myocardial infarction, and unplanned repeat revascularization for myocardial ischemia. The median baseline and post-PCI CSS were 30 (interquartile range, 21-40) and 23 (interquartile range, 14.5-33.5), respectively. During a median follow-up of 69 months, the prevalence of MACE and cardiac death differed significantly between the 2 post-PCI CSS groups (MACE: low, 13.8%; high, 28.6%; P<0.001; cardiac death: low, 6.2%; high, 16.7%; P=0.002). In multivariable analysis, the high post-PCI CSS divided by the median was associated with substantially greater cumulative MACE (hazard ratio, 2.09; 95% confidence interval, 1.31-3.34; P=0.002) and cardiac death (hazard ratio, 2.02; 95% confidence interval, 1.03-3.98; P=0.042) compared with the low post-PCI CSS. Net reclassification improvement analysis revealed that post-PCI CSS resulted in significantly improved prediction of MACE and cardiac death compared with baseline CSS.

CONCLUSIONS

In this external validation study, the CSS was a potential prognostic factor after subsequent PCI, even for previous coronary artery bypass graft surgery patients.

The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem

Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.

Revascularization in ischemic heart failure with reduced left ventricular ejection fraction. The impact of complete revascularization

Heart failure is a growing problem worldwide, with coronary artery disease being the underlying cause of over two-thirds of cases. Revascularization in this group of patients may potentially inhibit the progressive damage to the myocardium and lead to improved outcomes, but data in this area are scarce. This article emphasizes the role of qualification for revascularization and selection of method (percutaneous coronary intervention vs. coronary artery bypass grafting) and subsequently focuses on the issue of completeness of revascularization in this group of patients.

Is it time to change how we think about incomplete coronary revascularization?

The optimal degree of revascularization for patients with chronic multivessel coronary artery disease remains an unsolved issue. Intuitively, complete revascularization decreases cardiovascular events and improves outcomes compared to incomplete procedures, but in recent years the concept of incomplete revascularization moved from a sub-optimal or a defective treatment towards the most appropriate revascularization technique in some categories of patients. A reasonable level of incomplete anatomic revascularization has been shown to be safe and achievable with both percutaneous (PCI) and surgical procedures (CABG), despite with different long-term outcomes. What are the mechanisms underlying the clinical benefits of an incomplete revascularization and what are the factors explaining the discrepancy in the long-term clinical outcomes between the two modes of revascularization PCI and CABG? The biological consequences of coronary reperfusion might provide valuable hints in this context and at the same time cast new light on the way we think about incomplete revascularization.

Completeness of revascularization and its impact on the outcomes of a staged approach of percutaneous coronary intervention followed by minimally invasive valve surgery for patients with concomitant coronary artery and valvular heart disease

BACKGROUND

A staged approach of percutaneous coronary intervention (PCI) followed by minimally invasive valve surgery (MIVS) is an alternative to the conventional combined coronary artery bypass and valve surgery for patients with concomitant coronary artery and valve disease. Limited data exist on degree of the completeness of revascularization achieved with this approach and its impact on outcomes.

METHODS

A total of 138 patients, who underwent a staged approach between January 2009 and June 2013, were retrospectively evaluated. Coronary angiograms were reviewed by two cardiologists blinded to outcomes and were then categorized into two groups: complete or incomplete revascularization, which was defined as ≥1 major epicardial coronary arteries of at least 2.0 mm diameter with ≥70% untreated obstruction after the index PCI and before MIVS.

RESULTS

Complete and incomplete revascularization was achieved in 105 (76%) and 33 (24%) patients, respectively. The patients with incomplete revascularization had a lower ejection fraction, a higher STS score, and more prior myocardial infarctions and multi-vessel coronary artery disease. There were no differences in the post-operative complications, 30-day mortality, or 3-year survival (84 vs. 83%, P = 0.68). After a median follow-up of 29 months, incompletely revascularized patients had a higher incidence of acute coronary syndrome (2.9 vs. 12.9%, P = 0.05).

CONCLUSIONS

In patients undergoing a staged approach of PCI followed by MIVS, incomplete revascularization did not significantly impact the short or mid-term survival, but was associated with an increased incidence of acute coronary syndrome at follow-up. © 2015 Wiley Periodicals, Inc.

Early and Midterm Outcome of Redo Coronary Artery Bypass Grafting: On-Pump versus Off-Pump Bypass

BACKGROUND

Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality as compared to the first-time operation. Further, the application of the off-pump technique to redo CABG is limited due to technical difficulties. The aim of this retrospective study was to analyze early and midterm results after redo CABG and compare the outcome of redo on-pump and off-pump CABG.

METHODS

From June 1996 to October 2011, elective redo CABG was performed in 32 patients. Mean age was 64.8 years (on pump 64.3 years vs. off pump 65.5 years; p=0.658), and 21 patients were male. Among these patients, 14 (43.8%) underwent on-pump CABG, and 18 (56.2%) underwent off-pump CABG.

RESULTS

Internal thoracic artery was used in 22 patients (68.8%), and total arterial revascularization was achieved in 17 patients (53.1%). The average number of distal anastomoses was 2.13, and the rate of incomplete revascularization was 43.8%. The rate of total arterial revascularization was higher in the off-pump group (14.3% vs. 83.3%, p<0.001), and the use of saphenous vein graft was more in the on-pump group (78.6% vs. 16.7%, p<0.001). Overall hospital mortality was 3.1% (n=1) and was comparable in both groups (on pump 7.1% vs. off pump 0%; p=0.249). Postoperative complications occurred in 9 patients (64.2%), and the rate of complications was high in the on-pump group without statistical significance (64.2% vs. 33.3%, p=0.082). The mean follow-up duration was 5.4 years, and overall survival at 10 years was 86.0%±10.5%. There was no significant difference in the 10-year survival rate between the two groups (79.6% vs. 100%, p=0.225).

CONCLUSION

Redo CABG can be safely performed with acceptable mortality. Redo off-pump coronary artery bypass is feasible with low mortality and morbidity, comparable target vessel bypass grafting, and long-term survival. The off-pump technique might be considered a safe option for redo CABG in high-risk patients.

Posttreatment platelet reactivity on clopidogrel is associated with the risk of adverse events after off-pump coronary artery bypass

BACKGROUND

Dual antiplatelet therapy with aspirin and clopidogrel is currently recommended in off-pump coronary artery bypass (OPCAB). However, no data exist concerning platelet reactivity on clopidogrel after OPCAB. The aim of this study was to assess the relationship between platelet reactivity and late major adverse cardiovascular events (MACEs) after OPCAB.

METHODS

In this prospective, single-center, observational study, on-clopidogrel platelet reactivity was measured using a point-of-care assay (VerifyNow system; Accumetrics Inc, San Diego, CA) in 859 patients who underwent OPCAB with 1 or more vein grafts. The primary end point was late MACEs (30 days-1 year) including cardiac death, nonfatal myocardial infarction, and target vessel revascularization. Receiver operating characteristic curve analysis was used to estimate the cutoff value of P2Y12 reaction units (PRUs) for MACEs.

RESULTS

The optimal cutoff value for posttreatment reactivity for the incidence of late MACEs was ≥188 PRU (area under the curve 0.72, 95% CI 0.68-0.75, P = .002). The incidence of late MACEs was significantly higher in the high platelet reactivity (HPR; ≥188 PRU) group than in the low platelet reactivity (<188 PRU) group (3.6% vs. 1.4%, P = .040). Kaplan-Meier analysis revealed 1-year MACE-free survival rates of 98.4% ± 0.5% and 95.9% ± 1.3% in the low platelet reactivity and HPR groups, respectively (P = .034). According to a Cox regression hazard model, HPR was an independent risk factor for late MACE-free survival (hazard ratio 3.51, 95% CI 1.27-9.69, P = .015).

CONCLUSION

High residual platelet reactivity after clopidogrel administration is strongly associated with 1-year MACE-free survival. Routine measurement of platelet reactivity and thorough monitoring of patients with HPR after OPCAB are warranted.

Fractional flow reserve-guided coronary bypass surgery: should surgeons use it?

PURPOSE OF REVIEW

Physiology-based evaluation in stable ischemic heart disease is transforming percutaneous cardiovascular intervention (PCI). Fractional flow reserve (FFR)-guided PCI is associated with more appropriate and beneficial outcomes at lower costs. The surgical community can no longer ignore this development. We review evidence for the rationale, practicality and appropriateness of FFR-guided coronary artery bypass grafting (CABG), as compared with the current conventional, anatomy-based strategy for surgical revascularization.

RECENT FINDINGS

Physiologic evaluation links the nature (anatomic or functional) of coronary stenoses to the perfused myocardium supplied by the target vessel and challenges the use of anatomy as the sole criterion for revascularization intervention. In CABG, a functional perfusion deficit/ischemia identifies myocardial territories that would physiologically benefit from revascularization by grafting beyond the functional stenosis. Conversely, deliberately not grafting beyond an anatomic stenosis would dramatically change the procedure of CABG. Recent studies of functionally guided revascularization (PCI or CABG) support this approach, while recent trials of PCI vs. CABG demonstrated a late survival advantage with anatomy-based CABG. Finally, new intraoperative imaging technologies are elucidating the physiologic consequences of surgical revascularization in real time, yielding insights into resolving this dilemma.

SUMMARY

Physiologic-based revascularization is challenging our thinking about the historic strategy for CABG. Understanding better the physiologic consequences of revascularization will drive the evolution of CABG in the future.

FREEDOM, SYNTAX, FAME and FUNCTIONALITY: the future of surgical revascularization in stable ischemic heart disease

ABSTRACT: At the age of nearly 50 years, the procedure of coronary artery bypass grafting (CABG) now has the most solid evidence supporting its role in revascularization for stable ischemic heart disease in its history. In what is a relatively infrequent occurrence in medicine, the results from large-scale observational database analyses are now aligned with and supported by data from recent randomized trials, providing important contemporary evidence in support of CABG. However, even with strong evidence, the changing landscape of revascularization for stable ischemic heart disease threatens to make this evidence irrelevant in deciding which patients should be referred for CABG in the future. How the procedure of CABG could be modified and optimized for incorporation into this new landscape is discussed in this article.

Conduits for coronary bypass: strategies

Strategic planning is integral to any operation but complexity varies immensely and therefore the effort necessary to create the optimal plan. The previous three reports have discussed individual conduits and herein is an attempt to present approaches to common situations which the author favors. Although much has been learned over 45 years about use and subsequent behavior of venous and arterial grafts we continue to learn and, as a result, evolve new strategies or modify those now popular. Thus the reader must recognize that in spite of trying to be balanced and inclusive all surgeons have personal opinions and also prejudices which influence the approach taken and which may not be the optimal one for others or for the patient.

Arterial grafts balance survival between incomplete and complete revascularization: a series of 1000 consecutive coronary artery bypass graft patients with 98% arterial grafts

OBJECTIVE

Coronary artery bypass grafting (CABG) with incomplete revascularization (ICR) is thought to decrease survival. We studied the survival of patients with ICR undergoing total arterial grafting.

METHODS

In a consecutive series of all-comer 1000 patients with isolated CABG, operative and midterm survival were assessed for patients undergoing complete versus ICR, with odds ratios and hazard ratios, adjusted for European System for Cardiac Operative Risk Evaluation category, CABG urgency, age, and comorbidities.

RESULTS

In this series of 1000 patients with 98% arterial grafts (2922 arterial, 59 vein grafts), 73% of patients with multivessel disease received bilateral internal mammary artery grafts. ICR occurred in 140 patients (14%). Operative mortality was 3.8% overall, 8.6% for patients with ICR, and 3.2% for patients with complete revascularization (P = .008). For operative mortality using multivariable logistic regression, after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and CABG urgency (P = .03), there was no evidence of a statistically significant increased risk of death due to ICR (odds ratio, 1.73; 95% confidence interval, 0.80-3.77). For midterm follow-up (median, 54 months [interquartile range, 27-85 months]), after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and comorbidities (P = .017) there was a significant interaction between age ≥ 80 years and ICR (P = .017) in predicting mortality. The adjusted hazard ratio associated with ICR for patients older than age 80 years was 5.7 (95% confidence interval, 1.8-18.0) versus 1.2 (95% confidence interval, 0.7-2.1) for younger patients.

CONCLUSIONS

This is the first study to suggest that ICR in patients with mostly arterial grafts is not associated with decreased survival perioperatively and at midterm in patients younger than age 80 years. Arterial grafting, because of longevity, may balance survival between complete revascularization and ICR.

Detection of gender differences in incomplete revascularization after coronary artery bypass surgery varies with classification technique

Background. Incomplete revascularization negatively affects survival after coronary artery bypass surgery (CABG). Since gender and classification technique might impact outcome and reporting, we investigated their effect on revascularization patterns and mortality. Methods. A cohort of bypass patients (N = 1545, 23% women) was enrolled prospectively. The degree of revascularization was determined as mathematical difference between affected vessels upon diagnosis and number of grafts or the surgeon's rating on the case file. Results. Although men displayed more triple-vessel disease, they obtained complete revascularization more frequently than women (85% versus 77%, P < 0.001). The two calculation methods identified analogous percentages of incompletely revascularized patients, yet there was only a 50% overlap between the two groups. Mathematically, more women, older patients, and patients with NYHA class III/IV appeared incompletely revascularized, while the surgeons identified more patients undergoing technically challenging procedures. Regardless of the definition, incompleteness was a significant risk factor for mortality in both genders (mathematical calculation: HR 2.62, 95% CI 1.76–3.89, P < 0.001; surgeon: HR 2.04, 95% CI 1.35–3.89, P = 0.001). Conclusions. Given the differences in identification patterns, we advise that the mathematical calculation be performed after-procedure in all patients regardless of the surgeons' rating to uncover additional subjects at increased risk.

Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies

OBJECTIVES

This study sought to perform a systematic review and meta-analysis of studies comparing complete revascularization (CR) versus incomplete revascularization (IR) in patients with multivessel coronary artery disease.

BACKGROUND

There are conflicting data regarding the benefits of CR in patients with multivessel coronary artery disease.

METHODS

We identified observational studies and subgroup analysis of randomized clinical trials (RCT) published in PubMed from 1970 through September 2012 using the following keywords: "percutaneous coronary intervention" (PCI); "coronary artery bypass graft" (CABG); "complete revascularization"; and "incomplete revascularization." Main outcome measures were total mortality, myocardial infarction, and repeat revascularization procedures.

RESULTS

We identified 35 studies including 89,883 patients, of whom 45,417 (50.5%) received CR and 44,466 (49.5%) received IR. IR was more common after PCI than after CABG (56% vs. 25%; p < 0.001). Relative to IR, CR was associated with lower long-term mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.65 to 0.77; p < 0.001), myocardial infarction (RR: 0.78, 95% CI: 0.68 to 0.90; p = 0.001), and repeat coronary revascularization (RR: 0.74, 95% CI: 0.65 to 0.83; p < 0.001). The mortality benefit associated with CR was consistent across studies irrespective of revascularization modality (CABG: RR: 0.70, 95% CI: 0.61 to 0.80; p < 0.001; and PCI: RR: 0.72, 95% CI: 0.64 to 0.81; p < 0.001) and definition of CR (anatomic definition: RR: 0.73, 95% CI: 0.67 to 0.79; p < 0.001; and nonanatomic definition: RR: 0.57, 95% CI: 0.36 to 0.89; p = 0.014).

CONCLUSIONS

CR is achieved more commonly with CABG than with PCI. Among patients with multivessel coronary artery disease, CR may be the optimal revascularization strategy.

Impact of the Presence and Extent of Incomplete Angiographic Revascularization After Percutaneous Coronary Intervention in Acute Coronary Syndromes

Background—

The clinical significance of incomplete coronary revascularization (ICR) after percutaneous coronary intervention in patients with acute coronary syndromes is unknown.

Methods and Results—

We performed quantitative angiography of the entire coronary tree in 2954 patients with acute coronary syndromes in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. ICR was variably defined if any lesion with diameter stenosis (DS) cutoffs ranging from ≥30% to ≥70% with reference vessel diameter ≥2.0 mm remained after percutaneous coronary intervention. The primary outcome was 1-year composite rate of major adverse cardiac events (death, myocardial infarction, or ischemia-driven unplanned revascularization). With the use of DS cutoffs ≥30%, ≥40%, ≥50%, ≥60%, and ≥70%, the prevalence of ICR after percutaneous coronary intervention was 75%, 55%, 37%, 25%, and 17%, respectively. The 1-year major adverse cardiac event rate was increased among patients with ICR using all of the DS cutoffs. ICR (≥50% DS) was associated with higher 1-year rates of myocardial infarction (12.0% versus 8.2%; hazard ratio, 1.50; 95% confidence interval, 1.18–1.89; P =0.0007) and ischemia-driven unplanned revascularization (15.7% versus 10.2%; hazard ratio, 1.58; 95% confidence interval, 1.28–1.96; P <0.0001), with a trend toward increased mortality (3.1% versus 2.2%; hazard ratio, 1.43; 95% confidence interval, 0.90–2.27; P =0.13). By multivariable analysis, ICR (≥50% DS) was an independent predictor of 1-year major adverse cardiac events (hazard ratio, 1.36; 95% confidence interval, 1.12–1.64; P =0.002). The impact of ICR on major adverse cardiac events was similar regardless of chronic total occlusion presence, but it was more pronounced with a greater number of nonrevascularized lesions.

Conclusions—

Depending on the threshold of percent DS, ICR was present in 17% to 75% of patients with acute coronary syndromes after percutaneous coronary intervention. Regardless of the threshold, ICR was strongly associated with 1-year myocardial infarction, ischemia-driven unplanned revascularization, and major adverse cardiac events.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00093158.