Worldwide Trends in Multi-arterial Coronary Artery Bypass Grafting Surgery 2004-2014: A Tale of 2 Continents

Superior Outcomes of Dual-Arterial Coronary Artery Bypass Grafting Are Maintained in the Veterans Health Administration

INTRODUCTION

Controversy surrounds the long-term clinical benefit of coronary artery bypass grafting (CABG) using dual arterial grafts (DAGs) compared to single arterial grafts (SAGs). We investigated outcomes of DAG, using single internal thoracic artery and radial artery (DAG-RA) or bilateral internal thoracic artery grafts (DAG-BITA), compared to SAG, using the left internal thoracic artery and saphenous vein grafts, in the U.S. Veterans Health Administration (VA).

METHODS

We conducted a cross-sectional study of U.S. Veterans undergoing isolated on-pump CABG between 2005 and 2015 at 44 VA medical centers. The primary composite outcome was first occurrence of a major adverse cardiac and cerebrovascular event (MACCE), comprised of death from any cause, myocardial infarction, stroke, or repeat revascularization.

RESULTS

Among 25,969 Veterans undergoing isolated CABG, 1261 (4.9%) underwent DAG (66.8% DAG-RA and 33.2% DAG-BITA). Over a 5-y follow-up, DAG was associated with lower rates of all-cause death (adjusted hazard ratio [AHR] 0.70, 95% confidence interval [CI] 0.58-0.85), MACCE (AHR 0.80, 95% CI 0.71-0.91), and stroke (AHR 0.74, 95% CI 0.57-0.96) versus SAG. DAG-BITA was associated with lower rates of all-cause death (AHR 0.52, 95% CI 0.35-0.77) and MACCE (AHR 0.66, 95% CI 0.51-0.84) than SAG, while DAG-RA was associated with lower rates of all-cause death (AHR 0.79, 95% CI 0.64-0.99).

CONCLUSIONS

In the VA, DAG was associated with improved long-term MACCE outcomes compared to SAG. These results suggest that the practice of DAG in the VA benefits Veterans and should be promoted further.

Early Experiences of Serbian Surgeons Using No-Touch Technique for Vein Conduits in CABG Patients: A Follow-Up Study with Multi-Slice CT Angiography

Background and Objectives: The saphenous vein graft (SVG) remains the most frequently used conduit worldwide, despite its common disadvantage of early graft failure. To solve the problem and reduce the SVG damage, Souza implemented a new technique where a vein is harvested with surrounding fascia and fat tissue (the so-called no-touch technique). Materials and Methods. A prospective study conducted from February 2019 to June 2024 included 23 patients who underwent myocardial revascularization using a no-touch vein, with follow-up control examinations using computed tomographic angiography to detect graft stenosis or occlusion. Results. Of the entire patient group, 17 (73.9%) were male, with a mean age of 67.39 ± 7.71 years. The mean follow-up period was 25 months. There were no major adverse cardiovascular or cerebrovascular events (MACCEs) during hospitalization, although one patient died in the hospital. Another patient died due to malignancy, but no MACCEs occurred during the follow-up period. According to multi-slice CT coronary angiography, the results were impeccable, with an astonishing 100% patency observed in all 20 IMA grafts and 58 no-touch SVGs examined. Conclusions. The excellent patency rate during the early follow-up period confirmed that the no-touch technique is a good option for surgical revascularization.

Outcomes of myocardial revascularization in patients with obesity and multivessel coronary artery disease

BACKGROUND

There is uncertainty regarding the best revascularization approach-whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)-for obese patients suffering from multi-vessel coronary artery disease.

RESULTS

406 patients with low and intermediate SYNTAX scores (SS) underwent PCI with drug-eluting stents (n = 200, 100 with SS ≤ 22, and 100 with SS 23-32) and CABG (n = 206, 100 with SS ≤ 22, and 106 with SS 23-32). Patients were also categorized by body mass index (BMI): normal weight (12%, 48 patients), overweight (41.6%, 169 patients), and obese (46.6%, 189 patients). The follow-up period averaged 9 ± 1.9 years. The endpoints of the study were as follows: major adverse cardiac and cerebrovascular events, a repeat revascularization, diminished left ventricular ejection fraction (LVEF), and high SS (≥ 33) observed over time. When comparing PCI and CABG in overweight individuals, the risk of myocardial infarction (MI) following PCI was greater than after CABG (Hazard Ratio [HR] 2.7, 95% Confidence Interval [CI] 1.1-6.7, p = 0.03). In patients with overweight and Class I obesity, CABG was associated with the risk of coronary atherosclerosis progression (SS ≥ 33) (HR 4.4, 95% CI 1.5-13, p = 0.009 and HR 4.9, 95% CI 1.9-12, p = 0.001, respectively); whereas PCI was connected with the likelihood of repeat revascularization (HR 2.7, 95% CI 1.6-4.55, p < 0.0001 and HR 2, 95% CI 1.3-3.1, p = 0.002, respectively). At the same time, for stented patients, Class III obesity was associated with the risk of repeat revascularization (HR 2.5, 95% CI 1.02-6, p = 0.044).

CONCLUSION

There were no significant weight-related impacts on long-term outcomes among patients who underwent surgery. Whereas in stented patients, Class III obesity was associated with the risk of repeat revascularization. When comparing PCI and CABG, for overweight and Class I obesity patients, CABG was associated with a likelihood of coronary atherosclerosis progression (SS ≥ 33), while PCI was linked to the risk of repeat revascularization. For overweight patients, CABG outperformed PCI in terms of the risk of MI. For other adverse events in patients of different weight categories, PCI and CABG did not reveal any significant benefits.

Risk Score for Long-Term Survival and Major Adverse Cardiovascular and Cerebrovascular Events After Coronary Artery Bypass Grafting Surgery

To develop risk scoring models predicting long-term survival and major adverse cardiovascular and cerebrovascular events (MACCEs), including myocardial infarction and stroke after coronary artery bypass grafting (CABG). All 4,821 consecutive patients who underwent isolated CABG at Lankenau between January 2005 and July 2021 were included. MACCE was defined as all-cause mortality + myocardial infarction + stroke. Variable selection for both outcomes was obtained using a double-selection logit least absolute shrinkage and selection operator with adaptive selection. Model performance was internally evaluated by calibration and accuracy using bootstrap cross-validation. Mortality and MACCEs were compared in patients split into 3 groups based on the predicted risk scores for all-cause mortality and MACCEs. An external validation of our database was performed with 665 patients from the University of Brescia, Italy. Preoperative risk predictors were found to be predictors for all-cause mortality and MACCEs. In addition, being of African-American ethnicity is a significant predictor for MACCEs after isolated CABG. The areas under the curve (AUCs), which measures the discrimination of the models, were 80.4%, 79.1%, 81.3%, and 79.2% for mortality at 1, 2, 3, and 5 years follow-up. The AUCs for MACCEs were 75%, 72.5%, 73.8%, and 72.7% at 1, 2, 3, and 5 years follow-up. For external validation, the AUCs for all-cause mortality and MACCEs at 1, 2, 3, and 5 years were 73.7%, 70.8%, 68.7%, and 72.2% and 72.3%, 68.2%, 65.6%, and 69.6%, respectively. The Advanced (AD) Coronary Risk Score for All-Cause Mortality and MACCE provide good discrimination of long-term mortality and MACCEs after isolated CABG. External validation observed a more AUCs greater than 70%.

Intimal hyperplasia, saphenous vein graft disease, and clinical outcomes: Insights from the CTSN VEST randomized trial

BACKGROUND

Diffuse intimal hyperplasia and graft irregularity adversely affect the long-term patency of saphenous vein grafts (SVGs) and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). The VEST trial evaluated the efficacy of external graft support in limiting the development of intimal hyperplasia (IH) at 1 year postsurgery. In the present secondary analysis, we explored the associations between graft disease and IH and clinical events. We also examined risk factors for early graft occlusion.

METHODS

VEST is a within-patient randomized, multicenter trial that enrolled 224 patients with multivessel coronary disease undergoing CABG surgery, of whom 203 were evaluated by 1 year postsurgery. Intimal hyperplasia, lumen uniformity, graft stenosis, and graft perfusion were measured by intravascular ultrasound and angiography. Major cardiac and cerebrovascular events (MACCE; including death, myocardial infarction, stroke, and revascularization) were recorded over a median follow-up of 3 years.

RESULTS

Worse lumen uniformity, greater stenosis, and worse graft perfusion were associated with higher IH values and an increased incidence of clinical events. Consistent with previous findings, we identified endoscopic vein harvesting, female sex, and transit time flow measurement of pulsatility index and flow as risk factors for SVG occlusion during the first year postsurgery.

CONCLUSIONS

In this secondary analysis of the VEST trial, we observed an association between intimal hyperplasia area and clinical measures of SVG disease at 1 year postsurgery. More severe SVG disease and larger areas of IH were associated with a higher incidence of 3-year MACCE. Ongoing follow-up to 5 years will further elucidate the impact of SVG disease on long-term clinical outcomes of CABG.

Bilateral internal thoracic artery versus single internal thoracic artery plus radial artery: A double meta-analytic approach

OBJECTIVES

We explored the current evidence on the best second conduit in coronary surgery carrying out a double meta-analysis of propensity score matched or adjusted studies comparing bilateral internal thoracic artery (BITA) versus single internal thoracic artery plus radial artery.

METHODS

PubMed, Embase, and Google Scholar were searched for propensity score matched or adjusted studies comparing BITA versus single internal thoracic artery plus radial artery. The end point was long-term mortality. Two statistical approaches were used: the generic inverse variance method and the pooled meta-analysis of Kaplan-Meier-derived individual patient data.

RESULTS

Twelve matched populations comparing 6450 patients with BITA versus 9428 patients with single internal thoracic artery plus radial artery were included in our meta-analysis. The generic inverse variance method showed a statistically significant survival benefit of the BITA group (hazard ratio, 0.84; 95% CI, 0.74-0.95; P = .04). The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the BITA group were 97.0%, 91.3%, 80.0%, and 68.0%, respectively. The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the single internal thoracic artery plus radial artery group were 97.3%, 91.5%, 79.9%, and 63.9%, respectively. The Kaplan-Meier-derived individual patient data meta-analysis applied to very long follow-up time data, showed that BITA provided a survival benefit after 10 years from surgery (hazard ratio, 0.77; 95% CI, 0.63-0.94; P = .01). No differences in terms of survival between the 2 groups were detected when the analysis was focused on the first 10 years of follow-up (hazard ratio, 0.99; 95% CI, 0.91-1.09; P = .93).

CONCLUSIONS

The present meta-analysis suggests that double internal thoracic artery may provide, compared with single internal thoracic artery plus radial artery, a statistically significant survival advantage after 10 years of follow-up, but not before. VIDEO ABSTRACT.

Coronary Artery Bypass Surgery: Comparing the Long-Term Impact of Total Arterial Grafting With Multiarterial Plus Saphenous Vein Grafting

INTRODUCTION

This study aimed to compare the long-term outcomes in a propensity matched population receiving total arterial grafting (TAG) and multiple arterial grafts (MAG) in addition to saphenous vein graft (SVG) following multivessel coronary artery bypass grafting requiring at least three distal anastomoses.

METHODS

In this retrospective study, 655 patients from two centers met the inclusion criteria and were divided into two groups: TAG group (n = 231) and MAG + SVG group (n = 424). Propensity score matching was performed resulting in 231 pairs.

RESULTS

No significant differences were observed between both groups in terms of early outcomes. Survival probabilities at 5, 10, and 15 y were 89.1% versus 94.2%, 76.2% versus 76.1%, and 66.7% versus 69.8% in the TAG and MAG + SVG groups, respectively (hazard ratio stratified on matched pairs: 0.90; 95% confidence interval [0.45-1.77]; P = 0.754). Freedom from major adverse cardiac and cerebral events (MACCE) in the matched cohort did not show any significant difference between both groups. Probabilities at 5, 10, and 15 y were 82.7% versus 85.6%, 62.2% versus 75.3%, and 48.8% versus 59.5% in the TAG and MAG + SVG groups, respectively (hazard ratio stratified on matched pairs: 1.12; 95% confidence interval [0.65-1.92]; P = 0.679). Subgroup analyses of the matched cohort showed no significant difference between TAR with three arterial conduits compared to TAR with two arterial conduits with sequential grafting and MAG + SVG in terms of long-term survival and freedom from MACCE.

CONCLUSIONS

Multiple arterial revascularizations in addition to SVG may yield comparable long-term outcomes in terms of survival and freedom from MACCE compared to total arterial revascularization.

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.

Angiographic Outcomes for Arterial and Venous Conduits Used in CABG

Coronary artery bypass grafting is the most commonly performed cardiac surgical procedure. Conduit selection is crucial to achieving early optimal outcomes, with graft patency being likely the main driver to long-term survival. We present a review of current evidence on the patency of arterial and venous bypass conduits and of differences in angiographic outcomes.

Multiple arterial versus single arterial grafting in patients with diabetes undergoing coronary artery bypass surgery

Background

Data on long-term outcomes in patients with diabetes receiving multiarterial grafting (MAG) versus single-artery grafting (SAG) are limited.

Objectives

The objective of this study is to compare long-term outcomes between MAG and SAG for coronary artery bypass graft (CABG) surgery in patients with diabetes.

Methods

Patients with diabetes who underwent isolated CABG surgeries between 2000 to 2016 were identified using the New Jersey mandatory state clinical registry linked with death records and hospital discharge data (last follow-up December 31, 2019). Patients who underwent CABG for single-vessel disease, with only venous conduits, patients with previous heart surgeries, or hemodynamically unstable were excluded. Patients undergoing MAG and SAG were matched by propensity score. Cox proportional hazard models were used to investigate long-term survival and competing risk analysis was used for secondary outcomes.

Results

Of 24,944 patients, 2955 underwent MAG, and 21,989 underwent SAG CABG. Patients receiving MAG were younger, predominantly men, with a lower prevalence of hypertension, peripheral vascular disease, congestive heart failure, chronic lung disease, and renal failure. MAG was associated with lower long-term mortality compared with SAG in 2882 propensity score-matched pairs (hazard ratio [HR], 0.75; 95% CI, 0.68-0.83); lower risks of repeat revascularization (subdistribution HR, 0.86; 95% CI, 0.76-0.97); and composite outcome defined as death from any cause, stroke, postoperative myocardial infarction, and/or repeat revascularization (HR, 0.76; 95% CI, 0.71-0.82). These results were confirmed in subgroup analyses of women, men, age <70 years, and age ≥70 years patients with diabetes. MAG was also associated with lower mortality compared with SAG in patients with diabetes taking insulin in the entire cohort (Video Abstract).

Conclusions

Patients with diabetes benefit from receiving MAG over SAG and demonstrated improved long-term survival, and lower hazards of secondary and composite outcomes. Coordinated efforts are needed to offer MAG to patients with diabetes.

Vein Graft Use and Long-Term Survival Following Coronary Bypass Grafting

BACKGROUND

Although placement of at least 1 arterial graft during coronary artery bypass grafting (CABG) has a proven survival benefit, it is unknown what degree of revascularization with saphenous vein grafting (SVG) is associated with improved survival.

OBJECTIVES

The authors sought to determine whether undergoing surgery performed by a surgeon who is liberal with vein graft utilization is associated with improved survival in patients undergoing single arterial graft CABG (SAG-CABG).

METHODS

This was a retrospective, observational study of SAG-CABG performed in Medicare beneficiaries from 2001 to 2015. Surgeons were stratified by number of SVG utilized per SAG-CABG into conservative (≥1 SD below mean), average (within 1 SD of mean), and liberal (≥1 SD above mean). Long-term survival was estimated using Kaplan-Meier analysis and compared among surgeon groups before and after augmented inverse-probability weighting.

RESULTS

There were 1,028,264 Medicare beneficiaries undergoing SAG-CABG from 2001 to 2015 (mean age 72.0 ± 7.9 years, 68.3% male). Over time, 1-vein and 2-vein SAG-CABG utilization increased, whereas 3-vein and ≥4-vein SAG-CABG utilization decreased (P < 0.001). Surgeons who were conservative vein graft users performed a mean 1.7 ± 0.2 vein grafts per SAG-CABG, whereas those who were liberal vein graft users performed a mean 2.9 ± 0.2 vein grafts per SAG-CABG. Weighted analysis demonstrated no difference in median survival among patients undergoing SAG-CABG by liberal vs conservative vein graft users (adjusted median survival difference 27 days).

CONCLUSIONS

Among Medicare beneficiaries undergoing SAG-CABG, there is no association between surgeon proclivity for vein graft utilization and long-term survival, suggesting that a conservative approach to vein graft utilization is reasonable.

Influence of Three Different Surgical Techniques on Microscopic Damage of Saphenous Vein Grafts-A Randomized Study

Background and Objectives: The saphenous vein is one of the most common used grafts (SVG) for surgical revascularization. The mechanism of the SVGs occlusion is still unknown. Surgical preparation techniques have an important role in the early and late graft occlusion. Our study analyzed the influence of the three different surgical techniques on the histological and immunohistochemical characteristics of the vein grafts. Methods: Between June 2019 and December 2020, 83 patients who underwent surgical revascularization were prospectively randomly assigned to one of the three groups, according to saphenous vein graft harvesting (conventional (CVH), no-touch (NT) and endoscopic (EVH)) technique. The vein graft samples were sent on the histological (hematoxylin-eosin staining) and immunohistochemical (CD31, Factor VIII, Caveolin and eNOS) examinations. Results: The CVH, NT, and EVH groups included 27 patients (mean age 67.66 ± 5.6), 31 patients (mean age 66.5 ± 7.4) and 25 patients (mean age 66 ± 5.5), respectively. Hematoxylin-eosin staining revealed a lower grade of microstructural vein damage in the NT group (2, IQR 1-2) in comparison with CVH and EVH (3, IQR 2-4), (4, IQR 2-4) respectively (p < 0.001). Immunohistochemical examination revealed a high grade of staining in the NT group compared to the CVH and EVH group (CD 31 antibody p = 0.02, FVIII, p < 0.001, Caveolin, p = 0.001, and eNOS, p = 0.003). Conclusion: The best preservation of the structural vein integrity was in the NT group, while the lowest rate of leg wound complication was in the EVH group. These facts increase the interest in developing and implementing the endoscopic no-touch technique.

Treatment of Complex Two-Vessel Coronary Heart Disease with Single Left Internal Mammary Artery as T-Graft with Itself—A Retrospective Double Center Analysis of Short-Term Outcomes

Background and Objectives: The strategy of revascularization may be constrained in patients with insufficient bypass grafts and with increased risk of wound healing disorders. Among those with complex left-sided double-vessel disease in whom a percutaneous coronary intervention (PCI), as well as the surgical procedure of minimally invasive coronary artery bypass grafting via left minithoracotomy (MICS CABG), is not a treatment option, CABG using the left internal mammary artery as a T-graft with itself may be an effective treatment strategy. Materials and Methods: We reviewed the data from patients treated in Cologne and Tuebingen from 2019 to 2022. We included 40 patients who received left internal mammary artery (LIMA) grafting, and additional T-graft with the LIMA itself. The objective was focused on intraoperative and short-term outcomes. Results: A total of 40 patients were treated with the LIMA-LIMA T-graft procedure with a Fowler score calculated at 20.1 ± 3.0. A total of 37.5% of all patients had lacking venous graft material due to prior vein stripping, and 21 patients presented severe vein varicosis. An overall of 2.6 ± 0.5 distal anastomoses (target vessels were left anterior descending, diagonal, intermediate branch, and/or left marginal ramus) were performed, partly sequentially. Mean flow of LIMA-Left anterior descending (LAD) anastomosis was 59.31 ± 11.04 mL/min with a mean PI of 1.21 ± 0.18. Mean flow of subsequent T-Graft accounted for 51.31 ± 3.81 mL/min with a mean PI of 1.39 ± 0.47. Median hospital stay was 6.2 (5.0; 7.5) days. No incidence of postoperative wound healing disorders was observed, and all patients were discharged. There was one 30-day readmission with a diagnosis of pericardial effusion (2.5%). There was no 30-day mortality within the cohort. Conclusions: Patients requiring surgical myocardial revascularization due to complex two-vessel coronary artery disease (CAD) can be easily managed with LIMA alone, despite an elevated Fowler score and a promising outcome. A prospective study needs to be conducted, as well as longer term surveillance, to substantiate and benchmark the long-term results, as well as the patency rates.

Intraoperative transit time flow measurements during off-pump coronary artery bypass surgery: The impact of coronary stenosis on competitive flow

BACKGROUND

Combining preoperative angiography findings with intraoperative transit time flow measurements (TTFM) may improve patency of coronary artery bypass grafts. Nevertheless, graft flow might be impaired by native coronary flow based on the severity of stenoses, with inferior long-term outcomes. This study investigates the impact of left anterior descending artery (LAD) stenosis on competitive flow measured in left internal mammary artery (LIMA) grafts during off-pump coronary artery bypass grafting.

METHODS

Fifty patients were included in this prospective single-center cohort study. LAD stenosis was assessed with quantitative coronary analysis (QCA) and stratified into three groups based on its severity. TTFM of LIMA grafts were performed with LAD open and temporarily occluded. Change in mean graft flow after LAD snaring was the primary endpoint. Secondary endpoints included further TTFM parameters, clinical outcomes, and competitive flow index (CFI), defined as the ratio of mean graft flow with open or closed LAD.

RESULTS

Mean LAD stenosis as objectified with QCA was 58 ± 15%. Mean LIMA graft flow increased from 20 ml/min with open LAD to 30 ml/min with snared LAD (p < .001). TTFM cut-off values for graft patency improved in 26%-42% of patients after LAD occlusion. Median CFI was 0.66 (IQR: 0.56-0.82). Postoperative myocardial infarction occurred in 2.0% of patients, 120-day mortality was 0%, and 2-year mortality was 6.0%.

CONCLUSIONS

Routine snaring of the LAD with CFI calculation during coronary artery bypass grafting is useful to detect significant competitive flow in LIMA grafts, potentially preventing unnecessary intraoperative graft revisions.

Comparative Analysis Following Implementation of Two Types of Y-Composite Multiarterial Revascularization Strategies at a Single Academic Institution

Background

We compared early outcomes, at a single academic institution, of implementing full coronary revascularization in coronary artery bypass grafting using multiarterial Y‐composite grafts with multiple sequential anastomoses.

Methods and Results

Clinical records of 425 consecutive patients who underwent coronary artery bypass grafting using Y‐grafting with left internal mammary artery and radial artery (Y‐RA group) or right internal mammary artery (Y‐RIMA group) from 2015 to 2019, were reviewed. These were compared with the institutional experience of isolated coronary artery bypass grafting cases (in situ on pump/off pump) for the same period of time. When comparing the 4 groups, the Y‐RIMA/RA groups revealed a higher number of distal anastomosis than the in situ on‐ or off‐pump groups. When the number of distal arterial anastomosis was analyzed, there was a superiority of using the Y‐configuration compared with the in situ approach. Moreover, there were no significant differences among groups for mortality and/or major adverse cardiac and cerebrovascular events in hospital or at 30‐day follow‐up. A subanalysis comparing the Y‐RIMA group with the Y‐RA group showed that complementary grafts to the Y‐construct were required to accomplish full revascularization more frequently in the Y‐RIMA group. Full‐arterial revascularization was achieved in 92.2% of the Y‐RA group and 72.0% of the Y‐RIMA group (P<0.001). In 82.8% of the Y‐RA group and 30.8% of the Y‐RIMA group, revascularization was completed as an anaortic procedure (P<0.001).

Conclusions

The 2 types of arterial Y‐composite grafting were able to be introduced in the routine practice of our institution showing comparable results to the established institutional practice. This procedure allowed for more arterial distal anastomosis to be performed safely without compromising outcomes.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.

External stenting and disease progression in saphenous vein grafts two years after coronary artery bypass grafting: A multicenter randomized trial

OBJECTIVES

Little data exist regarding the potential of external stents to mitigate long-term disease progression in saphenous vein grafts. We investigated the effect of external stents on the progression of saphenous vein graft disease.

METHODS

A total of 184 patients undergoing isolated coronary artery bypass grafting, using an internal thoracic artery graft and at least 2 additional saphenous vein grafts, were enrolled in 14 European centers. One saphenous vein graft was randomized to an external stent, and 1 nonstented saphenous vein graft served as the control. The primary end point was the saphenous vein graft Fitzgibbon patency scale assessed by angiography, and the secondary end point was saphenous vein graft intimal hyperplasia assessed by intravascular ultrasound in a prespecified subgroup at 2 years.

RESULTS

Angiography was completed in 128 patients and intravascular ultrasound in the entire prespecified cohort (n = 51) at 2 years. Overall patency rates were similar between stented and nonstented saphenous vein grafts (78.3% vs 82.2%, P = .43). However, the Fitzgibbon patency scale was significantly improved in stented versus nonstented saphenous vein grafts, with Fitzgibbon patency scale I, II, and III rates of 66.7% versus 54.9%, 27.8% versus 34.3%, and 5.5% versus 10.8%, respectively (odds ratio, 2.02; P = .03). Fitzgibbon patency scale was inversely related to saphenous vein graft minimal lumen diameter, with Fitzgibbon patency scale I, II, and III saphenous vein grafts having an average minimal lumen diameter of 2.62 mm, 1.98 mm, and 1.32 mm, respectively (P < .05). Externally stented saphenous vein grafts also showed significant reductions in mean intimal hyperplasia area (22.5%; P < .001) and thickness (23.5%; P < .001).

CONCLUSIONS

Two years after coronary artery bypass grafting, external stenting improves Fitzgibbon patency scales of saphenous vein grafts and significantly reduces intimal hyperplasia area and thickness. Whether this will eventually lead to improved long-term patency is still unknown.

External stenting of vein grafts in coronary artery bypass grating: interim results from a two centers prospective study

BACKGROUND

previous studies evaluating external stents for saphenous vein grafts (SVG) in CABG were limited to on-pump isolated CABG and single grafting technique with one external stent per patient. The objective of this prospective study was to evaluate the safety and the short-term performance of external stents in a heterogeneous group of patients who underwent on- and off-pump CABG, single and sequential grafting.

METHODS

102 patients undergoing CABG were enrolled in two centers. All patients received internal mammary artery to the left anterior descending artery and additional arterial and/or venous grafts. In each patient, at least one SVG was supported with an external stent. Grafts' patency and SVG lumen uniformity were assessed using CT angiography at a pre-defined time window of 6-12 months post procedure. All patients were prospectively followed-up via phone call and/or visit every 6 months for Major Adverse Cardiac and Cerebrovascular Events.

RESULTS

51 patients (50%) underwent off-pump CABG and 23 patients (23%) were grafted with bilateral internal mammary arteries. Each patient received one or more SVG grafted in a sequential technique (44%) or as a single graft (56%). All SVG were externally stented in 84% of patients and in 16% (n = 16) one SVG was stented and one remained unsupported. At 6-12 months, patency rates of LIMA, RIMA, externally stented SVG and none-stented SVG were 100, 100, 98 and 87.5% respectively. 90% of the externally stented SVG had uniform lumen compared to 37% of the non-stented SVG. Clinical follow-up was completed for all patients with a mean duration of 20 months (range 6-54 months). During follow up period, one patient experienced myocardial infarction due to occlusion of the LIMA-LAD graft and one patient experienced a transient ischemic attack.

CONCLUSIONS

External stenting of SVG is feasible and safe in CABG setting which includes off pump CABG and sequential SVG grafting and associated with acceptable early patency rates.

TRIAL REGISTRATION

Study was registered at ClinicalTrials.gov. NCT01860274 (initial release 20.05.2013).

Percutaneous coronary intervention in saphenous vein grafts after coronary artery bypass grafting: a systematic review and meta-analysis

To investigate the results of percutaneous coronary intervention (PCI) in saphenous vein grafts after coronary artery bypass grafting (CABG). Design. MEDLINE, Embase, and the Cochrane library were searched for relevant articles published between 1 January 2000 and 29 February 2020. The PICO (population, intervention, comparison, outcome) model was applied in constructing the clinical question. Two independent researchers performed the literature search. Thirty-six articles were identified and subjected to a quality assessment. The primary outcomes of the meta-analysis were long-term in-stent restenosis and long-term major adverse cardiac events (MACE). Results. In-stent restenosis was 9.4% (95% CI: 4.2-14.7%) and MACE was 35.3% (95% CI: 27-43.7%) at mean time 2.7 ± 1.0 years. The secondary outcomes were the unsuccessful PCI rate (7.7%; 95% CI: 2.9-12.5%), 30-day MACE (4.3%; 95% CI: 2.5-6.1%), and 1-year MACE (15.5%; 95% CI: 11.7-19.3%). The use of drug-eluting stents resulted in better outcomes at least in term of in-stent restenosis, while the benefit of using embolic protection devices was questionable. Conclusions. PCI of a stenosed or occluded saphenous vein graft is a challenge for interventional cardiologists, and is still associated with relatively high rates of restenosis, MACE, and procedural failure. All efforts to enhance the results are warranted, including improved quality of the venous grafts used during CABG.

Total Arterial Coronary Bypass Graft Surgery is Associated with Better Long-Term Survival in Patients with Multivessel Coronary Artery Disease: a Systematic Review with Meta-Analysis

INTRODUCTION

The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients.

METHODS

The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed.

RESULTS

Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome.

CONCLUSION

This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Use of the left radial artery as vascular access for coronary angiography and as a bypass conduit: A clinical dilemma?

PURPOSE

International coronary revascularization guidelines recommend both, transradial vascular access for coronary angiography/intervention and use of the radial artery as a conduit for coronary artery bypass grafting (CABG). These recommendations may pose a clinical dilemma, as transradial access exposes these arteries to vascular trauma which makes them potentially unsuitable as future grafts. In this study, we investigated the awareness and views of cardiologists on these guideline recommendations.

METHODS

We performed semi-structured interviews with 50 cardiologists from 19 centers, who regularly perform coronary angiographies or interventions, and outlined clinical scenarios to evaluate their preference of vascular access. In addition, we assessed whether preference was related to sub-specialization.

RESULTS

The interviewed cardiologists had 16 ± 9.3 years of professional experience. There were 23 (46%) cardiologists from 7 centers without percutaneous coronary intervention facilities, and 27 (56%) cardiologists from 12 interventional centers. All 50 (100%) cardiologists indicated familiarity with the guidelines, yet 28 (56%) said not to be familiar with the aforementioned dilemma, and 9 (18%) stated there was no dilemma at all. Responses did not differ significantly between interventional (n = 28) and non-interventional (n = 22) cardiologists; however, if the right radial artery was unavailable (e.g., occluded), interventional cardiologists more often said to prefer access via the left radial artery (18/28 (64%) vs. 5/22 (23%), p = 0.001).

CONCLUSION

More than half of the interviewed cardiologists indicated that they had not realized that left transradial access preceding CABG may preclude later use of this artery as a conduit. Notably, in case of unavailability of the right radial artery, interventional cardiologists preferred left transradial access more often than non-interventional cardiologists.

Training for Multiple Arterial Grafting: A Thoracic Surgery Resident Survey

BACKGROUND

Utilization of multiple arterial grafting (MAG) in the United States is less than 10%. Trainee experience with MAG has not previously been examined.

METHODS

A total of 497 thoracic surgery residents in accredited training programs in March 2019 and 115 who completed residency in 2018 were electronically surveyed regarding their experience with MAG using a radial artery (RA) graft or bilateral internal mammary artery (BIMA) grafts with a skeletonized mammary (SM).

RESULTS

Eighty-four (14%) trainees responded: 54% had completed 2+ years of training and 87% declared their focus as cardiac, undecided, or both cardiac and thoracic (CUB). Of all 84 respondents, 76% (n = 64 of 84) had no experience with RA harvest. A total of 35% (n = 29 of 84) had no experience with SM harvest. The majority, 68% (n = 57 of 84), used BIMA grafting in 0% to 5% of cases. A total of 61% (n = 51 of 84) used RA conduit in 0% to 5% of cases. Among trainees with 2+ years of experience, 56% (n = 25 of 45) had performed more than 6 SM takedowns, 18% (n = 8 of 45) had no experience. In trainees with 2+ years, 20% (n = 9 of 45) performed more than 5 RA harvests, while 80% (n = 36 of 45) had no experience. Examining integrated 6-year residents with greater than 3 years of experience, only 33% (n = 5 of 15) performed more than 5% RA grafting. A total of 90% of CUB trainees wanted to perform MAG in practice and 75% felt prepared to do so.

CONCLUSIONS

Despite substantial variation in MAG training, respondents expressed an overwhelming interest in performing MAG. These data and the reality of MAG utilization in the United States indicate that a more rigorous, standardized approach to MAG training may be required.

Long-Term Results of the RAPCO Trials

Background:

An internal thoracic artery graft to the left anterior descending artery is standard in coronary bypass surgery, but controversy exists on the best second conduit. The RAPCO trials (Radial Artery Patency and Clinical Outcomes) were designed to compare the long-term patency of the radial artery (RA) with that of the right internal thoracic artery (RITA) and the saphenous vein (SV).

Methods:

In RAPCO-RITA (the RITA versus RA arm of the RAPCO trial), 394 patients <70 years of age (or <60 years of age if they had diabetes mellitus) were randomized to receive RA or free RITA graft on the second most important coronary target. In RAPCO-SV (the SV versus RA arm of the RAPCO trial), 225 patients ≥70 years of age (or ≥60 years of age if they had diabetes mellitus) were randomized to receive RA or SV graft. The primary outcome was 10-year graft failure. Long-term mortality was a nonpowered coprimary end point. The main analysis was by intention to treat.

Results:

In the RA versus RITA comparison, the estimated 10-year patency was 89% for RA versus 80% for free RITA (hazard ratio for graft failure, 0.45 [95% CI, 0.23–0.88]). Ten-year patient survival estimate was 90.9% in the RA arm versus 83.7% in the RITA arm (hazard ratio for mortality, 0.53 [95% CI, 0.30–0.95]). In the RA versus SV comparison, the estimated 10-year patency was 85% for the RA versus 71% for the SV (hazard ratio for graft failure, 0.40 [95% CI, 0.15–1.00]), and 10-year patient survival estimate was 72.6% for the RA group versus 65.2% for the SV group (hazard ratio for mortality, 0.76 [95% CI, 0.47–1.22]).

Conclusions:

The 10-year patency rate of the RA is significantly higher than that of the free RITA and better than that of the SV.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00475488.

Outcomes following surgical revascularization with single versus bilateral internal thoracic arterial grafts in patients with left main coronary artery disease undergoing coronary artery bypass grafting: insights from the EXCEL trial†

OBJECTIVES

Observational data suggest that the use of a single internal thoracic artery (SITA) may result in inferior outcomes compared with bilateral internal thoracic artery (BITA) use for coronary artery bypass grafting (CABG)-a finding not yet supported by randomized trial outcomes. However, the optimal number of internal thoracic artery grafts in patients with left main coronary artery disease has not been investigated.

METHODS

The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG. Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA. Differences in clinical event rates were estimated using the Kaplan-Meier method and compared with the log-rank test. Multivariable Cox regression was used to adjust for differences in baseline covariates.

RESULTS

Compared to SITA, patients treated with BITA were younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P = 0.020), were less likely female (24.3% vs 14.3%, P = 0.002) and diabetic (28.8% vs 15.2%, P < 0.001), and had a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P = 0.040). The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P = 0.17). The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P = 0.070). Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups. After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71-1.78; P = 0.62] nor mortality (HR 1.36, 95% CI 0.60-3.12; P = 0.46) was significantly higher with SITA. The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P = 0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93-1.74; P = 0.13). Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P > 0.99).

CONCLUSIONS

In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease.

Effect of Skeletonization of Bilateral Internal Thoracic Arteries on Deep Sternal Wound Infections

BACKGROUND

Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

METHODS

Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching.

RESULTS

We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories.

CONCLUSIONS

The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.

Positive family history of cardiovascular disease and long-term outcomes after coronary artery bypass grafting: a genetic paradox?

OBJECTIVES

Parental cardiovascular disease (CVD) is a known risk factor for premature CVD. It is unknown whether a positive family history (PFH) affects outcomes after coronary artery bypass grafting (CABG).

METHODS

Data come from a retrospective longitudinal study of CABG patients consecutively recruited from 2001 to 2018 (n = 5389). From this study, 2535 patients with premature CVD undergoing CABG under the age of 60 years and information on parental CVD were identified. The Framingham offspring study criteria were used to identify PFH of CVD. Multivariable Cox proportional hazards regression models were used to assess the effect of PFH on overall and major adverse cardiovascular and cerebrovascular event-free survival.

RESULTS

A total of 273 deaths and 428 major adverse cardiovascular and cerebrovascular events occurred during follow-up. PFH of CVD was found in 54.2% of patients (n = 1375). Within these patients, 66.1% had a father who experienced a premature cardiovascular event (n = 909), 27.8% a mother (n = 382) and 6.1% both a mother and a father (n = 84). In the majority of cases, the patient's parent had experienced a cardiac event (85.9%, n = 1181) and 14.1% of patients with PFH reported parental stroke (n = 194). Following CABG, PFH was associated with improved overall [adjusted hazards ratio (HR) 0.67, 95% confidence interval (CI) 0.50-0.90; P = 0.008] and major adverse cardiovascular and cerebrovascular event-free survival (adjusted HR 0.73, 95% CI 0.68-0.89; P = 0.01). Among the covariates adjusted for age, diabetes, renal insufficiency, peripheral arterial disease, ejection fraction, previous cerebrovascular events and previous mediastinal radiation were all associated with poorer outcomes.

CONCLUSIONS

Although it is well established that a PFH increases the risk of requiring CABG at younger ages, this study shows that, paradoxically, PFH is also protective regarding long-term outcomes.

REGISTRATION NUMBER LOCAL IRB

UN4232 297/4.3 (retrospective study).

Endoscopic Radial Artery Harvesting During Anesthesia Line Placement Reduces the Time and Cost of Multivessel Coronary Artery Bypass Grafting

Objective

Endoscopic radial artery (RA) harvesting performed concurrently with internal mammary artery (IMA) takedown and endoscopic saphenous vein (SV) harvesting creates a crowded and inefficient operating room environment. We assessed the effect of a presternotomy RA harvest strategy on surgery time and costs.

Methods

A total of 41 patients underwent elective, first-time, isolated multivessel on-pump coronary artery bypass grafting including an IMA, RA, and SV graft. The first 20 patients (Phase I) underwent endoscopic RA harvesting concurrently with IMA takedown and endoscopic SV harvesting after sternotomy, requiring two sets of endoscopic harvesting equipment per case, each used by a separate individual. The final 21 patients (Phase II) underwent endoscopic RA harvesting during anesthesia line placement, completing the procedure before sternotomy, thus requiring only one set of endoscopic harvesting equipment reused by a single individual.

Results

There were no differences in baseline patient characteristics, number of bypasses, duration of SV or RA harvest time, or duration of cardiopulmonary bypass or cross-clamp time between the two groups. Total surgery time was reduced by 32 minutes in Phase II ( P = 0.044). Relative to a total hospital direct cost of 100.00 units, total surgery costs were reduced from 29.33 units in Phase I to 25.62 units in Phase II ( P = 0.001). No anesthesia- or RA harvest-related complications occurred in either group.

Conclusions

Endoscopic RA harvesting can be safely performed during anesthesia line placement prior to sternotomy. Our simple but innovative strategy improves intraoperative workflow, reduces the time and cost of surgery, and advances the delivery of high-quality patient care.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Why Use the Radial Artery? The Saphenous Vein is the Second Graft of Choice for CABG in Brazil

The saphenous vein (SV) is the most commonly used conduit for coronary artery bypass surgery (CABG) and the second conduit of choice in Brazil and many other countries. The radial artery (RA) is suggested, by some, to be superior to SV grafts, although its use in the USA declined over a 10 year period. The patency of SV grafts (SVG) is improved when the vein is harvested with minimal trauma using the no-touch (NT) technique. This improved performance is due to the preservation of the outer pedicle surrounding the SV and reduction in vascular damage that occurs when using conventional techniques (CT) of harvesting. While the patency of NT SVGs has been shown superior to the RA at 36 months in one study, data from the RADIAL trial suggests the RA to be the superior conduit. When additional data using NT SVG is included in this trial the difference in risk of graft occlusion between the RA and SV grafts dissipates with there no longer being a significant difference in patency between conduits. The importance of preserving SV structure and the impact of NT harvesting on conduit choice for CABG patients are discussed in this short review.

Total arterial revascularization strategies: A meta-analysis of propensity score-matched observational studies

BACKGROUND AND AIM OF THE STUDY

We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy.

METHODS

PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding.

RESULTS

Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR with the bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77).

CONCLUSIONS

TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection.

Study of the association of 17 lipid-related gene polymorphisms with coronary heart disease

Objective

Blood lipids are well-known risk factors for coronary heart disease (CHD). The aim of this study was to explore the association between 17 lipid-related gene polymorphisms and CHD.

Methods

The current study examined with 784 CHD cases and 739 non-CHD controls. Genotyping was performed on the MassARRAY iPLEX^® assay platform.

Results

Our analyses revealed a significant association of APOE rs7259620 with CHD (genotype: χ²=6.353, df=2, p=0.042; allele: χ²=5.05, df=1, p=0.025; recessive model: χ²=5.57, df=1, p=0.018). A further gender-based subgroup analysis revealed significant associations of APOE rs7259620 and PPAP2B rs72664392 with CHD in males (genotype: χ²=8.379, df=2, p=0.015; allele: χ²=5.190, df=1, p=0.023; recessive model: χ²=19.3, df=1, p<0.0001) and females (genotype: χ²=9.878, df=2, p=0.007), respectively. Subsequent breakdown analysis by age showed that CETP rs4783961, MLXIPL rs35493868, and PON2 rs12704796 were significantly associated with CHD among individuals younger than 55 years of age (CETP rs4783961: χ²=8.966, df=1, p=0.011 by genotype; MLXIPL rs35493868: χ²=4.87, df=1, p=0.027 by allele; χ²=4.88, df=1, p=0.027 by dominant model; PON2 rs12704796: χ²=6.511, df=2, p=0.039 by genotype; χ²=6.210, df=1, p=0.013 by allele; χ²=5.03, df=1, p=0.025 by dominant model). Significant allelic association was observed between LEPR rs656451 and CHD among individuals older than 65 years of age (χ²=4.410, df=1, p=0.036).

Conclusion

Our study revealed significant associations of APOE, PPAP2B, CETP, MLXIPL, PON2, and LEPR gene polymorphisms with CHD among the Han Chinese.

Coronary Artery Bypass Surgery in Brazil: Analysis of the National Reality Through the BYPASS Registry

INTRODUCTION

Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015.

OBJECTIVE

To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry.

METHODS

A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed.

RESULTS

Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%.

CONCLUSION

CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

The radial artery in coronary surgery, 2018

It is now 25 years since the radial artery (RA) was reintroduced in coronary surgery. It has evolved into being a significant coronary artery bypass conduit and ranks third in usage after the internal thoracic artery (ITA) and saphenous vein grafts (SVG). Its advantages are that it can be readily and efficiently harvested, is of good length and appropriate size for coronary artery bypass graft (CABG) surgery, is robust and easy to handle, and remains free of atheroma, and there is minimal wound morbidity. The RA must be used judiciously with attention to spasm prophylaxis because of its muscular wall, and by avoiding competitive flow. Its patency is equivalent to the ITAs when placed to similar coronary territories and under similar conditions (stenosis, size, quality) and RA patencies are always superior to those of SVG in both observational and randomized studies-88-90% versus 50-60% at 10 years, and 80-87% versus 25-40% at 20 years. Its use and excellent patencies result in survival results equivalent to bilateral internal thoracic artery (BITA) grafting and always superior to left internal thoracic artery (LITA) +SVG. Typical radial artery multiarterial bypass grafting (RA-MABG) 10-year survivals are 80-90% versus 70-80% for LITA-SVG. In general, for every 100 patients undergoing CABG, 10 more patients will be alive at 10 years post-operatively. The RA also is important in achieving total arterial revascularization, and several reports indicate a further survival advantage for patients having three arterial grafts over two. The RAs are especially useful in diabetic, morbidly obese patients, those with conduit shortage, and leg pathology, and in coronary reoperations. Although the RA has equivalent patencies to the right internal thoracic artery (RITA), it is much more versatile. RAs that have been instrumented by angiography or percutaneous coronary intervention should be avoided. The radial artery has proved to be an excellent arterial conduit, is equivalent to but more versatile than the RITA, and is always superior to SVG. Its use should be part of every coronary surgeon's skill set.

The Incremental Value of Three or More Arterial Grafts in CABG: The Effect of Native Vessel Disease

BACKGROUND

We investigated whether extended arterial grafting with three or more arterial grafts in patients with a left internal thoracic artery to left anterior descending artery graft improves survival in coronary artery bypass graft surgery patients and whether its effects will depend on the extent of coronary artery disease; specifically three-vessel disease (3VD) versus two-vessel disease (2VD).

METHODS

Fifteen-year mortality was analyzed in 11,931 patients with multivessel disease and primary isolated left internal thoracic artery to left anterior descending artery coronary artery bypass graft surgery with 2 or more grafts. Patients were aged 64.3 ± 10.5 years; 3,484 (29.2%) were women; 2,532 (21.2%) had 2VD and 9,399 (78.8%) had 3VD. Patients were grouped into one single-artery group (n = 6,782, 56.9%; reference group), and two multiple artery groups: two arteries (n = 3,678, 30.8%) and three arteries (n = 1,471, 12.3%). Long-term survival was compared by Kaplan-Meier estimates. Risk-adjusted mortality hazard ratio (HR) with 95% confidence interval (CI) were derived by covariate adjusted Cox regression to quantify multiple artery effects versus one artery in the overall cohort and separately among patients with 2VD and 3VD.

RESULTS

Radial artery (94%) and right internal thoracic artery (6%) conduits were used for additional arterial grafts. For the entire multivessel cohort, increasing number of arterial grafts was associated with incrementally improved 15-year survival (two arteries HR 0.85, 95% CI: 0.78 to 0.92; three arteries HR 0.75, 95% CI: 0.65 to 0.85). The three arteries versus two arteries comparison was consistent, even if not significant (HR 0.89, 95% CI: 0.77 to 1.03). The benefits derived from additional arterial grafts were more pronounced in case of 3VD (two arteries HR 0.84 95% CI: 0.76 to 0.92; three arteries HR 0.73, 95% CI: 0.63 to 0.84), without survival benefit with 2VD.

CONCLUSIONS

Our results support the use of extended arterial grafting to maximize long-term coronary artery bypass graft surgery patient survival, especially for 3VD patients.