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Suwalski P, Dąbrowski EJ, Batko J, Pasierski M, Litwinowicz R, Kowalówka A, Jasiński M, Rogowski J, Deja M, Bartus K, Li T, Matteucci M, Wańha W, Meani P, Ronco D, Raffa GM, Malvindi PG, Kuźma Ł, Lorusso R, Maesen B, La Meir M, Lazar H, McCarthy P, Cox JL, Rankin S, Kowalewski M. Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry. Surgery 2024; 175:974-983. [PMID: 38238137 DOI: 10.1016/j.surg.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 03/17/2024]
Abstract
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.
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Affiliation(s)
- Piotr Suwalski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland. https://twitter.com/CentreThoracic
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Jakub Batko
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; CAROL-Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Michał Pasierski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Radosław Litwinowicz
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Adam Kowalówka
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland; Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Marek Jasiński
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jan Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdansk, Poland
| | - Marek Deja
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland; Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Tong Li
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Matteo Matteucci
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Paolo Meani
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Daniele Ronco
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Department, Polytechnic University of Marche, Ancona, Italy; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Bart Maesen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
| | - Harold Lazar
- Boston University School of Medicine, Boston, MA
| | - Patrick McCarthy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL
| | - James L Cox
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL
| | - Scott Rankin
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy; Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland.
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2
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Pasierski M, Staromłyński J, Finke J, Litwinowicz R, Filip G, Kowalówka A, Wańha W, Kołodziejczak M, Piekuś-Słomka N, Łoś A, Stefaniak S, Wojakowski W, Jemielity M, Rogowski J, Deja M, Jagielak D, Bartus K, Mariani S, Li T, Matteucci M, Ronco D, Jiritano F, Fina D, Martucci G, Meani P, Raffa GM, Słomka A, Malvidni PG, Lorusso R, Zembala M, Suwalski P, Kowalewski M. Clinical Insights to Complete and Incomplete Surgical Revascularization in Atrial Fibrillation and Multivessel Coronary Disease. Front Cardiovasc Med 2022; 9:910811. [PMID: 35783844 PMCID: PMC9240216 DOI: 10.3389/fcvm.2022.910811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/28/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Michal Pasierski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jakub Staromłyński
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Janina Finke
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Radoslaw Litwinowicz
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Kraków, Poland
| | - Grzegorz Filip
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Kraków, Poland
| | - Adam Kowalówka
- Department of Cardiac Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Michalina Kołodziejczak
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Anaesthesiology and Intensive Care, Antoni Jurasz University Hospital No. 1, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Division of Cardiology, Yale School of Medicine, New Haven, CT, United States
| | - Natalia Piekuś-Słomka
- Department of Inorganic and Analytical Chemistry, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Andrzej Łoś
- Department of Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Sebastian Stefaniak
- Department of Cardiac Surgery and Transplantology, Poznań University of Medical Sciences, Poznań, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Poznań University of Medical Sciences, Poznań, Poland
| | - Jan Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Marek Deja
- Department of Cardiac Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Dariusz Jagielak
- Department of Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Kraków, Poland
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Tong Li
- Department of Cardiac Surgery, University Hospital Düesseldorf, Düesseldorf, Germany
| | - Matteo Matteucci
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Daniele Ronco
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Federica Jiritano
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiac Surgery, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Dario Fina
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Gennaro Martucci
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Anesthesia and Intensive Care Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy
| | - Paolo Meani
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit (ICU), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | - Giuseppe Maria Raffa
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Cardiac Surgery Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS)-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), Palermo, Italy
| | - Artur Słomka
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Pathophysiology, Ludwik Rydygier Collegium Medicum Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland
| | - Pietro Giorgio Malvidni
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Michal Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
- *Correspondence: Mariusz Kowalewski,
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3
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Spadaccio C, Nenna A, Rose D, Piccirillo F, Nusca A, Grigioni F, Chello M, Vlahakes GJ. The Role of Angiogenesis and Arteriogenesisin Myocardial Infarction and Coronary Revascularization. J Cardiovasc Transl Res 2022; 15:1024-1048. [PMID: 35357670 DOI: 10.1007/s12265-022-10241-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 03/18/2022] [Indexed: 12/25/2022]
Abstract
Surgical myocardial revascularization is associated with long-term survival benefit in patients with multivessel coronary artery disease. However, the exact biological mechanisms underlying the clinical benefits of myocardial revascularization have not been elucidated yet. Angiogenesis and arteriogenesis biologically leading to vascular collateralization are considered one of the endogenous mechanisms to preserve myocardial viability during ischemia, and the presence of coronary collateralization has been regarded as one of the predictors of long-term survival in patients with coronary artery disease (CAD). Some experimental studies and indirect clinical evidence on chronic CAD confirmed an angiogenetic response induced by myocardial revascularization and suggested that revascularization procedures could constitute an angiogenetic trigger per se. In this review, the clinical and basic science evidence regarding arteriogenesis and angiogenesis in both CAD and coronary revascularization is analyzed with the aim to better elucidate their significance in the clinical arena and potential therapeutic use.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiac Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, USA. .,Cardiac Surgery, Golden Jubilee National Hospital & University of Glasgow, Glasgow, UK.
| | - Antonio Nenna
- Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - David Rose
- Cardiac Surgery, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | | | | | | | - Massimo Chello
- Cardiac Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Gus J Vlahakes
- Cardiac Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, USA
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