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Dahle G. Disparity issues in coronary artery surgery. Curr Opin Cardiol 2023; 38:478-483. [PMID: 37556404 DOI: 10.1097/hco.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
PURPOSE OF REVIEW Coronary artery disease is the third leading cause of mortality worldwide. Coronary artery surgery is an important treatment option. Certain groups such as people of color, those from lower socioeconomic backgrounds and women tend to have lower rates of receiving the surgery they need ( Fig. 1 ). RECENT FINDINGS Still there are disparities in treatment options for coronary artery disease among different groups, due to geographic location, economical situation, institutional tradition and sex. SUMMARY Through continued research, awareness and utilization of innovative technologies, we can improve access and equity in healthcare for all patients, including patients in need of coronary surgery.
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Affiliation(s)
- Gry Dahle
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
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2
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Frolov A, Lobov A, Kabilov M, Zainullina B, Tupikin A, Shishkova D, Markova V, Sinitskaya A, Grigoriev E, Markova Y, Kutikhin A. Multi-Omics Profiling of Human Endothelial Cells from the Coronary Artery and Internal Thoracic Artery Reveals Molecular but Not Functional Heterogeneity. Int J Mol Sci 2023; 24:15032. [PMID: 37834480 PMCID: PMC10573276 DOI: 10.3390/ijms241915032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/02/2023] [Accepted: 10/08/2023] [Indexed: 10/15/2023] Open
Abstract
Major adverse cardiovascular events occurring upon coronary artery bypass graft surgery are typically accompanied by endothelial dysfunction. Total arterial revascularisation, which employs both left and right internal thoracic arteries instead of the saphenous vein to create a bypass, is associated with better mid- and long-term outcomes. We suggested that molecular profiles of human coronary artery endothelial cells (HCAECs) and human internal mammary artery endothelial cells (HITAECs) are coherent in terms of transcriptomic and proteomic signatures, which were then investigated by RNA sequencing and ultra-high performance liquid chromatography-mass spectrometry, respectively. Both HCAECs and HITAECs overexpressed molecules responsible for the synthesis of extracellular matrix (ECM) components, basement membrane assembly, cell-ECM adhesion, organisation of intercellular junctions, and secretion of extracellular vesicles. HCAECs were characterised by higher enrichment with molecular signatures of basement membrane construction, collagen biosynthesis and folding, and formation of intercellular junctions, whilst HITAECs were notable for augmented pro-inflammatory signaling, intensive synthesis of proteins and nitrogen compounds, and enhanced ribosome biogenesis. Despite HCAECs and HITAECs showing a certain degree of molecular heterogeneity, no specific markers at the protein level have been identified. Coherence of differentially expressed molecular categories in HCAECs and HITAECs suggests synergistic interactions between these ECs in a bypass surgery scenario.
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Affiliation(s)
- Alexey Frolov
- Department of Experimental Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.F.); (D.S.); (V.M.); (A.S.); (E.G.); (Y.M.)
| | - Arseniy Lobov
- Laboratory for Regenerative Biomedicine, Research Institute of Cytology of the Russian Academy of Sciences, 4 Tikhoretskiy Prospekt, St. Petersburg 194064, Russia;
| | - Marsel Kabilov
- SB RAS Genomics Core Facility, Institute of Chemical Biology and Fundamental Medicine of the Siberian Branch of the Russian Academy of Sciences, 8 Prospekt Akademika Lavrentieva, Novosibirsk 630090, Russia; (M.K.); (A.T.)
| | - Bozhana Zainullina
- Centre for Molecular and Cell Technologies, Research Park, Saint Petersburg State University, 7/9 Universitetskaya Embankment, St. Petersburg 199034, Russia;
| | - Alexey Tupikin
- SB RAS Genomics Core Facility, Institute of Chemical Biology and Fundamental Medicine of the Siberian Branch of the Russian Academy of Sciences, 8 Prospekt Akademika Lavrentieva, Novosibirsk 630090, Russia; (M.K.); (A.T.)
| | - Daria Shishkova
- Department of Experimental Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.F.); (D.S.); (V.M.); (A.S.); (E.G.); (Y.M.)
| | - Victoria Markova
- Department of Experimental Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.F.); (D.S.); (V.M.); (A.S.); (E.G.); (Y.M.)
| | - Anna Sinitskaya
- Department of Experimental Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.F.); (D.S.); (V.M.); (A.S.); (E.G.); (Y.M.)
| | - Evgeny Grigoriev
- Department of Experimental Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.F.); (D.S.); (V.M.); (A.S.); (E.G.); (Y.M.)
| | - Yulia Markova
- Department of Experimental Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.F.); (D.S.); (V.M.); (A.S.); (E.G.); (Y.M.)
| | - Anton Kutikhin
- Department of Experimental Medicine, Research Institute for Complex Issues of Cardiovascular Diseases, 6 Sosnovy Boulevard, Kemerovo 650002, Russia; (A.F.); (D.S.); (V.M.); (A.S.); (E.G.); (Y.M.)
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3
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Vervoort D, Elbatarny M, Rocha R, Fremes SE. Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting. J Clin Med 2023; 12:jcm12062275. [PMID: 36983276 PMCID: PMC10056232 DOI: 10.3390/jcm12062275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Stephen E. Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1A1, Canada
- Division of Cardiac Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Correspondence: ; Tel.: +1-416-480-6073
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4
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Kim KM, Arghami A, Habib R, Daneshmand MA, Parsons N, Elhalabi Z, Krohn C, Thourani V, Bowdish ME. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research. Ann Thorac Surg 2023; 115:566-574. [PMID: 36623634 DOI: 10.1016/j.athoracsur.2022.12.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/05/2022] [Accepted: 12/10/2022] [Indexed: 01/08/2023]
Abstract
The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It is one of the most respected clinical data registries in health care, providing accurate risk-adjusted benchmarks, a foundation for quality measurement and improvement activities, and the ability to perform novel research. This report encompasses data from the years 2020 and 2021 and is the seventh in a series of reports that provide updated volumes, outcomes, database-related developments, and research summaries using the Adult Cardiac Surgery Database.
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Affiliation(s)
- Karen M Kim
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert Habib
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Vinod Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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5
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Heinisch PP, Winkler B. Editorial comment on "current practice of saphenous vein graft harvesting in coronary artery bypass graft surgery: an Indian survey". Indian J Thorac Cardiovasc Surg 2023; 39:112-114. [PMID: 36785601 PMCID: PMC9918625 DOI: 10.1007/s12055-022-01451-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/30/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Paul Phillip Heinisch
- German Heart Center Munich, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Winkler
- Department of Cardio-Vascular Surgery, Vienna Heart Center Clinic Floridsdorf and Karl Landsteiner Institute for Cardio-Vascular Research, Vienna, Austria
- Medical University of Vienna, Vienna, Austria
- Division of Cardiac Surgery, Vienna Heart Center Clinic Floridsdorf, Brünnerstrasse 68, 1210 Vienna, Austria
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6
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Rudenko NM, Pukas OY. Comparative Analysis of Early Postoperative Period in Patients with Total Arterial Revascularization and Conventional Coronary Artery Bypass Grafting. UKRAINIAN JOURNAL OF CARDIOVASCULAR SURGERY 2022. [DOI: 10.30702/ujcvs/22.30(04)/rp049-3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The use of total arterial myocardial revascularization in patients with multivessel lesions of the coronary arteries has a number of advantages, namely the duration of functioning or patency of the grafts. The level of total arterial myocardial revascularization implementation in developed and developing countries remains quite low.
The aim. Based on the analysis of our own experience, to determine the influence of the technique of total arterial revascularization on the frequency of complications in the early postoperative period.
Materials and methods. From February 22, 2016 to December 24, 2020, 390 consecutive patients were operated at the Ukrainian Children’s Cardiac Center. The patients were divided into two groups: participants of the group I underwent total arterial myocardial revascularization, and those includedin the group II underwent conventional coronary artery bypass grafting (CABG). The inclusion criteria were: ischemic heart disease, stable angina or exertional angina, multivascular coronary artery disease, absence of valvular pathology.
Results. There was zero 30-day mortality in both groups. The frequency of postoperative bleeding was higher in group II and amounted to 1.6%. Surgical wound complications (infection) were also more common in the group II: 1.2% versus 0.69% (p=0.906) in the group I. Similarly, laboratory parameters such as the level of creatine kinase-MB were almost identical.
Conclusions. Total arterial myocardial revascularization is a safe method with good immediate results. The frequency of complications in total arterial myocardial revascularizationdoes not differ from that in conventional CABG. For a wider application of the total arterial myocardial revascularization,it is necessary to continue toconduct studies of the remote postoperative period.
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7
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Abreu A, Máximo J, Leite-Moreira A. Long-term survival of single versus bilateral internal mammary artery grafting in patients under 70. Interact Cardiovasc Thorac Surg 2022; 35:6675473. [PMID: 36005896 PMCID: PMC9462425 DOI: 10.1093/icvts/ivac225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/04/2022] [Accepted: 08/23/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES
As definitive data from randomized controlled trials comparing the effect on long-term survival of using single internal mammary artery (SIMA) or bilateral internal mammary artery (BIMA) grafting are not yet available, observational studies allow for long-term follow-up in large and representative populations, which might complement the information potentially derived from randomized trials. To compare long-term survival in patients under 70 years of age undergoing SIMA or BIMA grafting.
METHODS
Retrospective analysis of 3384 consecutive patients under 70 years undergoing primary isolated coronary artery bypass grafting, performed from 2000 to 2015, in a Portuguese level III Hospital. We identified 2176 and 1208 patients from the study population who underwent SIMA and BIMA grafting, respectively. The primary end point was all-cause mortality at 10 years. We employed inverse probability weighting to restrict confounding by indication.
RESULTS
The mean age of the study population was 59.4 (± 7.6) years, and 567 (16.8%) were females. Inverse probability weighting was effective in eliminating differences in all significant baseline characteristics. Follow-up was 99.88% complete. The median follow-up time was 12.82 (interquartile range, 9.65, 16.74) years: the primary end point of all-cause mortality at 10 years occurred in 463 patients (21.3%) and 166 (13.7%) in the SIMA and BIMA grafting groups, respectively (hazard ratio, 0.78; 95% confidence interval, 0.66–0.92; P = 0.004).
CONCLUSIONS
Bilateral internal mammary grafting is associated with lower long-term mortality than single internal mammary grafting. Moreover, this survival benefit comes at no increased perioperative morbidity or mortality cost.
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Affiliation(s)
- Armando Abreu
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto , Porto, Portugal
- Department of Cardiothoracic Surgery, São João University Hospital Center , Porto, Portugal
| | - José Máximo
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto , Porto, Portugal
- Department of Cardiothoracic Surgery, São João University Hospital Center , Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto , Porto, Portugal
- Department of Cardiothoracic Surgery, São João University Hospital Center , Porto, Portugal
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8
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Little M, Gray AM, Altman DG, Benedetto U, Flather M, Gerry S, Lees B, Murphy J, Gaudino M, Taggart DP. Cost-effectiveness of bilateral vs. single internal thoracic artery grafts at 10 years. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:324-332. [PMID: 33502466 PMCID: PMC9071553 DOI: 10.1093/ehjqcco/qcab004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/08/2021] [Accepted: 01/25/2021] [Indexed: 12/18/2022]
Abstract
AIMS Using bilateral internal thoracic arteries (BITAs) for coronary artery bypass grafting (CABG) has been suggested to improve survival compared to CABG using single internal thoracic arteries (SITAs) for patients with advanced coronary artery disease. We used data from the Arterial Revascularization Trial (ART) to assess long-term cost-effectiveness of BITA grafting compared to SITA grafting from an English health system perspective. METHODS AND RESULTS Resource use, healthcare costs, and quality-adjusted life years (QALYs) were assessed across 10 years of follow-up from an intention-to-treat perspective. Missing data were addressed using multiple imputation. Incremental cost-effectiveness ratios were calculated with uncertainty characterized using non-parametric bootstrapping. Results were extrapolated beyond 10 years using Gompertz functions for survival and linear models for total cost and utility. Total mean costs at 10 years of follow-up were £17 594 in the BITA arm and £16 462 in the SITA arm [mean difference £1133 95% confidence interval (CI) £239 to £2026, P = 0.015]. Total mean QALYs at 10 years were 6.54 in the BITA arm and 6.57 in the SITA arm (adjusted mean difference -0.01 95% CI -0.2 to 0.1, P = 0.883). At 10 years, BITA grafting had a 33% probability of being cost-effective compared to SITA, assuming a cost-effectiveness threshold of £20 000. Lifetime extrapolation increased the probability of BITA being cost-effective to 51%. CONCLUSIONS BITA grafting has significantly higher costs but similar quality-adjusted survival at 10 years compared to SITA grafting. Extrapolation suggests this could change over lifetime.
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Affiliation(s)
- Matthew Little
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Alastair M Gray
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Douglas G Altman
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK
| | - Umberto Benedetto
- School of Clinical Sciences, University of Bristol and Bristol Royal Infirmary, 69 St Michael's Hill, Bristol BS2 8DZ, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich Research Park, Norwich, Norfolk NR4 7TJ, UK
| | - Stephen Gerry
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK
| | - Belinda Lees
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jacqueline Murphy
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Old Road Campus, Headington, Oxford OX3 7LF, UK
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 E 68th St, New York, NY 10065, USA
| | - David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
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Luthra S, Leiva-Juárez MM, Malvindi PG, Billing JS, Ohri SK. Survival benefit from a second arterial conduit to the circumflex circulation persists in elderly after coronary artery bypass surgery. Asian Cardiovasc Thorac Ann 2021; 29:910-915. [PMID: 33611930 DOI: 10.1177/0218492321997077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This retrospective propensity matched study investigated the impact of age on the survival benefit from a second arterial conduit to the left-sided circulation. METHODS Data for isolated coronary artery bypass surgery were collected from October 2004 to March 2014. All patients with an internal mammary artery graft to left anterior descending artery and additional arterial or venous graft to the circumflex circulation were included. Propensity matching was used to balance co-variates and generate odds of death for each observation. Odds ratios (venous vs. arterial) were charted against age. RESULTS The in-hospital mortality rate was 1.12% (arterial) vs. 1.24% (venous) (p = 0.77). The overall 10-year survival was 74.6% (venous) vs. 82.6% (arterial) (p = 0.001). A total of 1226 patients were successfully matched to the venous or arterial (second conduit to circumflex territory after left internal mammary artery to left anterior descending artery) cohorts. Odds ratio for death (venous to arterial) showed a linear decremental overall survival benefit for the second arterial graft to circumflex circulation with increasing age. CONCLUSIONS The survival benefit of a second arterial graft persists through all age groups with a gradual decline with increasing age over the decades. Elderly patients should not be denied a second arterial graft to the circumflex circulation based on age criterion alone.
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Affiliation(s)
- Suvitesh Luthra
- Division of Cardiac Surgery, University Hospital Southampton, Hampshire, UK
| | - Miguel M Leiva-Juárez
- Department of Surgery, Brookdale University Hospital and Medical Center, Brooklyn, NY, USA
| | - Pietro G Malvindi
- Division of Cardiac Surgery, University Hospital Southampton, Hampshire, UK
| | - John S Billing
- Department of Cardiothoracic Surgery, New Cross Hospital, West Midlands, UK
| | - Sunil K Ohri
- Division of Cardiac Surgery, University Hospital Southampton, Hampshire, UK
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10
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McNichols B, Spratt JR, George J, Rizzi S, Manning EW, Park K. Coronary Artery Bypass: Review of Surgical Techniques and Impact on Long-Term Revascularization Outcomes. Cardiol Ther 2021; 10:89-109. [PMID: 33515370 PMCID: PMC8126527 DOI: 10.1007/s40119-021-00211-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Indexed: 12/14/2022] Open
Abstract
Coronary revascularization for multivessel disease remains a common and costly source of hospitalizations in the United States. Surgical techniques influence outcomes for coronary bypass and also affect the need for percutaneous coronary intervention in the future. As more radial access has been used for coronary angiography, consideration for use of the radial artery as a surgical conduit remains unclear. Saphenous vein grafts are commonly used for coronary bypass, however long-term patency remains suboptimal, and is also associated with a higher risk of adverse events with percutaneous coronary intervention. Thus, understanding the interplay between coronary bypass techniques and percutaneous coronary intervention has become increasingly important.
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Affiliation(s)
- Brian McNichols
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - John R Spratt
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jerin George
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Scott Rizzi
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Eddie W Manning
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA.
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11
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Sellke FW. Secondary prevention after coronary artery bypass grafting: Anticoagulation and antiplatelet therapy is only one factor. J Card Surg 2021; 36:1100-1102. [PMID: 33506999 DOI: 10.1111/jocs.15286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 11/30/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel/ticagrelor/prasugrel does not lead to improved graft patency rates or clinical outcomes after coronary artery bypass grafting (CABG) over aspirin monotherapy, at least for on pump CABG. The protective effects of DAPT tended to be observed to be greater extent in patients undergoing off pump CABG. In general, the addition of the potent thienopyridines increased the risk of major bleeding, although the incidence of major bleeding is relatively low after either on pump or off pump surgical revascularization. There is a lack of evidence that anticoagulation post-CABG provides any protection against graft failure, but it may decrease the incidence of major adverse cardiovascular events. However, antiplatelet and anti thrombotic therapy after CABG is only one component of secondary prevention that needs to be taken into consideration when optimizing the long-term outcomes of patients after CABG.
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Affiliation(s)
- Frank W Sellke
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence, Rhode Island, USA
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12
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Bayer N, Hart WM, Arulampalam T, Hamilton C, Schmoeckel M. Is the Use of BIMA in CABG Sub-Optimal? A Review of the Current Clinical and Economic Evidence Including Innovative Approaches to the Management of Mediastinitis. Ann Thorac Cardiovasc Surg 2020; 26:229-239. [PMID: 32921659 PMCID: PMC7641892 DOI: 10.5761/atcs.ra.19-00310] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has traditionally been limited. This review looks at the recent outcome data on BIMA in CABG focusing on the management of risk factors for mediastinitis, one of the potential barriers for more extensive BIMA utilization. A combination of pre-, intra- and postoperative strategies are essential to reduce mediastinitis. Limited data indicate that the incidence of mediastinitis can be reduced using closed incision negative-pressure wound therapy as a part of these strategies with the possibility of offering patients best treatment options by extending BIMA to those with a higher risk of mediastinitis. Recent economic data imply that the technology may challenge the current low uptake of BIMA by reducing the short-term cost differentials between single internal mammary artery and BIMA. Given that most published randomized controlled trials and meta-analyses of observational long-term outcome data favor BIMA, if short-term complications of BIMA including mediastinitis can be controlled adequately, there may be opportunities for more extensive use of BIMA leading to improved long-term outcomes. An ongoing study looking at BIMA in high-risk patients may provide evidence to support the hypothesis that mediastinitis should not be a factor in limiting the use of BIMA in CABG.
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13
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Torregrossa G, Amabile A, Williams EE, Fonceva A, Hosseinian L, Balkhy HH. Multi-arterial and total-arterial coronary revascularization: Past, present, and future perspective. J Card Surg 2020; 35:1072-1081. [PMID: 32293059 DOI: 10.1111/jocs.14537] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/09/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Although abundant biological, clinical, and scientific evidence exists on the superiority of multi-arterial (MAR) and total-arterial revascularization (TAR) over the conventional strategy with a single internal thoracic artery, only 10% of patients undergoing coronary artery bypass grafting (CABG) in the United States receives a second arterial conduit, and only 5% of patients receives TAR. METHODS AND RESULTS In January 2020, the authors performed comprehensive search to identify studies that evaluated MAR and TAR strategies through the MEDLINE database. CONCLUSIONS In this paper, the authors reviewed the literature on the historical and current evidence in favor of MAR and TAR, thus underlying why current CABG practice needs qualitative improvement.
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Affiliation(s)
- Gianluca Torregrossa
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Elbert E Williams
- Department of Cardiovascular Surgery, Mount Sinai Hospital, New York City, New York
| | - Ana Fonceva
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Leila Hosseinian
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Chicago, Illinois
| | - Husam H Balkhy
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois
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Taggart DP. The Role of Multiple Arterial Grafts in CABG. J Am Coll Cardiol 2019; 74:2249-2253. [DOI: 10.1016/j.jacc.2019.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/16/2019] [Indexed: 11/24/2022]
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Right internal thoracic or radial artery as the second arterial conduit for coronary artery bypass surgery. Curr Opin Cardiol 2019; 34:564-570. [PMID: 31219879 DOI: 10.1097/hco.0000000000000654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To summarize the available evidence on the use of the right internal thoracic artery (RITA) and the radial artery as the second arterial graft in coronary artery bypass surgery. RECENT FINDINGS The current data support the equipoise of the two conduits in terms of clinical and angiographic outcomes. Both RITA and radial artery have better patency than saphenous vein grafts. The use of the RITA carries an increased risk of deep sternal wound infection (DSWI) if the artery is harvested as pedicle. Bilateral internal thoracic artery grafting is more technically demanding than radial artery use and there is a volume-outcome relationship in terms of mortality and incidence of DSWI. The radial artery is preferable over RITA in right-sided or distal circumflex artery targets with high-degree stenosis and in patients at higher risk for DSWI, whereas it is not recommended to graft vessels with moderate stenosis and in cases of insufficient collateralization from the ulnar artery or previous transradial procedures. SUMMARY The patency rate and clinical outcomes of radial artery and RITA are similar. The use of one or the other should be based on a careful evaluation of the patient's coronary anatomy and comorbidities, the conduit availability and the surgeon's and center's experience.
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Gaudino MFL, Spadaccio C, Taggart DP. State-of-the-Art Coronary Artery Bypass Grafting: Patient Selection, Graft Selection, and Optimizing Outcomes. Interv Cardiol Clin 2019; 8:173-198. [PMID: 30832941 DOI: 10.1016/j.iccl.2018.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Despite the progressive expansion of clinical indications for percutaneous coronary intervention and the increasingly high risk profile of referred patients, coronary artery bypass grafting (CABG) remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates. Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes. A surgical approach individualized to the patients' clinical and anatomic characteristics, and surgeon and team experience, are key to excellent outcomes. Current evidence regarding patient selection, indications, graft selection, and potential strategies to optimize outcomes in patients treated with CABG is summarized.
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Affiliation(s)
- Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, NewYork-Presbyterian Hospital, 525 East 68th Street, New York, NY 10021, USA.
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, Glasgow G81 4DY, UK; University of Glasgow, Institute of Cardiovascular and Medical Sciences, 126 University Place, Glasgow G128TA, UK
| | - David P Taggart
- Department of Cardiovascular Surgery, University of Oxford, Headley Way, Oxford, Oxforshire OX39DU, UK; Department Cardiac Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford, Oxfordshire OX3 9DU, UK
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