Influence of Prior Coronary Stenting on the Immediate and Mid-term Outcome of Isolated Coronary Artery Bypass Surgery

Coronary Artery Bypass Graft Surgery After Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction

OBJECTIVE

To determine whether primary percutaneous coronary intervention (PPCI) is associated with adverse outcomes following coronary artery bypass graft (CABG) among patients with ST-elevation myocardial infarction (STEMI).

METHODS

Patients presenting with acute STEMI who underwent CABG between September 2015 and November 2020 were included. Among 354 patients, 222 (62.7%) underwent PPCI prior to CABG (PPCI+CABG group) and were compared with the rest of the patients (CABG only group). The effects of PPCI on primary endpoints---including in-hospital mortality, length of stay (LOS), and bleeding events---were investigated using the stabilised inverse probability weighting method (S-IPW). Further, in-hospital mortality in various PPCI subgroups was analysed using univariable regression.

RESULTS

Patients with and without PPCI were comparable regarding their baseline and surgical characteristics, except that those without PPCI were more likely to have left-main disease (29.5% vs 16.2%, p-value=0.003). Among the PPCI+CABG group, 3.6% mortality and 55.9% bleeding events occurred, and the LOS was 7 [5-10] days. The respective figures for the CABG only group were 4.5%, 50.8%, and 7 [6-10.5] days. Primary percutaneous coronary intervention, as a whole, was not significantly associated with either morality (S-IPW odds ratio (S-IPW OR) 0.61; p=0.393), LOS logarithm (S-IPW β -0.050; p=0.403), or bleeding events (S-IPW OR 1.06; p=0.821). Nevertheless, the unadjusted mortality risk was significantly higher in complicated PPCIs compared with the CABG only group (OR 7.50, 95% CI 2.03-27.77); it was also higher among some other PPCI subgroups, albeit non-significantly.

CONCLUSION

This study found that PPCI did not confer additional risk regarding in-hospital mortality, LOS, or bleeding among patients with acute STEMI who underwent CABG. However, some PPCI subgroups, especially those with complicated PPCI, were at increased risk.

Prior percutaneous coronary intervention and outcomes in patients after coronary artery bypass grafting: a meta-analysis of 308,284 patients

Background:

The association between prior percutaneous coronary intervention (PCI) and prognosis after coronary artery bypass grafting (CABG) remains uncertain. We aimed to evaluate the aforementioned association in a meta-analysis.

Methods:

PubMed, Cochrane’s Library, and Embase databases were searched for potential studies. A random-effects model was used for the meta-analysis. Meta-regression was performed to evaluate the influence of study characteristics on the outcomes.

Results:

Thirty-six follow-up studies with 308,284 patients were included, and 40,892 (13.3%) patients had prior PCI. Pooled results showed that prior PCI was associated with higher risks of early (in-hospital or within 1 month) all-cause mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 1.11–1.44, p = 0.003; I² = 64%] and major adverse cardiovascular events (MACEs; OR: 1.36, 95% CI: 1.12–1.66, p = 0.002, I² = 79%), but not with late (follow-up durations from 1 to 13 years) mortality (OR: 1.03, 95% CI: 0.95–1.13, p = 0.44, I² = 46%) or MACEs (OR: 1.03, 95% CI: 0.97–1.09, p = 0.38, I² = 0%). Meta-regression showed that the study characteristics of patient number, age, sex, diabetic status, and proportion of patients with prior PCI did not affect the outcomes. Sensitivity analyses limited to multivariate studies excluding patients with acute PCI failure showed similar results (early mortality, OR: 1.25, p = 0.003; early MACE, OR: 1.50, p = 0.001; late mortality, OR: 1.03, p = 0.70).

Conclusion:

The current evidence, mostly from retrospective observational studies, suggests that prior PCI is related to poor early clinical outcomes, but not to late clinical outcomes, after CABG.

Balloon Angioplasty Versus Stenting in Patients With ST-Elevated Myocardial Infarction Before Subsequent Coronary Artery By-Pass Grafting

Decision of ad hoc revascularization strategy in patients who require coronary artery bypass grafting (CABG) following primary percutaneous coronary interventions (PCI) is challenging due to the pros and cons of only-ballooning and stenting. In this study, we aimed to compare the outcomes of only-balloon-angioplasty to stenting in primary PCI in patients with ST elevated myocardial infarction (STEMI) who required a subsequent CABG. We retrospectively analyzed 350 consecutive STEMI patients who needed CABG in addition to primary balloon angioplasty (n = 160) and stenting strategy (n = 190). In-hospital and 5-year outcomes of the patients were compared between the 2 groups. In-hospital mortality rates in the ballooning and stenting groups were not nonsignificantly different (11.2% vs 9.5%, respectively, P = .59); 5-year mortality rates were also similar between the 2 groups (9.2% vs 8.7%, P = .89). Additionally, major bleeding rates (3.8% vs 6.3%, P = .28) did not differ between the 2 groups. In conclusion, our study showed no significant difference in-hospital and long-term mortality rates in patients who require CABG after primary PCI irrespective of the ad hoc revascularization strategy.

Does Prior Percutaneous Coronary Intervention Influence the Outcomes of Coronary Artery Bypass Surgery?

Introduction

Percutaneous coronary intervention (PCI) has been increasingly performed to treat coronary artery disease. The performance of multiple PCI has also been increasing. Consequently, the percentage of patients presenting for coronary artery bypass graft (CABG) surgery is reported to vary from 13 to 40%. The influence of previous PCI on CABG outcomes has been studied in single center, regional studies, registries and meta-analyses. Some reports showed a negative effect on mortality and morbidity in early or long-term follow-up, but others did not find this influence.

Methods and Results

A cohort of 3007 patients consecutively operated for CABG, 261 of them with previous PCI, were included in this analysis. Comparison of the groups "previous PCI" and "primary CABG" was made in the original cohort and in a propensity score matched cohort of 261 patients. There were some differences in preoperative clinical characteristics in both types of cohort, even in the matched one. Outcomes were compared at 30 days, 1 year and 5 years of follow-up. There were no statistically significant differences in mortality in any period or cohort. There were some differences in other outcomes as readmission and composite events, including cardiovascular death at 1 and 5 years of follow-up. These differences, neverthless, were not confirmed in comparison with the matched cohort.

Conclusion

Although there are some limitations in this study, it was not found consistent negative influence of previous PCI on CABG.

The Functional Properties of Mg-Zn-X Biodegradable Magnesium Alloys

The implantation of metallic devices in orthopaedic surgical procedures and coronary angioplasty is associated with the risk of various adverse events: (i) mechanical (premature failure), (ii) chemo-mechanical (corrosion and corrosion-fatigue degradation) and (iii) biomedical (chronic local inflammatory reactions, tissue necrosis, etc.). In this regard, the development of biodegradable implants/stents, which provide the necessary mechanical support for the healing period of the bone or the vessel wall and then are completely resorbed, has bright prospects. Magnesium alloys are the most suitable candidates for that purpose due to their superior mechanical performance, bioresorbability and biocompatibility. This article presents the results of the comparative research on several wrought biodegradable alloys, assessing their potential for biomedical applications. The Mg-Zn-X alloys with different chemical compositions and microstructures were produced using severe plastic deformation techniques. Functional properties pivotal for biomedical applications-mechanical strength, in vitro corrosion resistance and cytotoxic activity-were included in the focus of the study. Excellent mechanical performance and low cytotoxic effects are documented for all alloys with a notable exception for one of two Mg-Zn-Zr alloys. The in vitro corrosion resistance is, however, below expectations due to critical impurities, and this property has yet to be drastically improved through the cleaner materials fabrication processing before they can be considered for biomedical applications.

Prior Percutaneous Coronary Interventions May Be Associated With Increased Mortality After Coronary Bypass Grafting: A Meta-Analysis

There is conflicting evidence for adverse outcomes after coronary artery bypass surgery (CABG) with prior percutaneous intervention (PCI). A literature search was performed from 1998 to 2017 and articles with primary or secondary outcomes of survival, major adverse cardiovascular events (MACE), and myocardial infarction in CABG patients with prior PCI were included. Forest plots were generated from odds ratios for survival, MACE, and myocardial infarction for unmatched and propensity-matched data. Heterogeneity between studies was assessed for all outcomes using I². Funnel plots were generated for early survival, survival at 5 years, survival at >5 years, and MACE. Thirty-one studies were included over 18 years with 194,544 patients without PCI prior to CABG and 23,519 patients (12.09%) with prior PCI. Prior PCI did not adversely affect survival among the included studies (inverse rate ratio: 1.12, 95% confidence interval: 0.98-1.27, P = 0.110. MACE was significantly worse for those with prior PCI (odds ratio: 1.26, confidence interval: 1.02-1.55, P = 0.03). The relative risk of mortality associated with prior PCI has decreased significantly over the last 2 decades. Studies with higher percentage of prior PCI patients had higher relative mortalities. There was significant heterogeneity between studies for the treatment effects. PCI prior to CABG in recent times does not adversely affect survival despite adverse early and late MACE rates. However, high institutional rates of prior PCI may be associated with increasing mortality after CABG.

Immediate Postoperative Complications in Patients Undergoing CABG; Investigating the Role of Prior Coronary Stenting

Introduction: Approximately 15 to 30% of patients undergoing percutaneous coronary intervention (PCI) will require repeated revascularization. There is an ongoing debate concerning the impact of prior PCI on subsequent coronary artery bypass graft (CABG) surgery. This study sought to compare immediate post-CABG complications between patients with and without previous coronary stenting.

Methods: A total of 556 CABG candidates including 73 patients with previous coronary stenting and 483 patients without prior stenting were enrolled in this retrospective-prospective study. Demographic information, cardiac markers (CK-MB, Troponin T), and postoperative data including inotrope administration, intra-aortic balloon pump (IABP) use, bleeding, pathological electrocardiography (ECG) changes, and overall complications were compared between the two groups.

Results: The mean age of the patients in stented group was significantly higher than that in unstented group (63.49±7.71 vs. 61.37±9.80 years, p=0.05). The mean serum level of Troponin T 12 h postoperation was significantly higher in the same group (323.26±33.16 vs. 243.30±11.52 ng/dL; p=0.03). Comparing the stented and unstented groups, the rates of inotrope use (17.8% vs. 7.2%; p=0.003), significant bleeding (15.1% vs. 4.3%; p=0.001), and overall complications (32.9% vs. 11.6%; odds ratio: 3.74 with 95% confidence interval of 2.13-6.55, p<0.001) were significantly higher in the former group. The association between overall complications and prior stenting was independent (odd ratio: 3.06). No significant connections were found between postoperative complications and stent number or type.

Conclusion: A positive history of previous coronary stenting significantly increases the risk of immediate post-CABG complications.

Impact of Previous PCI on Hospital Mortality After Off-Pump Coronary Artery Bypass Grafting in Diabetic Patients With Multivessel Disease

OBJECTIVE

: Because percutaneous coronary intervention (PCI) has been performed excessively, many patients initially managed with PCI are being referred for coronary artery bypass grafting (CABG). The purpose of this study was to assess the impact of previous PCI on surgical mortality after off-pump CABG in diabetic patients with multivessel disease.

METHODS

: Between January 2002 and April 2008, 595 consecutive patients (99.8% off-pump) had isolated CABG by one single surgeon. Of these, 274 patients with diabetes mellitus and multivessel disease were retrospectively analyzed. Patients with previous PCI (n = 79) were compared with patients with no previous PCI (n = 196), and risk-adjusted impact of previous PCI on surgical mortality after CABG was determined using multivariate and propensity score analyses.

RESULTS

: All patients underwent off-pump CABG without conversion to cardiopulmonary bypass during operation. Patients with previous PCI had a significantly higher prevalence of history of myocardial infarction, renal dysfunction, and hemodialysis. Rates of surgical mortality were higher in patients with previous PCI (7.6% versus 1.0%, P = 0.008). After multivariate logistic regression analysis including all potential univariate predictors, previous PCI remained a strong predictor of surgical mortality [odds ratio (OR), 6.9; 95% confidence interval (CI), 1.2 to 42.1; P = 0.035]. After matching and regression adjustment by propensity score, the impact of previous PCI on surgical mortality was similar in direction (matching OR, 6.5; 95% CI, 0.8 to 55.0; P = 0.088; regression adjustment OR, 6.3; 95% CI, 1.2 to 33.6; P = 0.031).

CONCLUSIONS

: Previous PCI increases the risk of surgical mortality after off-pump CABG in diabetic patients with multivessel disease.