1
|
Sandner S, Kurlansky P. Complete Revascularization Remains the Gold Standard in Coronary Artery Bypass Surgery. Ann Thorac Surg 2024; 118:545-547. [PMID: 38880272 DOI: 10.1016/j.athoracsur.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 06/01/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Sigrid Sandner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria; Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| | - Paul Kurlansky
- Department of Surgery, Columbia University Medical Center, New York, New York
| |
Collapse
|
2
|
Milutinovic S, Singh K, Oluic S, Lopez‐Mattei JC, Escárcega RO. Complete percutaneous coronary revascularization: An elegant solution to left ventricular dysfunction caused by severe coronary artery disease. Clin Case Rep 2024; 12:e9224. [PMID: 39104738 PMCID: PMC11299069 DOI: 10.1002/ccr3.9224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/19/2024] [Accepted: 06/25/2024] [Indexed: 08/07/2024] Open
Abstract
With increased complexity in both medical comorbidities and coronary anatomy, the proportion of surgically turndown patients and high-risk PCI will continue to rise. Impella-assisted complex PCI can be performed with high technical success and can improve quality of life, angina score, and potentially left ventricular ejection fraction.
Collapse
Affiliation(s)
- Stefan Milutinovic
- Department of Internal MedicineFlorida State University College of Medicine, Lee HealthFort MyersFloridaUSA
| | - Kamaldeep Singh
- Department of Cardiovascular DiseasesLee Health Heart InstituteFort MyersFloridaUSA
| | - Stevan Oluic
- Department of Internal MedicineMayo Clinic Health SystemMankatoMinnesotaUSA
| | - Juan C. Lopez‐Mattei
- Department of Cardiovascular DiseasesLee Health Heart InstituteFort MyersFloridaUSA
| | - Ricardo O. Escárcega
- Department of Internal MedicineFlorida State University College of Medicine, Lee HealthFort MyersFloridaUSA
- Department of Cardiovascular DiseasesLee Health Heart InstituteFort MyersFloridaUSA
- Department of Cardiovascular DiseasesFlorida Heart AssociatesFort MyersFloridaUSA
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Biancari F, Dalén M, Tauriainen T, Gatti G, Salsano A, Santini F, Feo MD, Zhang Q, Mazzaro E, Franzese I, Bancone C, Zanobini M, Mäkikallio T, Saccocci M, Francica A, Onorati F, El-Dean Z, Mariscalco G. Revascularization of Occluded Right Coronary Artery and Outcome After Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg 2023; 71:462-468. [PMID: 36736367 DOI: 10.1055/s-0043-1761625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The aim of the present study was to evaluate the results of isolated coronary artery bypass grafting (CABG) with or without revascularization of the occluded right coronary artery (RCA). METHODS Patients undergoing isolated CABG were included in a prospective European multicenter registry. Outcomes were adjusted for imbalance in preoperative variables with propensity score matching analysis. Late outcomes were evaluated with Kaplan-Meier's method and competing risk analysis. RESULTS Out of 2,948 included in this registry, 724 patients had a total occlusion of the RCA and were the subjects of this analysis. Occluded RCA was not revascularized in 251 (34.7%) patients with significant variability between centers. Among 245 propensity score-matched pairs, patients with and without revascularization of occluded RCA had similar early outcomes. The nonrevascularized RCA group had increased rates of 5-year all-cause mortality (17.7 vs. 11.7%, p = 0.039) compared with patients who had their RCA revascularized. The rates of myocardial infarction and repeat revascularization were only numerically increased but contributed to a significantly higher rate of MACCE (24.7 vs. 15.7%, p = 0.020) at 5 year among patients with nonrevascularized RCA. CONCLUSION In this multicenter study, one-third of totally occluded RCAs was not revascularized during isolated CABG for multivessel coronary artery disease. Failure to revascularize an occluded RCA in these patients increased the risk of all-cause mortality and MACCEs at 5 years.
Collapse
Affiliation(s)
- Fausto Biancari
- Hear and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Medicine, University of Helsinki, South-Karelia Central Hospital, Lappeenranta, Finland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery and Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tuomas Tauriainen
- Hear and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Marino, University of Genoa, Genoa, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Marino, University of Genoa, Genoa, Italy
| | - Marisa De Feo
- Department of Cardiothoracic Sciences, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Qiyao Zhang
- Department of Molecular Medicine and Surgery and Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Enzo Mazzaro
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Ilaria Franzese
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Ciro Bancone
- Department of Cardiothoracic Sciences, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Marco Zanobini
- Cardiovascular Department, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Timo Mäkikallio
- Department of Medicine, University of Helsinki, South-Karelia Central Hospital, Lappeenranta, Finland
| | - Matteo Saccocci
- Cardiac Surgery Unit, Poliambulanza Foundation, Brescia, Italy
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Zein El-Dean
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| |
Collapse
|
5
|
Nakae M, Kainuma S, Toda K, Yoshikawa Y, Hata H, Yoshioka D, Kawamura T, Kawamura A, Kashiyama N, Ueno T, Kuratani T, Kondoh H, Hiraoka A, Sakaguchi T, Yoshitaka H, Shirakawa Y, Takahashi T, Sakaki M, Masai T, Komukai S, Kitamura T, Hirayama A, Shimomura Y, Miyagawa S. Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy. JTCVS OPEN 2023; 15:211-219. [PMID: 37808015 PMCID: PMC10556818 DOI: 10.1016/j.xjon.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 03/24/2023] [Accepted: 04/06/2023] [Indexed: 10/10/2023]
Abstract
Objective In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. Methods We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. Results The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. Conclusions In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.
Collapse
Affiliation(s)
- Masaro Nakae
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ai Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Noriyuki Kashiyama
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Haruhiko Kondoh
- Japan Organization of Occupational Health and Safety Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Arudo Hiraoka
- Sakakibara Heart Institute of Okayama, Okayama, Japan
| | | | | | | | | | - Masayuki Sakaki
- National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | | | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Atsushi Hirayama
- Public Health, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshimitsu Shimomura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Osaka Cardiovascular Surgery Research (OSCAR) Group
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Japan Organization of Occupational Health and Safety Osaka Rosai Hospital, Sakai, Osaka, Japan
- Sakakibara Heart Institute of Okayama, Okayama, Japan
- Osaka Police Hospital, Osaka, Osaka, Japan
- National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
- Sakurabashi Watanabe Hospital, Osaka, Osaka, Japan
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Public Health, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| |
Collapse
|
6
|
Rotar EP, Scott EJ, Hawkins RB, Mehaffey JH, Strobel RJ, Charles EJ, Quader MA, Joseph M, Teman NR, Yarboro LT, Ailawadi G. Changes in Controllable Coronary Artery Bypass Grafting Practice for White and Black Americans. Ann Thorac Surg 2023; 115:922-928. [PMID: 35093386 DOI: 10.1016/j.athoracsur.2021.11.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 11/07/2021] [Accepted: 11/29/2021] [Indexed: 11/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Evan P Rotar
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Erik J Scott
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - J Hunter Mehaffey
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eric J Charles
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Mark Joseph
- Division of Cardiothoracic Surgery, Virginia Tech Carillion School of Medicine, Roanoke, Virginia
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
| | | |
Collapse
|
7
|
Javed A, Siddiqueh M, Anjum Q, Jalal A. Drug-coated balloon angioplasty, intraoperatively through left anterior descending arteriotomy access, a novel hybrid revascularization strategy: a case report. Eur Heart J Case Rep 2023; 7:ytad014. [PMID: 36727128 PMCID: PMC9883707 DOI: 10.1093/ehjcr/ytad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/21/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023]
Abstract
Background Patients undergoing coronary artery bypass graft (CABG) sometimes have critical proximal lesion in left anterior descending (LAD) artery or chronic total occlusion followed by either skip lesions or diffuse disease of late mid-to-distal LAD artery. Such lesions require endarterectomy or atheroma bridging via long venous or arterial patch (patch-plasty), for which clinical outcomes are conflicting in studies due to a more thrombogenic milieu created by patch-plasty as well as incomplete endarterectomy. We present a hybrid approach with drug-coated balloon (DCB) angioplasty of mid-to-distal LAD through LAD arteriotomy followed by left internal mammary artery (LIMA) insertion to LAD. Case summary A 35-year-old man who was thrombolyzed for anterior wall myocardial infarction in another city, reported to our hospital four weeks later with persistent angina. Coronary angiography showed severe multivessel coronary artery disease. There was diffuse disease in LAD distal to potential site of LIMA insertion and needed patch-plasty. We carried out a hybrid procedure by performing DCB angioplasty of mid-to-distal LAD through the LAD arteriotomy site during CABG followed by LIMA insertion to the LAD. The patient remained asymptomatic post procedure with a 6-month follow-up computerized tomography scan showing patent LIMA and mid-to-distal LAD. Discussion This case shows a novel technique, first in the world, of performing angioplasty during CABG through arteriotomy followed by graft insertion.
Collapse
Affiliation(s)
- Asim Javed
- Head of Cardiology Department/Director Cath Lab, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan
| | - Musfireh Siddiqueh
- Head of Cardiology Department/Director Cath Lab, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan
| | - Qudsia Anjum
- Head of Cardiology Department/Director Cath Lab, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan
| | - Anjum Jalal
- Head of Cardiology Department/Director Cath Lab, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan
| |
Collapse
|
8
|
Early and Long-Term Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction and a Giant Left Ventricle. J Cardiovasc Dev Dis 2022; 9:jcdd9090298. [PMID: 36135443 PMCID: PMC9502700 DOI: 10.3390/jcdd9090298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: No previous studies comparing the outcomes between off-pump coronary artery bypass grafting (off-pump CABG, OPCAB) and on-pump CABG (ONCAB) have been performed in patients with severe left ventricular dysfunction (LVD) and a giant left ventricle. We aimed to investigate whether such patients could benefit from OPCAB. Methods: From January 2011 to January 2021, a total of 98 patients with severe LVD and a giant left ventricle underwent isolated CABG (ONCAB 46, OPCAB 52) in Wuhan Union Hospital. The clinical data were collected retrospectively and propensity score matching was performed to adjust baseline characteristics. Results: After propensity matching, the two groups were comparable in baseline variables. The OPCAB group had a higher rate of incomplete revascularization than the ONCAB group (25.0% vs. 9.1%; p = 0.047). The 30-day mortality was similar between the matched groups (4.5% vs. 4.5%; p = 1.000) but the OPCAB group had a lower risk of postoperative IABP usage (9.1% vs. 25.0%; p = 0.047) and renal insufficiency (11.4% vs. 29.5%; p = 0.034). The long-term probability of survival (log-rank test, p = 0.450) was similar between the two groups but the OPCAB group had a lower probability of major adverse cardiovascular events (log-rank test, p = 0.038). Conclusions: For patients with severe LVD and a giant left ventricle, OPCAB reduced early postoperative complications while sacrificing long-term quality of life compared to those having ONCAB.
Collapse
|
9
|
Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
|
10
|
Pandit N, Rahatekar P, Rekwal L, Kuber D, Nath RK, Aggarwal P. Target Vessel Versus Complete Revascularization in Non-ST Elevation Myocardial Infarction Without Cardiogenic Shock. Cureus 2022; 14:e23139. [PMID: 35444901 PMCID: PMC9009965 DOI: 10.7759/cureus.23139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR. Methods It was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes. Results The mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively. Conclusion CR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.
Collapse
|
11
|
Vo TX, Ruel M. Reply: The incomplete puzzle of complete revascularization. JTCVS OPEN 2022; 9:118-119. [PMID: 36003438 PMCID: PMC9390247 DOI: 10.1016/j.xjon.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 08/29/2021] [Accepted: 09/01/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Thin X Vo
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| |
Collapse
|
12
|
Martins J, Afreixo V, Santos L, Fernandes L, Briosa A. Physiology or Angiography-Guided Coronary Artery Bypass Grafting: A Meta-Analysis. Arq Bras Cardiol 2021; 117:1115-1123. [PMID: 35613169 PMCID: PMC8757150 DOI: 10.36660/abc.20200763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/11/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While invasive coronary angiography is considered the gold standard for the diagnosis of coronary artery disease (CAD) involving the epicardial coronary vessels, coronary physiology-guided revascularization represents a contemporary gold-standard practice for the invasive management of patients with intermediate CAD. Nevertheless, the long-term results of assessing the severity of stenosis through physiology compared to the angiogram as the guide to bypass surgery - coronary artery bypass grafting (CABG) are still uncertain. This meta-analysis aims to assess the clinical outcomes of a physiology guided CABG compared to the angiography-guided CABG. OBJECTIVES We sought to determine if outcomes differ between a physiology guided CABG compared to an angiography-guided CABG. METHODS We searched Medline, EMBASE, and the Cochrane Library. The last date for this search was June 2020, and all of the previous studies were included. We conducted a pooled risk-ratio meta-analysis for four main outcomes: all-cause death, myocardial infarction (MI), target vessel revascularization (TVR) and major adverse cardiovascular events (MACE). P-value <0.05 was considered as statistically significant. Heterogeneity was assessed with Cochran's Q test and quantified by the I2 index. RESULTS We identified five studies that included a total of 1,114 patients. A pooled meta-analysis showed no significant difference between a physiology guided strategy and an angiography-guided strategy in MI (risk ratio [RR] = 0.72; 95%CI, 0.39-1.33; I2 = 0%; p = 0.65), TVR (RR = 1.25; 95%CI = 0.73-2.13; I2 = 0%; p = 0.52), or MACE (RR = 0.81; 95%CI = 0.62-1.07; I2 = 0%; p = 1). The physiology guided strategy has 0.63 times the risk of all-cause death compared to the angiography-guided strategy (RR = 0.63; 95%CI = 0.42-0.96; I2 = 0%; p = 0.55). CONCLUSION This meta-analysis demonstrated a reduction in all-cause death when a physiology guided CABG strategy was used. Nevertheless, the short follow-up period, small sample size of the included studies and the non-discrimination of the causes of death can largely justify these conclusions. Studies with an extended follow-up period of observation are required to draw more robust and definitive conclusions.
Collapse
Affiliation(s)
- José Martins
- Baixo Vouga Hospital CentreAveiroPortugalBaixo Vouga Hospital Centre, Aveiro - Portugal
| | - Vera Afreixo
- University of AveiroCIDMA/IBIMED/Department of MathematicsAveiroPortugalCIDMA/IBIMED/Department of Mathematics, University of Aveiro, Aveiro - Portugal
| | - Luís Santos
- Baixo Vouga Hospital CentreAveiroPortugalBaixo Vouga Hospital Centre, Aveiro - Portugal
| | - Luís Fernandes
- University of YorkCentre for Health EconomicsYorkReino UnidoCentre for Health Economics, University of York, York - Reino Unido
| | - Ana Briosa
- Baixo Vouga Hospital CentreAveiroPortugalBaixo Vouga Hospital Centre, Aveiro - Portugal
| |
Collapse
|
13
|
What does complete revascularization mean in 2021? - Definitions, implications, and biases. Curr Opin Cardiol 2021; 36:748-754. [PMID: 34483299 DOI: 10.1097/hco.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Coronary revascularization is known to be an excellent treatment for coronary artery disease. However, whether incomplete myocardial revascularization compromises long-term outcomes, as compared to complete revascularization (CR), remains contentious. Herein, we review the concept of and evidence on CR/incomplete revascularization (ICR) and discuss future perspectives. RECENT FINDINGS When possible, achieving CR in coronary artery bypass grafting is desirable; nonetheless, ICR is also a reasonable option to balance the therapeutic benefits against the risks. SUMMARY Although angiography-based assessment currently remains the standard of care, fractional flow reserve guidance may reduce the number of lesions requiring revascularization, which may be helpful for an appropriate surgical revascularization strategy. In particular, utilizing this approach may refine hybrid revascularization procedures, especially among high-risk patients.
Collapse
|
14
|
Fiddicke M, Fleissner F, Brunkhorst T, Kühn EM, Obed D, Boethig D, Ismail I, Haverich A, Warnecke G, Sommer W. Coronary artery bypass grafts to chronic occluded right coronary arteries. JTCVS OPEN 2021; 7:169-179. [PMID: 36003729 PMCID: PMC9390466 DOI: 10.1016/j.xjon.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/04/2021] [Indexed: 11/15/2022]
Abstract
Background The benefit of revascularizing chronically occluded coronary arteries remains debatable, and available long-term outcome reports are sparse. Current guidelines recommend revascularization of chronically occluded arteries only in patients with myocardial ischemia and/or symptoms associated with angina. We investigated outcome of patients with total chronic occlusion of the right coronary artery (RCA) receiving coronary artery bypass grafting (CABG) surgery with and without revascularization of the RCA. Methods We retrospectively analyzed all patients with chronically occluded RCAs receiving CABG with (group 1 = RCA-CABG; n = 487) and without (group 2 = No-RCA-CABG; n = 100) revascularization of the RCA. In total, 587 patients with complete follow-up of a minimum of 6 years were included (92%). Results In total, 82% in group 1 versus 86% in group 2 were male (P = .38). European System for Cardiac Operative Risk Evaluation II was comparable between both groups (4.35 ± 7.09% vs 4.80 ± 5.77%, P = .56) with no major differences regarding preoperative characteristics between groups. Patients in group 1 received 3.24 ± 0.79 distal anastomoses, whereas group 2 received 2.45 ± 0.83 distal anastomoses (P < .001). Although in-hospital mortality was comparable (2.9% in group 1 vs 5.0% in group 2, P = .27), long-term survival was significantly better in group 1 (P = .002). No difference in the incidence of further major adverse cardiac and cerebrovascular events was found. Conclusions Patients with a chronically occluded RCA undergoing CABG who did not receive an RCA graft showed a significantly reduced long-term survival. Given the herein presented data, revascularization of chronically occluded right arteries during CABG should be recommended whenever technically feasible.
Collapse
Affiliation(s)
- Maleen Fiddicke
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleissner
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tonita Brunkhorst
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Eva M. Kühn
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Doha Obed
- Department of Plastic- and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Issam Ismail
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
- Address for reprints: Wiebke Sommer, MD, Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany.
| |
Collapse
|
15
|
Bianco V, Kilic A, Aranda-Michel E, Serna-Gallegos D, Ferdinand F, Dunn-Lewis C, Wang Y, Thoma F, Navid F, Sultan I. Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events. J Thorac Cardiovasc Surg 2021:S0022-5223(21)00900-4. [PMID: 34272071 DOI: 10.1016/j.jtcvs.2021.05.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 04/26/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Complete revascularization literature is limited by variance in patient cohorts and inconsistent definitions. The objective of the current study was to provide risk-adjusted outcomes for complete revascularization of significant nonmain-branch and main-branch vessel stenoses. METHODS All patients that underwent first-time isolated coronary artery bypass grafting procedures were included. Kaplan-Meier survival estimates, cumulative incidence function, and Cox regression were used to analyze outcomes. RESULTS The total population consisted of 3356 patients that underwent first-time isolated coronary artery bypass grafting. Eight hundred eighty-nine (26.5%) patients had incomplete and 2467 (73.5%) had complete revascularization. For main-branch vessels, 677 (20.2%) patients had incomplete revascularization and 2679 (79.8%) were completely revascularized. Following risk adjustment with inverse probability treatment weighting, all baseline characteristics were balanced (standardized mean difference, ≤ 0.10). On Kaplan-Meier estimates, survival at 1 year (94.6% vs 92.5%) and 5 years (86.5% vs 82.1%) (P = .05) was significantly better for patients who received complete revascularization. Freedom from major adverse cardiac and cerebrovascular events was significantly higher for the complete revascularization cohort at both 1 year (89.2% vs 84.2%) and 5 years (72.5% vs 66.7%) (P < .001). Complete revascularization (hazard ratio, 0.82; 95% confidence interval, 0.70-0.95; P = .01) was independently associated with a significant reduction in major adverse cardiac and cerebrovascular events. Incomplete revascularization of nonmain-branch vessels was not associated with mortality (hazard ratio, 1.14; 95% confidence interval, 0.74-1.8; P = .55) or major adverse cardiac and cerebrovascular events (hazard ratio, 0.90; 95% confidence interval, 0.66-1.24; P = .52). CONCLUSIONS Complete surgical revascularization of all angiographically stenotic vessels in patients with multivessel coronary artery disease is associated with fewer major adverse events. Incomplete revascularization of nonmain-branch vessels is not associated with survival or major adverse cardiac and cerebrovascular events.
Collapse
Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Francis Ferdinand
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Courtenay Dunn-Lewis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Floyd Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| |
Collapse
|
16
|
Rosenblum JM, Binongo J, Wei J, Liu Y, Leshnower BG, Chen EP, Miller JS, Macheers SK, Lattouf OM, Guyton RA, Thourani VH, Halkos ME, Keeling WB. Priorities in coronary artery bypass grafting: Is midterm survival more dependent on completeness of revascularization or multiple arterial grafts? J Thorac Cardiovasc Surg 2021; 161:2070-2078.e6. [DOI: 10.1016/j.jtcvs.2019.11.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 10/15/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
|
17
|
Rate of Incomplete Revascularization Following Coronary Artery Bypass Grafting at a Single Institution Between 2007 and 2017. Am J Cardiol 2021; 144:33-36. [PMID: 33383011 DOI: 10.1016/j.amjcard.2020.12.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 12/20/2022]
Abstract
Incomplete revascularization following coronary artery bypass grafting (CABG) is associated with increased repeat revascularization, myocardial infarction and death. Whether the rate of incomplete revascularization is increasing over time has not been previously described. All patients with multivessel coronary artery disease who underwent isolated and elective CABG at our Institution in 2007 (n = 291) were compared to patients who underwent CABG in 2017 (n = 290). A Revascularization Index Score was created to compare rates of incomplete revascularization between the 2 years based on the coronary anatomy and degree of stenosis. Comparison of the 2 years disclose that the rate of incomplete revascularization increased from 17.9% in 2007 to 28.3% in 2017 (p = 0.003) and was accompanied by a decline in the Revascularization Index Score from 0.73 to 0.67 (p = 0.005). Left ventricular function improved in both groups following CABG. Two-year cardiovascular mortality was significantly higher in the 2017 cohort compared to the 2007 cohort. These differences may be attributable to patient factors including more severe coronary artery disease associated with older age, greater incidence of smoking and previous percutaneous coronary intervention. In conclusion, the rate of incomplete revascularization following CABG significantly increased in 2017 compared to 2007 and was associated with higher cardiovascular mortality.
Collapse
|
18
|
Lin TH, Wang CW, Shen CH, Chang KH, Lai CH, Liu TJ, Chen KJ, Chen YW, Lee WL, Su CS. Clinical outcomes of multivessel coronary artery disease patients revascularized by robot-assisted vs conventional standard coronary artery bypass graft surgeries in real-world practice. Medicine (Baltimore) 2021; 100:e23830. [PMID: 33545949 PMCID: PMC7837900 DOI: 10.1097/md.0000000000023830] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 11/20/2020] [Indexed: 11/18/2022] Open
Abstract
The treatment of patients with multivessel coronary artery disease (MVD) by coronary stenting (PCI) and the "gold standard" conventional coronary-artery bypass grafting (C-CABG) has been well explored in the literature. However, the clinical outcomes of robot-assisted CABG (R-CABG) vs C-CABG in MVD patients in real-world practice were unknown. We aimed to study the clinical outcomes of MVD patients who underwent R-CABG (robotic MIDCAB) and C-CABG at our institution between January 2005 and December 2013.A total of 516 MVD patients received CABG were recruited into this study. Among them, 281 patients received R-CABG and 235 patients underwent C-CABG. Patients in the R-CABG group were younger, and had fewer vessels with coronary artery disease (CAD), lower prevalence of chronic renal disease (CKD), higher left ventricular ejection fraction (LVEF), as well as lower Euro scores. The in-hospital and long-term mortalities were lower in the R-CABG group, but the incidences of target lesion revascularization (TLR), target vessel revascularization (TVR), myocardial infarction (MI), and stroke were not significantly different between the two groups. The long-term mortality was related to age, lower LVEF, and CKD, but not residual SYNTAX score, or completeness of revascularization. The revascularization modality (R-CABG vs C-CABG) was a borderline significantly independent predictor of long-term mortality (OR 1.76 [0.99-3.14], P = .055).Our study concluded that R-CABG, in comparison with C-CABG, for MVD carried out in younger patients involved fewer clinical complexities was associated with lower in-hospital and long-term mortalities in real-world practice. However, the long-term rates of TLR, TVR, MI, and stroke were similar. The long-term mortality was correlated with age, lower LVEF, and CKD, where R-CABG remained a borderline significant predictor after correcting for confounding factors. R-CABG could be an effective alternative to C-CABG for MVD patients with fewer clinical complexities in real-world practice.
Collapse
Affiliation(s)
- Tzu-Hsiang Lin
- Cardiovascular Center, Taichung Veterans General Hospital
| | - Chi-Wei Wang
- Division of Cardiology, Asia University Hospital
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung
- Department of Medicine and Surgery, National Yang Ming University School of Medicine, Taipei
| | - Keng-Hao Chang
- Department of Internal Medicine, Cheng Ching Hospital, Taichung
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital
- Institute of Clinical Medicine
| | - Tsun-Jui Liu
- Cardiovascular Center, Taichung Veterans General Hospital
- Department of Medicine, National Yang Ming University School of Medicine
| | - Kuan-Ju Chen
- Cardiovascular Center, Taichung Veterans General Hospital
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Wei Chen
- Cardiovascular Center, Taichung Veterans General Hospital
| | - Wen-Lieng Lee
- Cardiovascular Center, Taichung Veterans General Hospital
- Department of Medicine, National Yang Ming University School of Medicine
| | - Chieh-Shou Su
- Cardiovascular Center, Taichung Veterans General Hospital
- Institute of Clinical Medicine
| |
Collapse
|
19
|
Joshi MM, Paul S, Bhosle KN, Nagre SW, Parashi H, Jadhao M, Rawekar K, Ravikumar V, Sawkar V, Selwyn JA. Individual Versus Sequential Saphenous Vein Grafts for on-Pump Coronary Artery Bypass Grafting - Does Smaller Coronaries in Indians Affect Graft Choice? - A Mid-Term Patency Comparison Study. J Saudi Heart Assoc 2020; 33:109-116. [PMID: 34183906 PMCID: PMC8143723 DOI: 10.37616/2212-5043.1245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although multiarterial grafting or bilateral mammary artery use is being increasingly emphasized for contemporary coronary artery bypass grafting (CABG) practice, saphenous vein graft (SVG) still accounts for 80% of all CABG conduits (Park et al., 2020) [1]. In India, both the individual and sequential saphenous grafting techniques are used arbitrarily, and there has not been a study that compares the mid-term patency of these two. This is specially relevant in view of smaller coronaries in Indians than the Caucasian counterparts. This study aims to compare the patency for on pump CABG's. METHODS In the present study, 323 patients underwent either sequential (group A, N = 151 grafts, each graft having two anastomoses each) or individual (group B, N = 344 grafts) saphenous vein CABG, between February 2014 and June 2017. The SVG anastomoses were created on obtuse marginal (OM1/OM2) and posterior descending artery (PDA). The graft patency of the vein grafts as well as the left internal mammary artery were assessed by serial coronary angiograms. RESULTS Results were evaluated at 6 months, 1, 2 and 3 years post operatively. Group A showed a higher graft patency at 3 years at 80.8%, and group B, 67.1% (P = 0.002). Also, anastomoses on sequential conduits had overall better patency rates at three years (77.2% vs 67.2%, P = 0.005). The groups showed similar results at one year post operatively. CONCLUSIONS Sequential bypass grafts were associated with superior mid-term patency compared with individual grafts. These findings suggest the more favourable results of sequential bypass grafting to be attributed to the enhanced flow haemodynamics.
Collapse
Affiliation(s)
- Manoj M. Joshi
- Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, 400008, Mumbai, Maharashtra,
India
| | - Saptarshi Paul
- Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, 400008, Mumbai, Maharashtra,
India
| | - Krishnarao N. Bhosle
- Department of Cardiovascular and Thoracic Surgery, D Y Patil Medical College, Navi, 400706, Mumbai, Maharashtra,
India
| | - Suraj W. Nagre
- Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, 400008, Mumbai, Maharashtra,
India
| | - Hrishikesh Parashi
- Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, 400008, Mumbai, Maharashtra,
India
| | - Manish Jadhao
- Department of Cardiovascular and Thoracic Surgery, Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai, 400022, Maharashtra,
India
| | - Kunal Rawekar
- Department of Cardiovascular and Thoracic Surgery, Government Medical College, Nagpur, 440003, Mumbai, Maharashtra,
India
| | - Vignesh Ravikumar
- Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, 400008, Mumbai, Maharashtra,
India
| | - Vishal Sawkar
- Department of Cardiovascular and Thoracic Surgery, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, 400008, Mumbai, Maharashtra,
India
| | - Joshua A. Selwyn
- Department of Preventive and Social Medicine and Biostatistics, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, 400008, Mumbai, Maharashtra,
India
| |
Collapse
|
20
|
Kalarus Z, Svendsen JH, Capodanno D, Dan GA, De Maria E, Gorenek B, Jędrzejczyk-Patej E, Mazurek M, Podolecki T, Sticherling C, Tfelt-Hansen J, Traykov V, Lip GYH, Fauchier L, Boriani G, Mansourati J, Blomström-Lundqvist C, Mairesse GH, Rubboli A, Deneke T, Dagres N, Steen T, Ahrens I, Kunadian V, Berti S. Cardiac arrhythmias in the emergency settings of acute coronary syndrome and revascularization: an European Heart Rhythm Association (EHRA) consensus document, endorsed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Acute Cardiovascular Care Association (ACCA). Europace 2020; 21:1603-1604. [PMID: 31353412 DOI: 10.1093/europace/euz163] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 12/22/2022] Open
Abstract
Despite major therapeutic advances over the last decades, complex supraventricular and ventricular arrhythmias (VAs), particularly in the emergency setting or during revascularization for acute myocardial infarction (AMI), remain an important clinical problem. Although the incidence of VAs has declined in the hospital phase of acute coronary syndromes (ACS), mainly due to prompt revascularization and optimal medical therapy, still up to 6% patients with ACS develop ventricular tachycardia and/or ventricular fibrillation within the first hours of ACS symptoms. Despite sustained VAs being perceived predictors of worse in-hospital outcomes, specific associations between the type of VAs, arrhythmia timing, applied treatment strategies and long-term prognosis in AMI are vague. Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia that may be asymptomatic and/or may be associated with rapid haemodynamic deterioration requiring immediate treatment. It is estimated that over 20% AMI patients may have a history of AF, whereas the new-onset arrhythmia may occur in 5% patients with ST elevation myocardial infarction. Importantly, patients who were treated with primary percutaneous coronary intervention for AMI and developed AF have higher rates of adverse events and mortality compared with subjects free of arrhythmia. The scope of this position document is to cover the clinical implications and pharmacological/non-pharmacological management of arrhythmias in emergency presentations and during revascularization. Current evidence for clinical relevance of specific types of VAs complicating AMI in relation to arrhythmia timing has been discussed.
Collapse
Affiliation(s)
- Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice, Poland.,Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Davide Capodanno
- Division of Cardiology, CAST, P.O. "Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Gheorghe-Andrei Dan
- "Carol Davila" University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Elia De Maria
- Ramazzini Hospital, Cardiology Unit, Carpi (Modena), Italy
| | | | - Ewa Jędrzejczyk-Patej
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Michał Mazurek
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Tomasz Podolecki
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Christian Sticherling
- Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jacob Tfelt-Hansen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vassil Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Clinic of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Université de Tours, Faculté de Médecine., Tours, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | | | | | - Georges H Mairesse
- Department of Cardiology - Electrophysiology, Cliniques du Sud Luxembourg - Vivalia, Arlon, Belgium
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Thomas Deneke
- Clinic for Electrophysiology, Rhoen-Clinic Campus Bad Neustadt, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Torkel Steen
- Department of Cardiology, Pacemaker- & ICD-Centre, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Ingo Ahrens
- Department of Cardiology & Intensive Care, Augustinerinnen Hospital, Cologne, Germany
| | - Vijay Kunadian
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sergio Berti
- Department of Cardiology, Fondazione C.N.R. Reg. Toscana G. Monasterio, Heart Hospital, Massa, Italy
| |
Collapse
|
21
|
Gaba P, Gersh BJ, Ali ZA, Moses JW, Stone GW. Complete versus incomplete coronary revascularization: definitions, assessment and outcomes. Nat Rev Cardiol 2020; 18:155-168. [PMID: 33067581 DOI: 10.1038/s41569-020-00457-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Coronary artery disease is the leading cause of morbidity and mortality worldwide. Selected patients with obstructive coronary artery disease benefit from revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Many (but not all) studies have demonstrated increased survival and greater freedom from adverse cardiovascular events after complete revascularization (CR) than after incomplete revascularization (ICR) in patients with multivessel disease. However, achieving CR after PCI or CABG surgery might not be feasible owing to patient comorbidities, anatomical factors, and technical or procedural considerations. These factors also mean that comparisons between CR and ICR are subject to multiple confounders and are difficult to understand or apply to real-world clinical practice. In this Review, we summarize and critically appraise the evidence linking various types of ICR to adverse outcomes in patients with multivessel disease and stable ischaemic heart disease, non-ST-segment elevation acute coronary syndrome or ST-segment elevation myocardial infarction, with or without cardiogenic shock. In addition, we provide practical recommendations for revascularization in patients with high-risk multivessel disease to optimize their long-term clinical outcomes and identify areas requiring future clinical investigation.
Collapse
Affiliation(s)
- Prakriti Gaba
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ziad A Ali
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Jeffrey W Moses
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.,Cardiovascular Research Foundation, New York, NY, USA
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, NY, USA. .,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
22
|
El-Gamel A, Chan B. Full Metal Jacket Endarterectomy of Left Anterior Descending Coronary Artery is Safe With Good Midterm Outcomes. Heart Lung Circ 2020; 30:605-611. [PMID: 32952038 DOI: 10.1016/j.hlc.2020.08.007] [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: 05/30/2020] [Revised: 07/16/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Multiple overlapping stents (Full metal jacket, FMJ) from percutaneous coronary artery intervention (PCI) renders coronary artery bypass modus operandi unmanageable. We report our surgical revascularisation in patients with failed full metal jacket of left anterior descending coronary artery (FMJ-LAD). METHODS We reviewed 22 patients who presented with FMJ-LAD From 2006 to 2019. Extensive endarterectomy involving almost the whole length of the left anterior descending (LAD) was performed, the arteriotomy patched up with a saphenous vein. All reconstructed LADs were grafted with the left internal mammary artery. We compared the group to propensity-matched patients with single proximal LAD lesions requiring coronary artery bypass graft (CABG). RESULTS The mean age was 54±3.5 years. Twenty-one (21) patients (95%) were in angina class III or IV despite maximum medical therapy. Fourteen (14) patients (63.6%) presented with MI within 1 month. All patients had a preoperative positive test for ischaemia. Cross-clamp and bypass times were significantly shorter (25.5±7 mins and 65±5 mins, versus 52±3 mins and 77.2±4 mins) in the CABG group compared to FMJ-LAD group, the mean hospital stay of 6±1.5 days was not different between the groups. Postoperative electrocardiograms showed non-specific changes in 75% (n=16) with no enzyme rise. Early postoperative angiography was performed in 10 patients because of the new electrocardiograph (ECG) changes; all FMJ-LAD patients had an angiogram at 1 year, two late angiograms (2 and 3 years postoperatively), and one computed tomography (CT)-angiogram for readmission with angina. All patients in the FMJ-LAD group had 12 months follow-up angiogram or cardiac CT scan. All the endarterectomies' LADs were patent. There was no mortality within the 30 days. Patients' follow-up time was between 1-13 years. CONCLUSIONS Open stent endarterectomy is a valuable alternative option for patients with "full metal jacket" diseased LAD that is not graftable using standard techniques with acceptable midterm results.
Collapse
Affiliation(s)
- Adam El-Gamel
- Department of Cardiothoracic Surgery, Waikato Hospital, Waikato, New Zealand; Department of Surgery, Auckland University, Auckland, New Zealand.
| | - Brian Chan
- Department of Cardiothoracic Anesthesia, Waikato Hospital, Waikato, New Zealand
| |
Collapse
|
23
|
Revascularization in Patients With Left Main Coronary Artery Disease and Left Ventricular Dysfunction. J Am Coll Cardiol 2020; 76:1395-1406. [DOI: 10.1016/j.jacc.2020.07.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 01/10/2023]
|
24
|
Tarus A, Tinica G, Bacusca A, Artene B, Popa IV, Burlacu A. Coronary revascularization during treatment of severe aortic stenosis: A meta-analysis of the complete percutaneous approach (PCI plus TAVR) versus the complete surgical approach (CABG plus SAVR). J Card Surg 2020; 35:2009-2016. [PMID: 32667080 DOI: 10.1111/jocs.14814] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The management of patients with coexisting severe aortic stenosis (AS) and coronary artery disease (CAD) is still facing a great deal of uncertainty when it comes to choosing between the entire surgical versus the complete percutaneous approaches, after accurately balancing risks versus outcomes. AIM To evaluate clinical outcomes and mortality of transcatheter aortic valve replacement (TAVR) plus percutaneous coronary intervention (PCI) compared with surgical aortic valve replacement (SAVR) plus coronary arteries bypass grafting (CABG) procedures in patients with concomitant AS and CAD. METHODS Electronic databases of PubMed, EMBASE, and SCOPUS were searched for relevant articles assessing outcome parameters of interest. The study endpoints were the rate of overall myocardial infarction and stroke within 30 days and the rate of 30-day mortality and 2-year mortality between patients with TAVR/PCI and those with SAVR/CABG. RESULTS Random-effect meta-analysis did not reveal any significant difference between 30-day safety outcomes: myocardial infarction (TAVR/PCI vs SAVR/CABG: odds ratio [OR]: 0.52; 95% confidence interval [CI]: 0.20-1.33; I2 = 0%), stroke (TAVR/PCI vs SAVR/CABG: OR: 0.88; 95% CI: 0.45-1.73; I2 = 0%). No significant difference in 30-day mortality (OR: 0.72; 95% CI: 0.43-1.21; I2 = 0%) and 2-year mortality (OR: 1.50; 95% CI: 0.77-2.94; I2 = 81%) rate was noted between patients with TAVR/PCI and those with SAVR/CABG. CONCLUSIONS When comparing the total percutaneous and total surgical treatment, no significant difference in short-term safety outcomes or early and late mortality was observed. More evidence is needed to guide the clinical decision.
Collapse
Affiliation(s)
- Andrei Tarus
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania
| | - Grigore Tinica
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania.,Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alberto Bacusca
- Department of Cardiovascular Surgery, Cardiovascular Diseases Institute, Iasi, Romania
| | - Bogdan Artene
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| | - Iolanda V Popa
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Alexandru Burlacu
- Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.,Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
| |
Collapse
|
25
|
Sirgo J, Gil Ó, Campos E, Taylor J, Dalmau MJ, Juez M, García-Fuster R, Hornero F, Martínez-León J. Cirugía coronaria asistida con circulación extracorpórea sin pinzamiento aórtico en pacientes con disfunción ventricular severa: resultados a corto y medio plazo. CIRUGIA CARDIOVASCULAR 2020. [DOI: 10.1016/j.circv.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
26
|
Bangalore S, Guo Y, Samadashvili Z, Hannan EL. Outcomes With Complete Versus Incomplete Revascularization in Patients With Multivessel Coronary Disease Undergoing Percutaneous Coronary Intervention With Everolimus Eluting Stents. Am J Cardiol 2020; 125:362-369. [PMID: 31810515 DOI: 10.1016/j.amjcard.2019.10.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 01/10/2023]
Abstract
The aim of the study was to evaluate the outcomes with completeness of revascularization (CR) in patients with multivessel disease (MVD) who underwent PCI using everolimus-eluting stent (EES). Patients with MVD who underwent PCI using EES in New York State were chosen. Patients were categorized into CR, attempted but failed CR or incomplete revascularization (ICR). The primary outcome was death/myocardial infarction (MI). Secondary outcomes were death/MI/repeat revascularization and the individual components of the composite outcomes. Multiple propensity score adjustment analysis was used to adjust for differences in covariates among the 3 groups. Among 15,046 patients, 4,545 (30%) had CR. The strongest predictors of ICR were the number of vessels diseased (χ2 = 428.48; p <0.0001) and presence of chronic total occlusion (CTO) (χ2 = 184.27; p <0.0001). In the multiple propensity score-adjusted analysis, over a mean follow-up of 2.9 years, compared with CR, ICR was associated with significant higher risk of death/MI (17.49% vs 12.69%; hazard ratio [HR] = 1.15; 95% confidence interval [CI] 1.02 to 1.29; p = 0.02), death/MI/repeat revascularization (48.01% vs 37.85%; HR = 1.19; 95% CI 1.12 to 1.27; p <0.0001), death (12.41% vs 8.63%; HR = 1.16; 95% CI 1.00 to 1.35; p = 0.047), and repeat revascularization (39.16% vs 31.63%; HR = 1.20; 95% CI 1.12 to 1.28; p <0.0001), with numerically higher rates of MI (7.18% vs 4.90%; HR = 1.17; 95% CI 0.98 to 1.40; p = 0.09). The risk with attempted but failed CR was intermediate between CR and ICR. In conclusion, in patients with MVD who underwent PCI with EES, incomplete revascularization is associated with significantly higher risk of cardiovascular events including death compared with complete revascularization.
Collapse
Affiliation(s)
| | - Yu Guo
- New York University School of Medicine, New York, New York
| | - Zaza Samadashvili
- School of Public Health, State University of New York at Albany, Albany, New York
| | - Edward L Hannan
- School of Public Health, State University of New York at Albany, Albany, New York
| |
Collapse
|
27
|
Rocha RV, Tam DY, Fremes SE. Commentary: Complete or incomplete? Just use more arteries. J Thorac Cardiovasc Surg 2020; 161:2079-2080. [PMID: 31973897 DOI: 10.1016/j.jtcvs.2019.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/04/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Rodolfo V Rocha
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
28
|
Kwon DH, Obuchowski NA, Marwick TH, Menon V, Griffin B, Flamm SD, Hachamovitch R. Jeopardized Myocardium Defined by Late Gadolinium Enhancement Magnetic Resonance Imaging Predicts Survival in Patients With Ischemic Cardiomyopathy: Impact of Revascularization. J Am Heart Assoc 2019; 7:e009394. [PMID: 30571486 PMCID: PMC6404459 DOI: 10.1161/jaha.118.009394] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The prognostic impact of jeopardized myocardium ( JM ) in patients with advanced ischemic cardiomyopathy ( ICM ) is unclear. We hypothesized that JM is an independent predictor of mortality in patients with advanced ICM . Methods and Results Patients with ICM who underwent cardiac magnetic resonance imaging between January 2002 and January 2013 were included in our study. JM was identified as a vascular territory with <50% myocardial scarring on cardiac magnetic resonance imaging and with >70% stenosis in a major coronary vessel that was not subsequently revascularized. A propensity score was developed for revascularization. A multivariable Cox proportional hazards model was used to evaluate the association of JM with all-cause mortality. We evaluated 631 patients over a mean follow-up of 5.1 years. Overall, 336 patients underwent subsequent revascularization during the follow-up period, among whom 23% had remaining JM , while 295 patients were medically treated (57% with JM ). There were 204 deaths (32%). On multivariable analysis, JM (hazard ratio, 1.88; 95% confidence interval, 1.38-2.55 [ P<0.001]) was independently associated with all-cause mortality after adjusting for multiple other factors. The risk associated with the presence of JM increased by 5% for every 10-unit increase in left ventricular end-systolic volume index. Conclusions JM is an independent and incremental predictor of mortality in patients with advanced ICM . Patients undergoing revascularization with residual JM had similar risk of mortality compared with medically treated patients with JM . The risk associated with JM significantly increased in the presence of worsening adverse left ventricular remodeling. Cardiac magnetic resonance viability assessment may provide important risk stratification in patients with ICM .
Collapse
Affiliation(s)
- Deborah H Kwon
- 1 Heart and Vascular Institute Cleveland Clinic Cleveland OH.,2 Imaging Institute Cleveland Clinic Cleveland OH
| | - Nancy A Obuchowski
- 2 Imaging Institute Cleveland Clinic Cleveland OH.,3 Quantitative Health Sciences Cleveland Clinic Cleveland OH
| | - Thomas H Marwick
- 4 Baker Heart and Diabetes Institute Melbourne Victoria Australia
| | - Venu Menon
- 1 Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Brian Griffin
- 1 Heart and Vascular Institute Cleveland Clinic Cleveland OH
| | - Scott D Flamm
- 1 Heart and Vascular Institute Cleveland Clinic Cleveland OH.,2 Imaging Institute Cleveland Clinic Cleveland OH
| | | |
Collapse
|
29
|
Su CS, Shen CH, Chang KH, Lai CH, Liu TJ, Chen KJ, Lin TH, Chen YW, Lee WL. Clinical outcomes of patients with multivessel coronary artery disease treated with robot-assisted coronary artery bypass graft surgery versus one-stage percutaneous coronary intervention using drug-eluting stents. Medicine (Baltimore) 2019; 98:e17202. [PMID: 31567970 PMCID: PMC6756629 DOI: 10.1097/md.0000000000017202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A number of studies have reported on treatment outcomes of coronary stenting (PCI) for multivessel coronary artery diseases (MVD), and compared them with the conventional coronary artery bypass grafting (CABG). However, the clinical outcomes of robot-assisted CABG (R-CABG) in comparison with PCI in MVD patients have not been investigated.We recruited retrospectively MVD patients receiving R-CABG and PCI with drug-eluting stents for all vessels in one stage between January 2005 and December 2013 at our institution with at least 3 years of outcomes were retrospectively recruited and analyzed.A total of 638 MVD patients were studied. Among them, 281 received R-CABG, and 357 received PCI. Similar complete revascularizations were achieved in both groups (R-CABG: 40.2%, PCI: 41.5%, P = .751). The residual stenosis was 4.1 ± 4.4 in the R-CABG group, and comparably 3.5 ± 3.7 in the PCI group (P = .077). Patients in the R-CABG group were younger, with more severe coronary artery disease (CAD) and had more background risk factors. The in-hospital and long-term mortalities as well as the incidence of TLR, myocardial infarction (MI), stroke were all similar between groups. But the incidence of TVR and any revascularization were lower in the R-CABG group. The long-term mortality was predicted by age, left ventricular ejection fraction, and chronic kidney disease, but not by the revascularization modality, completeness of revascularization, nor residual SYNTAX scores. The last 3 factors were not predictors of long-term TLR, TVR, MI, and stroke.The in-hospital and long-term survival rates of MVD were similar for both the R-CABG and PCI groups. But the R-CABG group had rates of TVR and any revascularization lower than PCI. Revascularization modality, completeness of revascularization, and residual SYNTAX scores were not predictors of in-hospital and long-term mortalities, MI, and stroke in real-world practice. R-CABG was associated with lower rates of TLR and TVR, and is likely a safe and effective treatment and an alternative choice of PCI for MVD patients who have low surgical risks.
Collapse
Affiliation(s)
- Chieh-Shou Su
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Institute of Clinical Medicine, and Department of Medicine, National Yang-Ming University School of Medicine, Taipei
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung
- School of Medicine, National Yang-Ming University, Taipei
| | - Keng-Hao Chang
- Department of Internal Medicine, Cheng Ching Hospital, Taichung
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Institute of Clinical Medicine, and Department of Medicine, National Yang-Ming University School of Medicine, Taipei
| | - Tsun-Jui Liu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei
| | - Kuan-Ju Chen
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Tzu-Hsiang Lin
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Yu-Wei Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Wen-Lieng Lee
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei
| |
Collapse
|
30
|
Ly HQ, Nosair M, Cartier R. Surgical Turndown: “What’s in a Name?” for Patients Deemed Ineligible for Surgical Revascularization. Can J Cardiol 2019; 35:959-966. [DOI: 10.1016/j.cjca.2019.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/29/2019] [Accepted: 05/05/2019] [Indexed: 12/22/2022] Open
|
31
|
Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019. [DOI: 10.1097/01243895-200500110-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background The purpose of this evidence-based consensus statement is to systematically review and meta-analyze the randomized and nonrandomized evidence comparing off-pump (OPCAB) to conventional coronary artery bypass (CCAB) surgery and to provide consensus on the role of OPCAB in low- and high-risk surgical patients. Methods and Results This consensus conference was conducted according to the American College of Cardiology (ACC)/American Heart Association (AHA) standards for development of clinical practice guidelines. The Steering Committee collated all published studies of OPCAB versus CCAB through May 2004 and developed six questions central to controversies surrounding OPCAB surgery in mortality, morbidity, and resource utilization. For mixed-risk patient populations, meta-analysis of 37 randomized clinical trials (3,369 patients, Level A) reported across a total of 53 papers, and two meta-analyses of nonrandomized trials (Level B) comparing OPCAB versus CCAB were identified. For high-risk patient populations, we performed a meta-analysis of 3 randomized and 42 nonrandomized trials (26,349 patients, Level B). Conclusion Meta-analysis of Level A and B evidence provided the basis for the following consensus statements in patients undergoing surgical myocardial revascularization: (1) OPCAB should be considered a safe alternative to CCAB with respect to risk of mortality [Class I, Level A]; (2) With appropriate use of modern stabilizers, heart positioning devices, and adequate surgeon experience, similar completeness of revascularization and graft patency can be achieved [Class IIa, Level A]; (3) OPCAB is recommended to reduce perioperative morbidity [Class I, Level A]; (4) OPCAB may be recommended to minimize midterm cognitive dysfunction [Class IIa, Level A]; (5) OPCAB should be considered as an equivalent alternative to CCAB in regard to quality of life [Class I, Level A]; (6) OPCAB is recommended to reduce the duration of ventilation, ICU and hospital stay, and resource utilization [Class I, Level A]; (7) OPCAB should be considered in high-risk patients to reduce perioperative mortality, morbidity, and resource utilization [Class IIa, Level B].
Collapse
|
32
|
Natale E, Denitza Tinti M. Angina after incomplete revascularization: therapeutic solutions. Eur Heart J Suppl 2019; 21:B57-B58. [PMID: 30948950 PMCID: PMC6439909 DOI: 10.1093/eurheartj/suz010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
33
|
Puskas J, Cheng D, Knight J, Angelini G, DeCannier D, Diegeler A, Dullum M, Martin J, Ochi M, Patel N, Sim E, Trehan N, Zamvar V. Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019. [DOI: 10.1177/155698450500100102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John Puskas
- Division of Cardiothoracic Surgery, Emory University, Atlanta, USA
| | - Davy Cheng
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - John Knight
- Cardiothoracic Surgical Unit, Flinders Medical Center, Bedford Park, Australia
| | | | | | - Anno Diegeler
- Herz-Und Gefasse Klinik Bad Neustadt, University of Leipzig, Bad Neustadt, Germany
| | - Mercedes Dullum
- Department of Cardiothoracic Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Masami Ochi
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Nirav Patel
- Lenox Hill Hospital, New York, New York, USA
| | - Eugene Sim
- Department of Cardiovascular Surgery, National University Hospital, Singapore, Singapore
| | - Naresh Trehan
- Escorts Heart Institute and Research Center, New Delhi, India
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
34
|
Completeness of Revascularization as a Determinant of Outcome: A Contemporary Review and Clinical Perspectives. Can J Cardiol 2019; 35:948-958. [PMID: 31167712 DOI: 10.1016/j.cjca.2018.12.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/24/2018] [Accepted: 12/30/2018] [Indexed: 11/23/2022] Open
Abstract
It has been debated whether patients with multivessel coronary artery disease should undergo complete revascularization (CR). The benefit of CR is biologically plausible, and numerous studies and large meta-analyses suggested that CR achievement was associated with a substantial reduction of mortality and future coronary events. In patients with multivessel coronary artery disease, the aim of myocardial revascularization is to minimize residual ischemia. Therefore, CR of all significant coronary lesions has been proposed as the first priority in decision-making for myocardial revascularization between coronary artery bypass grafting and percutaneous coronary intervention (PCI). Reflecting the contemporary practice of ischemia-based revascularization, a physiological/functional approach, such as measurement of fractional flow reserve or instantaneous wave-free ratio, is considered more reasonable and should be encouraged for appropriate CR. In patients who present with acute ST-elevation myocardial infarction, current evidence suggests that an immediate or staged CR strategy might be equivalent or superior to culprit-only revascularization. There is still uncertainty on when and how to perform CR in ST-elevation myocardial infarction patients; comprehensive studies dedicated to this issue are required. Hybrid coronary revascularization includes the advantages of minimally invasive bypass grafting for the left anterior descending artery and PCI for non-left anterior descending arteries and has been proposed as a viable alternative for coronary artery bypass grafting or PCI only for achieving CR. In clinical practice, the extent of revascularization and strategy for CR should be individualized, taking account of different aspects of the patients, lesions, and treating physicians. Collaboration of coronary heart teams would confer balanced decision-making and advanced therapeutic capabilities.
Collapse
|
35
|
Takase S. Does the Cardiac Surgeon Accept Coronary Artery Bypass Grafting With Incomplete Revascularization for Patients With Low Ventricular Function and Complex Multivessel Coronary Disease? Circ J 2018; 83:25-26. [PMID: 30531120 DOI: 10.1253/circj.cj-18-1241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shinya Takase
- Department of Cardiovascular Surgery, Fukushima Medical University, School of Medicine
| |
Collapse
|
36
|
Lee Y, Ohno T, Uemura Y, Osanai A, Miura S, Taketani T, Fukuda S, Ono M, Takamoto S. Impact of Complete Revascularization on Long-Term Outcomes After Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction. Circ J 2018; 83:122-129. [PMID: 30369591 DOI: 10.1253/circj.cj-18-0653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The long-term outcomes of complete revascularization (CR) in patients with left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) remain unclear. METHODS AND RESULTS We evaluated a consecutive series of 111 patients with LV ejection fraction ≤35% who underwent isolated first-time CABG: 63 underwent CR and 48 underwent incomplete revascularization (IR). At a median follow-up of 10.1 years, the rates of death from any cause, cardiac death, and major adverse cardiac and cerebrovascular events (MACCE) were significantly greater in the IR group. After adjusting for propensity score, no significant difference was found between the CR and IR groups regarding death from any cause (hazard ratio [HR], 1.45; 95% CI: 0.75-2.81; P=0.271) and cardiac death (HR, 1.45; 95% CI: 0.68-3.10; P=0.337). In contrast, IR increased the risk of MACCE (HR, 1.92; 95% CI: 1.08-3.41; P=0.027), which was principally attributed to an increased risk of repeat revascularization (HR, 3.92; 95% CI: 1.34-11.44; P=0.013). CONCLUSIONS Although IR was not significantly associated with an increased risk of long-term mortality in patients with LV dysfunction who underwent CABG, CR might reduce the risks of repeat revascularization and subsequent MACCE.
Collapse
Affiliation(s)
- Yangsin Lee
- Department of Cardiac Surgery, The University of Tokyo Hospital
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukari Uemura
- Biostatistics Division, Clinical Research Support Center, The University of Tokyo Hospital
| | - Akira Osanai
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Sumio Miura
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | | | - Sachito Fukuda
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | |
Collapse
|
37
|
Allen KB, Mahoney A, Aggarwal S, Davis JR, Thompson E, Pak AF, Heimes J, Michael Borkon A. Transmyocardial revascularization (TMR): current status and future directions. Indian J Thorac Cardiovasc Surg 2018; 34:330-339. [PMID: 33060956 DOI: 10.1007/s12055-018-0702-7] [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] [Received: 04/25/2018] [Revised: 06/07/2018] [Accepted: 07/13/2018] [Indexed: 01/22/2023] Open
Abstract
Purpose Cardiac surgeons are increasingly faced with a more complex patient who has developed a pattern of diffuse coronary artery disease (CAD), which is refractory to medical, percutaneous, and surgical interventions. This paper will review the clinical science surrounding transmyocardial revascularization (TMR) with an emphasis on the results from randomized controlled trials. Methods Randomized controlled trials which evaluated TMR used as sole therapy and when combined with coronary artery bypass grafting were reviewed. Pertinent basic science papers exploring TMR's possible mechanism of action along with future directions, including the synergism between TMR and cell-based therapies were reviewed. Results Two laser-based systems have been approved by the United States Food and Drug Administration (FDA) to deliver laser therapy to targeted areas of the left ventricle (LV) that cannot be revascularized using conventional methods: the holmium:yttrium-aluminum-garnet (Ho:YAG) laser system (CryoLife, Inc., Kennesaw, GA) and the carbon dioxide (CO2) Heart Laser System (Novadaq Technologies Inc., (Mississauga, Canada). TMR can be performed either as a stand-alone procedure (sole therapy) or in conjunction with coronary artery bypass graft (CABG) surgery in patients who would be incompletely revascularized by CABG alone. Societal practice guidelines have been established and are supportive of using TMR in the difficult population of patients with diffuse CAD. Conclusions Patients with diffuse CAD have increased operative and long-term cardiac risks predicted by incomplete revascularization. The documented operative and long-term benefits associated with sole therapy and adjunctive TMR in randomized trials supports TMR's increased use in this difficult patient population.
Collapse
Affiliation(s)
- Keith B Allen
- Saint Luke's Mid America Heart Institute, 4320 Wornall Rd, Medical Plaza II, Suite 50, Kansas City, MO 64111 USA
| | | | - Sanjeev Aggarwal
- Saint Luke's Mid America Heart Institute, 4320 Wornall Rd, Medical Plaza II, Suite 50, Kansas City, MO 64111 USA
| | - John Russell Davis
- Saint Luke's Mid America Heart Institute, 4320 Wornall Rd, Medical Plaza II, Suite 50, Kansas City, MO 64111 USA
| | - Eric Thompson
- Saint Luke's Mid America Heart Institute, 4320 Wornall Rd, Medical Plaza II, Suite 50, Kansas City, MO 64111 USA
| | - Alex F Pak
- Saint Luke's Mid America Heart Institute, 4320 Wornall Rd, Medical Plaza II, Suite 50, Kansas City, MO 64111 USA
| | - Jessica Heimes
- Saint Luke's Mid America Heart Institute, 4320 Wornall Rd, Medical Plaza II, Suite 50, Kansas City, MO 64111 USA
| | - A Michael Borkon
- Saint Luke's Mid America Heart Institute, 4320 Wornall Rd, Medical Plaza II, Suite 50, Kansas City, MO 64111 USA
| |
Collapse
|
38
|
Ji Q, Song K, Xia L, Shi Y, Ma R, Shen J, Ding W, Wang C. Sequential Saphenous Vein Coronary Bypass Grafting. Int Heart J 2018; 59:1211-1218. [PMID: 30305585 DOI: 10.1536/ihj.17-639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The enormous majority of previous reports focused on evaluating the safety and efficacy of sequential saphenous vein (SV) coronary bypass grafting; however, no reports to date have revealed concern regarding the impacts of the number of distal anastomoses of sequential SV grafting on graft patency after coronary artery bypass grafting (CABG). This single-center retrospective study aimed to evaluate the impacts of three versus two distal anastomoses per single SV conduit on SV graft patency after off-pump CABG, and to determine the independent risk factors for sequential SV graft failure.From January 2011 to December 2014, 1320 eligible patients were assigned to either a triple group (three distal anastomoses of sequential SV grafting, n = 758) or a double group (two distal anastomoses of sequential SV grafting, n = 562). The primary endpoint was over a 2-year follow-up SV graft failure after off-pump CABG.The triple and double group received a similar total patency rate of sequential SV conduits (86.5% versus 87.1%, P = 0.757). The number of distal anastomoses of sequential SV grafting (three versus two) was not a predictive factor for the follow-up graft failure of sequential SV conduits (HR = 0.91, 95% CI: 0.66-2.29, P = 0.137). Moreover, the two groups received a similar follow-up survival freedom from repeat revascularization (χ2 = 1.881, log-rank P = 0.170).Three versus two distal anastomoses per single SV conduit received a similar SV graft patency. The number of distal anastomoses of sequential SV grafting was not an independent risk factor for graft failure.
Collapse
Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University
| | - Kai Song
- Shanghai Institute of Cardiovascular Disease
| | - LiMin Xia
- Shanghai Institute of Cardiovascular Disease
| | - YunQing Shi
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University
| | - RunHua Ma
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University
| | - JinQiang Shen
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University
| | - WenJun Ding
- Shanghai Institute of Cardiovascular Disease
| | - ChunSheng Wang
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University
| |
Collapse
|
39
|
Abouzaki NA, Exaire JE, Guzmán LA. Role of Percutaneous Chronic Total Occlusion Interventions in Patients with Ischemic Cardiomyopathy and Reduced Left Ventricular Ejection Fraction. Curr Cardiol Rep 2018; 20:124. [PMID: 30276495 DOI: 10.1007/s11886-018-1066-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to examine current evidence on the benefit of chronic total occlusion (CTO) revascularization in patients with ischemic cardiomyopathy and propose a systematic approach on how and when to accomplish revascularization in these patients. RECENT FINDINGS Coronary revascularization in patients with reduced ejection fraction (EF) is advocated for to improve left ventricular function and consequently clinical outcomes. Approximately 16-31% of angiograms in patients with advanced CAD are noted to have a concomitant coronary CTO. Its presence is a main predictor of worse outcomes. Over the past 15 years, advancements in interventional technologies and techniques have made it possible to treat CTO lesions percutaneously with success rates exceeding 90%. Different revascularization techniques have been organized into widely used algorithms for systematic CTO lesion crossing and treatment. Patients with reduced EF can be revascularized percutaneously with goal of complete functional revascularization. However, randomized prospective data is needed to justify the increased patient risks and healthcare costs associated with these procedures.
Collapse
Affiliation(s)
- Nayef A Abouzaki
- Division of Cardiology, Medical College of Virginia/VCU School of Medicine, Virginia Commonwealth University, 1200 East Broad St, 5th Floor-West wing, Room #526, Richmond, VA, 23298, USA.,Hunter Holmes McGuire Richmond VA Medical Center, Richmond, VA, 23249, USA
| | - Jose E Exaire
- Division of Cardiology, Medical College of Virginia/VCU School of Medicine, Virginia Commonwealth University, 1200 East Broad St, 5th Floor-West wing, Room #526, Richmond, VA, 23298, USA.,Hunter Holmes McGuire Richmond VA Medical Center, Richmond, VA, 23249, USA
| | - Luis A Guzmán
- Division of Cardiology, Medical College of Virginia/VCU School of Medicine, Virginia Commonwealth University, 1200 East Broad St, 5th Floor-West wing, Room #526, Richmond, VA, 23298, USA.
| |
Collapse
|
40
|
Moscona JC, Stencel JD, Milligan G, Salmon C, Maini R, Katigbak P, Saleh Q, Nelson R, Srivastav S, Mogabgab O, Samson R, Le Jemtel T. Physiologic assessment of moderate coronary lesions: a step towards complete revascularization in coronary artery bypass grafting. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:300. [PMID: 30211188 DOI: 10.21037/atm.2018.06.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background An accurate diagnostic assessment of coronary artery disease is crucial for patients undergoing coronary artery bypass grafting (CABG). Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) to guide complete revascularization have not been adequately studied in patients prior to CABG. We compared an anatomic to a physiologic assessment of moderate coronary lesions (40-70% stenosis) in patients referred for CABG. Methods We retrospectively reviewed 109 medical records of patients who underwent CABG at Tulane Medical Center from 2014 to 2016. Patients were divided into an FFR/iFR-guided and an angiography-guided group. Clinical characteristics, procedural outcomes, and clinical outcomes for the two groups were compared over an 18-month follow-up period. Results There were significantly higher rates of three-vessel anastomoses (85.7% vs. 74.7%, P<0.05) and venous grafting (85.7% vs. 76.8%, P<0.05) in the FFR/iFR group. The FFR/iFR group had a lower rate of grafts placed to the left anterior descending artery (LAD) distribution than the angiography group (7.1% vs. 29.5%, P<0.05). The FFR/iFR group had a higher rate of grafts placed to the left circumflex (LCx) artery distribution than the angiography group (28.6% vs. 9.5%, P<0.05). We observed a trend toward reduction in major adverse cardiac events (MACEs) (7.1% vs. 11.6%, P=0.369) and angina (0.0% vs. 6.3%, P=0.429) in the FFR/iFR group compared to the angiography group over 18 months. Conclusions Physiologic assessment of coronary lesions can effectively guide complete revascularization in patients undergoing CABG. Moreover, FFR/iFR-guided CABG was associated with significantly higher rates of three-vessel anastomoses, venous grafting, and graft distribution to the circumflex system.
Collapse
Affiliation(s)
- John C Moscona
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jason D Stencel
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Gregory Milligan
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Christopher Salmon
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Rohit Maini
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Paul Katigbak
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Qusai Saleh
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ryan Nelson
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sudesh Srivastav
- Department of Global Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Owen Mogabgab
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Rohan Samson
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| | - Thierry Le Jemtel
- Tulane Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA, USA
| |
Collapse
|
41
|
Schwann TA, Yammine MB, El-Hage-Sleiman AKM, Engoren MC, Bonnell MR, Habib RH. The effect of completeness of revascularization during CABG with single versus multiple arterial grafts. J Card Surg 2018; 33:620-628. [PMID: 30216551 DOI: 10.1111/jocs.13810] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG). METHODS We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression. RESULTS Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]). CONCLUSIONS Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.
Collapse
Affiliation(s)
- Thomas A Schwann
- College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio.,Mercy Saint Vincent Medical Center, Toledo, Ohio
| | - Maroun B Yammine
- Department of Internal Medicine, Outcomes Research Unit, Vascular Medicine Program, American University of Beirut, Beirut, Lebanon
| | - Abdul-Karim M El-Hage-Sleiman
- Department of Internal Medicine, Outcomes Research Unit, Vascular Medicine Program, American University of Beirut, Beirut, Lebanon
| | - Milo C Engoren
- Mercy Saint Vincent Medical Center, Toledo, Ohio.,Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Mark R Bonnell
- College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio
| | - Robert H Habib
- Department of Internal Medicine, Outcomes Research Unit, Vascular Medicine Program, American University of Beirut, Beirut, Lebanon.,Society of Thoracic Surgery Research Center, Chicago, Illinois
| |
Collapse
|
42
|
Kalra S, Bhatt H, Kirtane AJ. Stenting in Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction. Methodist Debakey Cardiovasc J 2018; 14:14-22. [PMID: 29623168 DOI: 10.14797/mdcj-14-1-14] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The treatment of ST-segment elevation myocardial infarction (STEMI) has advanced dramatically over the past 30 years since the introduction of reperfusion therapies, such that mechanical reperfusion with primary percutaneous coronary intervention is now the standard of care. With STEMI, as with other forms of acute coronary syndrome, stent deployment in culprit lesions is the dominant form of reperfusion in the developed world and is supported by contemporary guidelines. However, the precise timing of stenting and the extent to which both culprit and non-culprit lesions should be treated continue to be active areas of study. In this review, we revisit key data that support the use of mechanical reperfusion therapy in STEMI patients and explore the optimal timing for and extent of stent implantation in this complex patient group. We also review data surrounding the deleterious effects of untreated residual myocardial ischemia, the importance of complete revascularization, and the recent data exploring culprit-only versus multivessel stenting in the STEMI setting.
Collapse
Affiliation(s)
- Sanjog Kalra
- aEINSTEIN MEDICAL CENTER, PHILADELPHIA, PENNSYLVANIA
| | - Hemal Bhatt
- aEINSTEIN MEDICAL CENTER, PHILADELPHIA, PENNSYLVANIA
| | - Ajay J Kirtane
- bCOLUMBIA UNIVERSITY/IRVING MEDICAL CENTER, NEW YORK, NEW YORK
| |
Collapse
|
43
|
Leviner DB, Torregrossa G, Puskas JD. Incomplete revascularization: what the surgeon needs to know. Ann Cardiothorac Surg 2018; 7:463-469. [PMID: 30094210 DOI: 10.21037/acs.2018.06.07] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
For many years, the concept of "complete revascularization" (CR) was considered an absolute truth in coronary surgery with improved long-term survival and a lower rate of reintervention. This was derived from early publications which showed a survival benefit for patients undergoing coronary artery bypass grafting (CABG) who received CR. Many advances in the field of coronary revascularization have been made in the years that passed since those publications, including more frequent use of percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). This has led some to question the importance of CR and raise the option of "reasonable incomplete revascularization" (IR) for selected patients. The definition of CR is variable in the literature with the two most common definitions being an anatomical (revascularization of all coronary segments with stenosis and larger than a predefined size) and a functional definition (where revascularization is considered complete if all ischemic and viable territories are reperfused). No randomized control trials have been conducted to compare complete versus IR, and a significant proportion of data is based on post hoc analysis of data from randomized control trials and registries. Multiple studies have proven that CR is achieved more frequently with CABG then with PCI. A review of the available data from the past three to four decades shows a trend toward improved results with CR, regardless of the reperfusion strategy chosen. This should impact the heart team discussion when choosing a revascularization strategy and impact the surgical decision making while preforming CABG. IR can be part of a hybrid revascularization strategy or be reserved for rare cases where the cost of achieving CR much outweighs the benefit.
Collapse
Affiliation(s)
- Dror B Leviner
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gianluca Torregrossa
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
44
|
Konstanty-Kalandyk J, Bartuś K, Piątek J, Kędziora A, Darocha T, Bryniarski KL, Wróżek M, Ceranowicz P, Bartuś S, Bryniarski L, Kapelak B. Is right coronary artery chronic total vessel occlusion impacting the surgical revascularization results of patients with multivessel disease? A retrospective study. PeerJ 2018; 6:e4909. [PMID: 29922510 PMCID: PMC6005161 DOI: 10.7717/peerj.4909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/15/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Chronic total occlusion (CTO) is common in the presence of other significantly narrowed coronary arteries. The impact of total occlusion and its association with completeness of revascularization on patients with multivessel disease undergoing coronary artery bypass graft (CABG) remains largely unknown. Aim The aim of our study was to compare CABG operation characteristics, as well as 30-day mortality, incidence of post-operative major adverse cardiac and cerebrovascular events (MACCE) between patients with and without CTO in right coronary artery (RCA). Materials and Methods A total of 156 consecutive patients were included in the analysis. CTO of RCA or right posterior descending artery (RPD) was diagnosed in 57 patients (CTO-RCA group). Coronary stenosis without CTO in RCA was diagnosed in 99 patients (nonCTO-RCA group). Baseline characteristics were comparable in both groups. Results The majority of patients had class II (49.1% vs. 46%, p = 0.86) or class III (42.1% vs. 43%, p = 1.0) Canadian Cardiovascular Society grading system symptoms. Patients in the CTO-RCA group had in average 2.2 grafts implanted, as opposed to 2.4 grafts in patients in the nonCTO-RCA group (p = 0.003). Graft to the RCA was performed in 40.3% patients in the CTO-RCA group and in 81% patients in the nonCTO-RCA group (p = 0.001). The 30-day mortality from any cause or cardiac cause did not differ between groups (7% vs. 2%, p = 0.14 and 3.5% vs. 2%, p = 0.57 respectively). In a multivariate analysis CTO in RCA or RPD and peripheral artery disease were independent predictors of post-operative MACCE (7.9 (1.434-43.045) p = 0.02; 18.8 (3.451-101.833) p < 0.01, respectively). Conclusions Chronic total occlusion of RCA was found to be associated with smaller number of grafts performed during the CABG procedure. Although mortality between patients in the CTO-RCA and nonCTO-RCA groups did not differ, patients in the CTO-RCA group had higher incidence of post-operative MACCE.
Collapse
Affiliation(s)
- Janusz Konstanty-Kalandyk
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Jacek Piątek
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Anna Kędziora
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Tomasz Darocha
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Krzysztof L Bryniarski
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Marcin Wróżek
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Piotr Ceranowicz
- Department of Physiology, Jagiellonian University Medical College, Krakow, Poland
| | - Stanisław Bartuś
- 2nd Department of Cardiology, Jagiellonian University Medical College, The University Hospital, Krakow, Poland
| | - Leszek Bryniarski
- 1st Department of Cardiology, Interventional Electrocardiology, and Arterial Hypertension, Jagiellonian University Medical College, The University Hospital, Krakow, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| |
Collapse
|
45
|
Gasior M, Gierlotka M, Pyka Ł, Zdrojewski T, Wojtyniak B, Chlebus K, Rozentryt P, Niedziela J, Jankowski P, Nessler J, Opolski G, Hoffman P, Jankowska E, Polonski L, Ponikowski P. Temporal trends in secondary prevention in myocardial infarction patients discharged with left ventricular systolic dysfunction in Poland. Eur J Prev Cardiol 2018; 25:960-969. [DOI: 10.1177/2047487318770830] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The proportion of patients discharged after myocardial infarction with left ventricular systolic dysfunction remains high and the prognosis is unfavourable. The aim of this study was to analyse the temporal trends in the treatment and outcomes of a nationwide cohort of patients. Methods and results Data from the Polish Registry of Acute Coronary Syndromes and Acute Myocardial Infarction in Poland Registry were combined to achieve complete information on inhospital course, treatment and outcomes. An all-comer population of patients discharged with left ventricular ejection fraction of 40% or less formed the sample population ( n = 28,080). The patients were analysed for the incidence of significant temporal trends and their possible consequences. The implementation of guideline-based treatment at discharge was high. In the post-discharge course a trend towards a higher frequency of percutaneous coronary intervention and a lower prevalence of planned coronary artery bypass grafting procedures was observed. The number of implantable cardioverter defibrillator/cardiac resynchronisation therapy defibrillator implantations was increasing. Cardiac rehabilitation was performed in 19–23% cases. The post-discharge outpatient care was based on general practitioner visits, with only 47.9–48.1% of patients attending an ambulatory cardiology specialist visit. In 12 months of observation the frequency of heart failure rehospitalisations was 17.5–19.1%, while the prevalence of rehospitalisations due to myocardial infarction decreased (8.3% in 2009 to 6.7% in 2013, P < 0.001). A trend towards lower all-cause mortality was observed. Assessment of composite outcomes (death, myocardial infarction, stroke or heart failure rehospitalisation) adjusted for sex and age at 12 months revealed a significant decreasing trend. Conclusion The overall prognosis in this population is improving slowly. This may be due to the increasing prevalence of guideline-based forms of secondary prevention. Efforts aimed at maintaining these trends are essential, as overall compliance with these guideline remains suboptimal.
Collapse
Affiliation(s)
- Mariusz Gasior
- 3rd Department of Cardiology, Medical University of Silesia, Poland
| | - Marek Gierlotka
- 3rd Department of Cardiology, Medical University of Silesia, Poland
| | - Łukasz Pyka
- 3rd Department of Cardiology, Medical University of Silesia, Poland
| | - Tomasz Zdrojewski
- Department of Preventive Medicine and Didactics, Medical University of Gdansk, Poland
| | - Bogdan Wojtyniak
- Centre for Monitoring and Analyses of Population Health Status and Health Care System, National Institute of Health, Poland
| | | | - Piotr Rozentryt
- 3rd Department of Cardiology, Medical University of Silesia, Poland
| | - Jacek Niedziela
- 3rd Department of Cardiology, Medical University of Silesia, Poland
| | - Piotr Jankowski
- 1st Department of Cardiology and Hypertension, Jagiellonian University Medical College, Poland
| | - Jadwiga Nessler
- Department of Coronary Artery Disease and Heart Failure, Jagiellonian University Medical College and John Paul II Hospital, Poland
| | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Poland
| | - Piotr Hoffman
- Department of Congenital Heart Diseases, The Cardinal Stefan Wyszyński Institute of Cardiology, Poland
| | - Ewa Jankowska
- Department of Heart Diseases, Medical University, Poland
| | - Lech Polonski
- 3rd Department of Cardiology, Medical University of Silesia, Poland
| | | |
Collapse
|
46
|
Kranjec I, Zavrl Džananovič D, Mrak M, Bunc M. Robustness of Percutaneously Completed Coronary Revascularization in Stable Coronary Artery Disease: Obstructive Versus Occlusive Lesions. Angiology 2018; 70:78-86. [PMID: 29631418 DOI: 10.1177/0003319718767737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our study sought to assess long-term outcomes of percutaneously completed coronary revascularization (CCR) in patients with obstructive coronary artery disease (CAD) comprising chronic total occlusions (CTOs). Between 2010 and 2014, percutaneous coronary interventions (PCIs) of the CTOs were attempted in 213 patients: the CCR was achieved in 125 patients (group 1), while the PCI failed in 88 patients (group 2). They were matched against 252 patients (group 3) with the CCR obtained by the non-CTO PCIs. In the 5-year follow-up, more adverse cardiovascular (CV) events occurred in group 2 (29.5% vs 4.8% in group 1 vs 3.5% in group 3, P = .0001), mainly due to recurrent severe symptoms and additional revascularization of the CTOs; CV mortality did not seem to be significantly affected. Survival curves for the successful CTO and non-CTO PCIs appeared indistinguishable. Stent thromboses were infrequent in the CCR groups. In conclusion, long-term outcomes of the patients with the obstructive CAD containing the CTOs showed a favorable outcome if the CCR had been achieved percutaneously.
Collapse
Affiliation(s)
- Igor Kranjec
- 1 Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | | | - Miha Mrak
- 1 Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | - Matjaz Bunc
- 1 Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| |
Collapse
|
47
|
Hsieh IC, Hsieh MJ, Chen CC, Wang CY, Chang SH, Lee CH, Chen DY, Yang CH, Tsai ML. Comparison of the Acute and Long-Term Outcomes of Patients With Multivessel Coronary Artery Disease After Angiographic Complete and Incomplete Revascularization With Drug-Eluting Stents. Circ J 2018; 82:992-998. [PMID: 29503406 DOI: 10.1253/circj.cj-17-0812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Data regarding the long-term outcomes of a large patient population with multivessel coronary artery disease (MV-CAD) after complete revascularization (CR) and incomplete revascularization (IR) with drug-eluting stent (DES) implantation are controversial. The objective of this study was to evaluate differences between the clinical outcomes of CR and IR in such patients. METHODS AND RESULTS A total of 1,502 patients with MV-CAD who received DES between April 2005 and August 2016 were enrolled in this study after propensity score matching. The CR group had 751 patients with 1,368 stents implanted in 1,215 lesions, and the IR group had 751 patients with 1,077 stents implanted in 948 lesions. The CR group had a similar rate of in-hospital major adverse cardiovascular events to the IR group (1.9% vs. 1.6%, P=0.844). Follow-up angiography at 9 months showed no significant difference between the 2 groups for restenosis. The CR group had a higher cardiovascular event-free survival rate than the IR group during a mean follow-up period of 71±62 months (81.8% vs. 72.0%, P<0.001). Kaplan-Meier survival analysis also showed better results in the CR group than in the IR group. CONCLUSIONS Angiographic CR was associated with more favorable long-term cardiovascular outcomes than angiographic IR in patients with MV-CAD after DES implantation.
Collapse
Affiliation(s)
- I-Chang Hsieh
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Ming-Jer Hsieh
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Chun-Chi Chen
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Chao-Yung Wang
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Shang-Hung Chang
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Cheng-Hung Lee
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Dong-Yi Chen
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Chia-Hung Yang
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| | - Ming-Lung Tsai
- Division of Cardiology, Department of Medicine and Percutaneous Coronary Intervention Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine
| |
Collapse
|
48
|
Benedetto U, Gaudino M, Di Franco A, Caputo M, Ohmes LB, Grau J, Glineur D, Girardi LN, Angelini GD. Incomplete revascularization and long-term survival after coronary artery bypass surgery. Int J Cardiol 2018; 254:59-63. [PMID: 29407133 DOI: 10.1016/j.ijcard.2017.08.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/24/2017] [Accepted: 08/04/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND We sought to investigate the impact of incomplete revascularization (IR) on long-term survival after isolated coronary artery bypass grafting (CABG). The possible interaction between IR and off-pump surgery was also explored. METHODS A total of 13,701 patients with multivessel disease undergoing CABG were included in the analysis. All patients received left internal thoracic artery (LITA) to the left anterior descending artery (LAD) territory. IR was defined as at least one diseased arterial territory (right coronary artery [RCA] and/or circumflex [CX] artery) incompletely revascularized. RESULTS Overall, 3107 (22.7%) patients received IR. After propensity score matching, IR did not increase all-cause death in the overall group (HR 1.09; 95%CI 0.96-1.22; P=0.17). However, when both RCA and CX artery were incompletely revascularized, late survival was significantly lower (HR 2.15; 95%CI 1.57-2.93). IR was associated with a higher risk of death after off-pump (HR 1.26; 95%CI 1.05-1.49) regardless the extent of IR. After on-pump, IR significantly affected survival only when both RCA and CX artery only were incompletely revascularized (HR 2.32; 95%CI 1.27-4.22). CONCLUSIONS The present analysis shows that in patients with LITA-LAD graft the impact of IR on survival is marginal when only one coronary territory is left ungrafted. When both the RCA and CX territory remain unrevascularized the survival rate is significantly reduced. IR after off-pump CABG is associated with significantly lower survival and affects long-term outcome even when only one coronary territory is not revascularized.
Collapse
Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, USA.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, USA
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom
| | - Lucas B Ohmes
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, USA
| | - Juan Grau
- Division of Cardiac Surgery, Ottawa Heart Institute, Ottawa, Canada
| | - David Glineur
- Division of Cardiac Surgery, Ottawa Heart Institute, Ottawa, Canada
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, USA
| | - Gianni D Angelini
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom
| |
Collapse
|
49
|
Vafaey HR, Salehi Omran MT, Abbaspour S, Banihashem N, Faghanzadeh Ganji G. Anti-coagulation therapy following coronary endarterectomy in patient with coronary artery bypass graft. CASPIAN JOURNAL OF INTERNAL MEDICINE 2018; 9:27-31. [PMID: 29387316 PMCID: PMC5771357 DOI: 10.22088/cjim.9.1.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Background Since there is a lack of research on postoperative anticoagulation protocol in patients undergoing coronary artery bypass graft (CABG) / coronary endarterectomy (CE), we recommend a new protocol for anticoagulation in these patients. Methods In this double-blind randomized clinical trial study, 52 patients undergoing CABG / CE entered the study and were divided into two groups. In group 1, the patients were given warfarin(international normalized ratio (INR) between 2-3) together with 80 mg aspirin daily for 3 months. In group 2, the patients were given 75 mg plavix daily together with 80 mg aspirin daily for 3 months. We evaluated patients with electrocardiography, echocardiography and checking ceratin phosphokinase MB and troponin I in the several stages. The data were analysed SPSS Version18 software. Results There was no significant difference between pre and post-operative Ejection fraction in patients with plavix (P=0.21) and warfarin (P=0.316) regimen. However, wall mrotion score was significantly better in clopidogrel - aspirin patients in late (3 months) post operation (p<0.001). Conclusions Since warfarin has serious hemorrhagic complications and requires closed monitoring of serum drug activity by serial INR checking, it is recommended that clopidogrel - aspirin can be the preferred alternative anticoagulation therapy in CABG / CE patients.
Collapse
Affiliation(s)
- Hamdi Reza Vafaey
- Department of Cardiac Surgery, Ayatollah Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
| | | | - Sadaf Abbaspour
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Nadia Banihashem
- Department of Anesthesiology, Babol University of Medical Sciences, Babol, Iran
| | - Ghassem Faghanzadeh Ganji
- Department of Cardiac Surgery, Ayatollah Rouhani Hospital, Babol University of Medical Sciences, Babol, Iran
| |
Collapse
|
50
|
Auchoybur ML, Chen X. Complete revascularization reduces adverse outcomes in patients with multivessel coronary artery disease. World J Meta-Anal 2017; 5:167-176. [DOI: 10.13105/wjma.v5.i6.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/13/2017] [Accepted: 10/29/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the influence of complete and incomplete revascularization (ICR) in patients with multivessel coronary artery disease undergoing coronary artery bypass or percutaneous coronary intervention.
METHODS We searched PubMed using the keywords “complete revascularization”, “incomplete revascularization”, “coronary artery bypass”, and “percutaneous coronary intervention”. We selected randomized controlled studies (RCT) and observational studies only for review. The main outcomes of interest were mortality, myocardial infarction (MI) and repeat revascularization. We identified further studies by hand searching relevant publications and included those that met with the inclusion criteria in our final analysis and performed a systematic review.
RESULTS Ten studies were identified, including 13327 patients of whom, 8053 received complete revascularization and 5274 received ICR. Relative to ICR, CR was associated with lower mortality (RR: 0.755, 95%CI: 0.66 to 0.864, P = 0.765, I2 = 0.0%), lower rates of MI (RR: 0.759, 95%CI: 0.615 to 0.937, P = 0.091, I2 = 45.1%), lower rates of MACCE (RR: 0.731, 95%CI: 0.668 to 0.8, P = 0.453, I2 = 0.0%) and reduced rates of repeat coronary revascularization (RR: 0.691, 95%CI: 0.541 to 0.883, P = 0.0, I2 = 88.3%).
CONCLUSION CR is associated with lower rates of adverse outcomes. CR can be used as a standard in the choice of any particular revascularization strategy.
Collapse
Affiliation(s)
- Merveesh L Auchoybur
- Department of Cardiovascular Surgery, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing 210006, Jiangsu Province, China
| | - Xin Chen
- Department of Cardiovascular Surgery, Nanjing First Hospital Affiliated to Nanjing Medical University, Nanjing Cardiovascular Disease Research Institute, Nanjing 210006, Jiangsu Province, China
| |
Collapse
|