Does Timing of Coronary Artery Bypass Surgery Affect Early and Long-Term Outcomes in Patients With Non-ST-Segment-Elevation Myocardial Infarction?

Optimal Revascularization Timing of Coronary Artery Bypass Grafting in Acute Myocardial Infarction

INTRODUCTION

Acute myocardial infarction (AMI) is a major global health concern. However, the optimum timing of coronary artery bypass grafting (CABG) in AMI patients remains controversial. This study investigated the optimal timing of CABG and its impact on postoperative outcomes. We hypothesized that determining the optimal timing of CABG could positively impact postoperative outcomes.

METHODS

We conducted a nationwide retrospective analysis of the National Health Insurance Service of Korea database, focusing on 1 705 843 adult AMI patients diagnosed between 2007 and 2018 who underwent CABG within 1 year of diagnosis. Patients were categorized based on CABG timing. Primary endpoints included cohort identification and the time interval from AMI diagnosis to CABG. Secondary endpoints encompassed major adverse cardiac and cerebrovascular events (MACCEs) and the impact of postoperative medications.

RESULTS

Of the patients, 20 172 underwent CABG. Surgery within 24 h of AMI diagnosis demonstrated the most favorable outcomes, reducing cardiac death, myocardial infarction recurrence, and target vessel revascularization. Delayed CABG within 3 days also outperformed surgery within 1-2 days post-AMI. Additionally, postoperative aspirin use was associated with improved MACCE outcomes.

CONCLUSION

CABG within 24 h of AMI diagnosis was associated with significantly minimized myocardial injury, emphasizing the critical role of rapid revascularization. Delayed CABG within 3 days related to better outcomes compared with that of surgery within 1-2 days. These findings provide evidence-based recommendations for optimizing CABG timing in AMI patients, consequentially reducing morbidity and mortality.

Timing of coronary artery bypass grafting after myocardial infarction influences late survival

Objectives

The role of timing of coronary artery bypass grafting after acute myocardial infarction on early and late outcomes remains uncertain.

Methods

We reviewed 1631 consecutive adult patients who underwent isolated coronary artery bypass grafting with information on timing of acute myocardial infarction. Early and late mortality were compared between patients receiving coronary artery bypass grafting within 24 hours after acute myocardial infarction, between 1 and 7 days after acute myocardial infarction, and more than 7 days after acute myocardial infarction. Sensitivity analyses were performed in subgroups of patients with ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction, and other high-risk groups.

Results

A total of 124 patients (5.7%) underwent coronary artery bypass grafting within 24 hours, 972 patients (51.2%) received coronary artery bypass grafting between 1 and 7 days after acute myocardial infarction, and 535 patients (43.2%) underwent coronary artery bypass grafting more than 7 days after acute myocardial infarction. Overall operative mortality was 2.7% with comparable adjusted early mortality among 3 groups. Over a median follow-up of 13.5 years (interquartile range, 8.9-17.1), compared with patients receiving coronary artery bypass grafting between 1 and 7 days after acute myocardial infarction, those receiving coronary artery bypass grafting at 7 days had greater adjusted risk for late overall mortality (hazard ratio, 1.39, 95% CI, 1.16-1.67; P < .001), whereas those receiving coronary artery bypass grafting within 24 hours had comparable risk of late overall mortality (hazard ratio, 1.12, 95% CI, 0.86-1.47; P = .39). Timing of coronary artery bypass grafting was associated with late mortality in patients with non-ST-segment elevation myocardial infarction (patients receiving coronary artery bypass grafting at >7 days had a higher risk of late mortality [hazard ratio, 1.38, 95% CI, 1.14-1.67, P < .001] compared with those receiving coronary artery bypass grafting between 1 and 7 days), but not in patients with ST-segment elevation myocardial infarction.

Conclusions

Early revascularization through coronary artery bypass grafting within 7 days during the same hospitalization appears beneficial, especially for patients presenting with non-ST-segment elevation myocardial infarction.

Outcomes of Patients Presenting With Non-ST Elevation Myocardial Infarction Who Underwent Surgical Revascularization

Non-ST-segment elevation myocardial infarction (NSTEMI) is a leading cause of emergency hospitalization across Europe. This study evaluates the in-hospital and mid-term outcomes of patients who underwent coronary artery bypass graft (CABG) after NSTEMI. A retrospective analysis of all cases who underwent isolated CABG after NSTEMI from September 2017 to September 2022 at our center. Patients were stratified according to in-hospital survival. Patient characteristics, operative details, and procedural complications were compared between those who survived and those who did not. Predictors of in-hospital and mid-term mortality were evaluated using logistic and Cox regression modeling. Kaplan-Meier analysis was used to generate a survival curve for all alive patients at the time of discharge. Among 1,011 patients (median age 64 [56 to 72] years, 852 [84.3%] male), 735 (72.7%) underwent urgent, 239 (23.6%) elective, and 37 (3.7%) emergency CABG. The in-hospital mortality was 1.5% (15/1,011 patients). Those who died were more likely to be New York Heart Association class III/IV, have left ventricular ejection fraction <21%, severe renal impairment, peripheral vascular disease (PVD), or poor mobility. Emergency procedures, preoperative ventilation, inotropic support, and intra-aortic balloon pump (IABP) use were also more prevalent among those who died. Logistic regression modeling revealed new postoperative stroke (odds ratio 22.0, 95% confidence interval 3.6 to 135.5, p = 0.001), preoperative IABP use (11.4; 2.4 to 53.7, p = 0.002), new hemodialysis (9.6; 2.7 to 34.7, p <0.001), PVD (5.6; 1.6 to 20.0, p = 0.008), and poor mobility (odds ratio 4.8, 95% confidence interval 1.3 to 18.2, p = 0.022) as independent predictors of in-hospital mortality. In conclusion, new postoperative stroke, preoperative IABP use, new hemodialysis, PVD, and poor mobility are independent predictors of mortality in patients with NSTEMI who underwent isolated CABG.

The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States

BACKGROUND

In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA.

METHODS

We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost.

RESULTS

A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h.

CONCLUSION

CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.

Pretreatment with a P2Y12 receptor inhibitor and delay to coronary artery bypass surgery in patients with non-ST segment elevation acute coronary syndrome

BACKGROUND

2020 ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against the pretreatment with P2Y12 receptor inhibitors (P2Y12i) in patients undergoing early invasive management (<24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable coronary anatomy. This study aimed to analyze the theoretical impact of pretreatment with a P2Y12i on delay to CABG surgery in a real-world population with NSTE-ACS.

METHODS

Single-center retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG or nonobstructive coronary disease were excluded.

RESULTS

The total cohort included 262 patients (mean age 68±12 years, 69% male, 15% with unstable angina and mean GRACE score 134±35). Median time from FMC to angiography was 2 (1-4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pretreatment with P2Y12i (clopidogrel or ticagrelor). The median time from angiography to CABG was 12 (7-15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P=0.017 and 82.4% vs. 21.4%, P<0.001, respectively), although there were no differences regarding major bleeding.

CONCLUSIONS

Pretreatment with P2Y12i was a potential but not the sole driver of CABG delay in our cohort. Adopting the new recommendations of withholding pretreatment might decrease this delay, but other factors must be considered.

Optimal Timing of Coronary Artery Bypass Grafting in Haemodynamically Stable Patients after Myocardial Infarction

During the acute phase of myocardial infarction, the culprit artery must be revascularized quickly with angioplasty. Surgery then completes the procedure in a second stage. If emergency surgery is performed, the resulting death rate is high; 15-20% of patients are operated on within the first 48 h after the myocardial infarction. The timing of surgical revascularization and the patient's preoperative state influence the mortality rate. We aimed to evaluate the impact of surgery delay on morbimortality. Between 2007 and 2017, a retrospective monocentric study was conducted including 477 haemodynamically stable patients after myocardial infarction who underwent an urgent coronary bypass. Three groups were described, depending on the timing of the surgery: during the first 4 days (Group 1, n = 111, 23%), 5 to 10 days (Group 2, n = 242, 51%) and after 11 days (Group 3, n = 124, 26%). The overall thirty-day mortality was 7.1% (n = 34). The death rate was significantly higher in Group 1 (n = 16; 14% vs. n = 10; 4.0% vs. n = 8; 6%, p < 0.01). The mortality risk factors identified were age (OR: 1.08; CI 95%: 1.04-1.12; p < 0.001), peripheral arteriopathy (OR: 3.31; CI 95%: 1.16-9.43; p = 0.024), preoperative renal failure (OR: 6.39; CI 95%: 2.49-15.6; p < 0.001) and preoperative ischemic recurrence (OR: 3.47; CI 95%: 1.59-7.48; p < 0.01). Ninety-two patients presented with preoperative ischemic recurrence (19%), with no difference between the groups. The optimal timing for the surgical revascularization of MI seems to be after Day 4 in stable patients. However, timing is not the only factor influencing the death rate: the patient's health condition and disease severity must be considered in the individual management strategy.

Consequences of Obesity on Short-Term Outcomes in Patients Who Underwent Off-Pump Coronary Artery Bypass Grafting Surgery

The correlation between off-pump coronary artery bypass (OPCAB) surgery and obesity-related outcomes is still uncertain. The aim of our study was to analyse the pre-, intra-, and postoperative short-term outcomes between obese and non-obese patients after off-pump bypass surgery. We performed a retrospective analysis from January 2017 until November 2022, including a total of 332 (non-obese (n = 193) and obese (n = 139)) patients who underwent an OPCAB procedure due to coronary artery disease (CAD). The primary outcome was all-cause in-hospital mortality. Our results showed no difference regarding mean age of the study population between both groups. The use of the T-graft technique was significantly higher (p = 0.045) in the non-obese group compared to the obese group. The dialysis rate was significantly lower in non-obese patients (p = 0.019). In contrast, the wound infection rate was significantly higher (p = 0.014) in the non-obese group compared to the obese group. The all-cause in-hospital mortality rate did not differ significantly (p = 0.651) between the two groups. Furthermore, ST-elevation myocardial infarction (STEMI) and reoperation were relevant predictors for in-hospital mortality. Therefore, OPCAB surgery remains a safe procedure even in obese patients.

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction (NIHR Health Informatics Collaborative: TROP-CABG study)

Implications of elevated troponin on time-to-surgery in non-ST elevation myocardial infarction(NIHR Health Informatics Collaborative:TROP-CABG study). Benedetto et al. BACKGROUND: The optimal timing of coronary artery bypass grafting (CABG) in patients with non-ST elevation myocardial infarction (NSTEMI) and the utility of pre-operative troponin levels in decision-making remains unclear. We investigated (a) the association between peak pre-operative troponin and survival post-CABG in a large cohort of NSTEMI patients and (b) the interaction between troponin and time-to-surgery. METHODS AND RESULTS: Our cohort consisted of 1746 patients (1684 NSTEMI; 62 unstable angina) (mean age 69 ± 11 years,21% female) with recorded troponins that had CABG at five United Kingdom centers between 2010 and 2017. Time-segmented Cox regression was used to investigate the interaction of peak troponin and time-to-surgery on early (within 30 days) and late (beyond 30 days) survival. Average interval from peak troponin to surgery was 9 ± 15 days, with 1466 (84.0%) patients having CABG during the same admission. Sixty patients died within 30-days and another 211 died after a mean follow-up of 4 ± 2 years (30-day survival 0.97 ± 0.004 and 5-year survival 0.83 ± 0.01). Peak troponin was a strong predictor of early survival (adjusted P = 0.002) with a significant interaction with time-to-surgery (P interaction = 0.007). For peak troponin levels <100 times the upper limit of normal, there was no improvement in early survival with longer time-to-surgery. However, in patients with higher troponins, early survival increased progressively with a longer time-to-surgery, till day 10. Peak troponin did not influence survival beyond 30 days (adjusted P = 0.64). CONCLUSIONS: Peak troponin in NSTEMI patients undergoing CABG was a significant predictor of early mortality, strongly influenced the time-to-surgery and may prove to be a clinically useful biomarker in the management of these patients.

Appropriate Timing of Coronary Artery Bypass Graft Surgery for Acute Myocardial Infarction Patients: A Meta-Analysis

Background

Currently, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are commonly used in the treatment of coronary atherosclerotic heart disease. But the optimal timing for CABG after acute myocardial infarction (AMI) is still controversial. The purpose of this article was to evaluate the optimal timing for CABG in AMI.

Methods

We searched the PubMed, Embase, and Cochrane library databases for documents that met the requirements. The primary outcome was in-hospital mortality. The secondary outcomes were perioperative myocardial infarction (MI) incidence and cerebrovascular accident incidence.

Results

The search strategy produced 1,742 studies, of which 19 studies (including data from 113,984 participants) were included in our analysis. In total, 14 studies compared CABG within 24 h with CABG late 24 h after AMI and five studies compared CABG within 48 h with CABG late 48 h after AMI. The OR of in-hospital mortality between early 24 h CABG and late 24 h CABG group was 2.65 (95%CI: 1.96 to 3.58; P < 0.00001). In the undefined ST segment elevation myocardial infarction (STEMI)/non-ST segment elevation myocardial infarction (NSTEMI) subgroup, the mortality in the early 24 h CABG group (OR: 3.88; 95%CI: 2.69 to 5.60; P < 0.00001) was significantly higher than the late 24 h CABG group. Similarly, in the STEMI subgroup, the mortality in the early 24 h CABG group (OR: 2.62; 95% CI: 1.58 to 4.35; P = 0.0002) was significantly higher than that in the late 24 h CABG group. However, the mortality of the early 24 h CABG group (OR: 1.24; 95%CI: 0.83 to 1.85; P = 0.29) was not significantly different from that of the late 24 h CABG group in the NSTEMI group. The OR of in-hospital mortality between early 48 h CABG and late 48 h CABG group was 1.91 (95%CI: 1.11 to 3.29; P = 0.02). In the undefined STEMI/NSTEMI subgroup, the mortality in the early 48 h CABG group (OR: 2.84; 95%CI: 1.31 to 6.14; P < 0.00001) was higher than the late 48 h CABG group. The OR of perioperative MI and cerebrovascular accident between early CABG and late CABG group were 1.38 (95%CI: 0.41 to 4.72; P = 0.60) and 1.31 (95%CI: 0.72 to 2.39; P = 0.38), respectively.

Conclusion

The risk of early CABG could be higher in STEMI patients, and CABG should be delayed until 24 h later as far as possible. However, the timing of CABG does not affect mortality in NSTEMI patients. There was no statistical difference in perioperative MI and cerebrovascular accidents between early and late CABG.

Meta-Analysis of Nonrandomized Studies to Assess the Optimal Timing of Coronary Artery Bypass Grafting After Acute Myocardial Infarction

The optimal timing of coronary artery bypass grafting (CABG) in patients after an acute myocardial infarction (MI) is unknown. We performed a systematic review and meta-analysis of studies comparing mortality rates in patients who underwent CABG at different time intervals after acute MI. Bias assessments were completed for each study, and summary of proportions of all-cause mortality were calculated based on CABG at various time intervals after MI. A total of 22 retrospective studies, which included a total of 137,373 patients were identified. The average proportion of patients who died when CABG was performed within 6 hours of MI was 12.7%, within 6 to 24 hours of MI was 10.9%, within 1 day of MI was 9.8%, any time after 1 day of MI was 3.0%, within 7 days of MI was 5.9%, and any time after 7 days of MI was 2.7%. Interstudy heterogeneity, assessed using I² values, showed significant heterogeneity in death rates within subgroups. Only 1 study accounted for immortal time bias, and there was a serious risk of selection bias in all other studies. Confounding was found to be a serious risk for bias in 55% of studies because of a lack of accounting for type of MI, MI severity, or other verified cardiac risk factors. The current publications comparing timing of CABG after MI is at serious risk of bias because of patient selection and confounding, with heterogeneity in both study populations and intervention time intervals.

The timing of surgical revascularisation in acute myocardial infarction: when should we intervene?

INTRODUCTION

Coronary artery bypass grafting (CABG) is a crucial intervention in acute myocardial infarction (AMI), particularly when AMI is not amenable for management with primary percutaneous coronary intervention (PCI). To optimise outcome in these patients, surgical teams must consider a host of predictive factors, with the most prominent being the timing of CABG. Despite numerous studies exploring timing of CABG following AMI in the past, optimal surgical timing remains controversial. The mortality rates vary with timing of CABG, but confounding factors such as age, impaired pulmonary function, renal insufficiency, and poor left ventricular function may contribute to varied outcomes reported.

EVIDENCE ACQUISITON

An electronic literature search of articles that discussed acute myocardial presentation and urgent in-patient or elective CABG was conducted.

EVIDENCE SYNTHESIS

The evidence was synthesised based on each reported article and their outcomes.

CONCLUSIONS

Current literature suggests multiple factors can guide CABG timing including, type of AMI at initial presentation, distinctive pathological status and patient characteristics. Thus, there is a need for large, multi-centre studies to identify optimal CABG timing in complex coronary artery disease or failed PCI in patients with AMI. Future guidelines should emphasise patient cohorts by taking their risk factors into consideration. As such, a need for greater cardiac screening methods and development of scoring systems can aid in the optimisation of CABG timing.

Timing of coronary artery bypass grafting after acute myocardial infarction: does it influence outcomes?

Introduction

The optimal timing of coronary artery bypass grafting (CABG) operations in patients with recent acute myocardial infarction (AMI) remains unclear.

Aim

To assess the influence of timing on post-operative outcomes in patients undergoing CABG following AMI.

Material and methods

In this retrospective analysis 12,224 consecutive patients undergoing CABG were included. 2477 (20.5%) patients had a history of AMI. Based on timing, patients were divided into 3 groups: those operated within 7 days of AMI; those operated after 7 days but within 1 month; and a third group operated after 1 month but within 3 months. The 3 groups were compared in terms of baseline, intra-operative, and post-operative morbidity and mortality. Multivariate analysis was carried out to assess the independent influence of timing of CABG on outcomes.

Results

There was no difference in terms of previous neurological events (p = 0.554), presence of carotid artery disease (p = 0.555), prevalence of hypertension (p = 0.119), diabetes (p = 0.144), hypothyroidism (p = 0.53), chronic obstructive pulmonary disease (p = 0.079), peripheral vascular disease (p = 0.771), and impaired left ventricular function (p = 0.072). On univariate analysis, mortality risk was highest between 1 week and 1 month (p = 0.003). Multivariate analysis showed that the closer the MI and CABG duration, the higher the mortality (co-efficient -0.517; p = 0.019; odds ratio = 0.596; 95% CI: 0.388-0.917).

Conclusions

The duration between MI and CABG has a direct influence on outcomes after CABG. While it is clear that the longer the duration between MI and CABG, the lower the mortality risk, it is however difficult to decide on an exact cut-off time frame.

Timing of Coronary Artery Bypass Grafting in Acute Coronary Syndrome: A National Analysis

BACKGROUND

Timing of surgical revascularization for acute coronary syndrome (ACS) remains debated. We assessed the impact of timing to CABG on mortality and resource utilization in a national cohort.

METHODS

Adults admitted for ACS in the 2009-2018 National Inpatient Sample were grouped by time from coronary angiography to CABG (Δt): 0, 1-3, 4-7, and >7 days. Generalized linear models were fit to evaluate associations between Δt and in-hospital mortality and hospitalization costs. Timing and mortality of CABG for ACS was compared between high-performing hospitals (below the median risk adjusted mortality for all CABG and valve operations) and others.

RESULTS

Of 444,065 patients, time to CABG was Δt=0 in 12.3%, Δt=1-3 in 57.3%, Δt=4-7 in 26.3%, and Δt>7 in 4.2%. Risk-adjusted mortality was greatest at Δt=0 (4.5%, 95% confidence interval, CI, 4.1-4.9) and Δt>7 (4.0%, 95% CI 3.4-4.7), but similar for operations performed at Δt=1-3 (1.8%, 95% CI 1.7-1.9) and Δt=4-7 (2.1%, 95% CI 1.9-2.3). Compared to Δt=1-3, hospitalization costs were greater by $6,400 (95% CI 5,900-6,900) for Δt=4-7 and $21,200 (95% CI 19,800-22,600) for Δt>7. High-performing hospitals had similar time to CABG as others (2 vs 2 days, p=0.17), but lower mortality (0.9% vs 3.3%, p<0.001).

CONCLUSIONS

Revascularization on day 1-3 and 4-7 led to comparable in-hospital mortality, with greater rates on day 0 and after day 7. Costs were greater for revascularization at day 4-7 compared to day 1-3. These findings support the reduction of time to revascularization to 1-3 days when deemed clinically appropriate and feasible.

[Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: in-hospital outcomes. Part 2]

AIM

To assess in-hospital outcomes of coronary artery bypass grafting in patients with acute coronary syndrome, depending on the presence or absence of myocardial infarction.

PATIENTS AND METHODS

Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and subjected to coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction, who underwent surgery at an average of 16 (11; 20) days after manifestation of the clinical signs of myocardial infarction. The endpoints of the study were major adverse cardiovascular events during the in-hospital period: death, myocardial infarction, acute cerebral circulation impairment/transitory ischaemic attack, repeat revascularization, septic complications, multiple organ failure syndrome, wound infectious complications, requirement for repeated surgical debridement, remediastinotomy due to haemorrhage, the frequency of extracorporeal membrane oxygenation and renal replacement therapy.

RESULTS

The mortality rate in the compared groups was similar: 3% (n=3) and 3% (n=2), respectively. Perioperative myocardial infarction occurred in 1 (1%) patient of the first group, with no cases of this complication observed in the second group. The frequency of reoperations due to haemorrhage in the early postoperative period in the group of unstable angina pectoris amounted to 3% (n=3) and was associated with administration of dual antithrombotic therapy, with no cases of this complication in the group of myocardial infarction. Wound complication in the second group were observed in 7.6% (n=5) and in the first group in 4% (n=4) (p=0.33). The differences turned out to be statistically insignificant for such postoperative complications as multiple organ failure syndrome, requirement for repeated surgical debridement, renal replacement therapy, and extracorporeal membrane oxygenation. The residual SYNTAX Score in the group of myocardial infarction amounted to 2.3±2.8, whereas in the group of unstable angina pectoris to 2.3±3, thus suggesting complete revascularization in the total sample of patients with acute coronary syndrome. The average length of hospital stay (including the postoperative period) in the first group amounted to 26.3±6.6 days and in the second group to 27.4±7.2 days (p=0.53). The postoperative bed-day in the group with unstable angina pectoris was 12.6±3.2 and in the myocardial infarction group - 14.9±5.3 (p=0.06).

CONCLUSION

The obtained in-hospital outcomes suggest that coronary artery bypass grafting may be an efficient and safe method of complete revascularization for patients with non-ST-elevation acute coronary syndrome, including that resulting in myocardial infarction, performed averagely on day 16 (11; 20) after the onset of clinical manifestations of myocardial infarction.

Utility of logistic clinical SYNTAX score in prediction of in-hospital mortality in ST-elevation myocardial infarction patients undergoing emergent coronary artery bypass graft surgery

AIM

The logistic clinical SYNTAX score (log CSS) is a combined risk scoring system including clinical and anatomic parameters; it has been found to be effective for the prediction of mortality in patients with ST-elevation myocardial infarction (STEMI). Coronary artery bypass grafting (CABG) in the primary treatment of acute myocardial infarction is still debated. In the present study, we aimed to evaluate the utility of log CSS to stratify the risk of in-hospital mortality in acute STEMI patients undergoing emergent CABG for primary revascularization.

METHOD

In total, 88 consecutive patients with acute STEMI, who did not qualify for primary percutaneous coronary intervention and required emergent CABG were included in our study. Nine of 88 patients died during hospitalization. The study population was divided into two groups as in-hospital survivors and non-survivors. Log CSS and SYNTAX score (SS) were calculated for both groups and two groups were compared in terms of demographics, preoperative, intraoperative, postoperative characteristics, SS and log CSS.

RESULTS

Log CSS was found to be an independent predictor of in-hospital mortality, log CSS > 10.5 had 89% sensitivity, 81% specificity (area under the curve: 0.927; 95% confidence interval: 0.855-0.993). Moreover, peak troponin level was an independent predictor of in-hospital mortality. Glucose level, cardiopulmonary resuscitation before operation, glomerular filtration rate, left ventricular ejection fraction, and Killip class were significantly associated with in-hospital mortality.

CONCLUSION

Log CSS may improve the accuracy of risk assessment in patients who are undergoing emergent CABG for primary revascularization of STEMI.

[Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: analysis of perioperative factors. Part 1]

AIM

The purpose of this study was to assess the perioperative clinical, demographic and anatomo-angiographic factors in patients presenting with non-ST-segment elevation acute coronary syndrome and being candidates for coronary artery bypass grafting, depending on the presence or absence of myocardial infarction.

PATIENTS AND METHODS

Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and recommended by the cardiosurgical team to undergo coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction. A lethal outcome occurred in 2 (3%) Group Two patients prior to revascularization, hence they were not included into the analysis comparing the results of surgery in both groups, however these data were taken into consideration, being analysed separately.

RESULTS

The group of patients with myocardial infarction appeared to include significantly more female patients (20 (30.3%) versus 15 (15.3%) in the group of patients with unstable angina pectoris, p=0.02). However, by such parameters as the average age, left ventricular ejection fraction, and the frequency of diabetes mellitus the compared groups did not differ. The group with myocardial infarction was characterised by a severe clinico-angiographic status: more frequently encountered was stage II obesity (3%, n=3 in the first group and 10.6% n=7 in the second group, p=0.04). On the whole, the majority of patients were at intermediate and high risk (44.7% in the group with unstable angina pectoris versus 81.8% in the group of myocardial infarction, p<0.05). Group Two patients significantly more often presented with three-vessel lesions of the coronary bed (40 (40.8%) and 39 (59%), p=0.02). The level of low-density lipoproteins appeared to be significantly higher in patients with myocardial infarction (3.3±1 mmol/l and 2.9±0.9, p=0.04). In the same group more often encountered were peripheral artery lesions (28 (21%) and 12 (11.3%), p=0.04). In its turn, in the group of unstable angina pectoris, there were significantly more patients having received dual antithrombotic therapy prior to surgery (44 (44.9%) and 17 (25%), p=0.01). Approximately half of the patients in the first group (53%, n=52) had a history of myocardial infarction (p=0.001).

CONCLUSION

The obtained findings suggested that amongst the patients with non-ST-elevation acute coronary syndrome resulting in myocardial infarction prevailing were those of female gender, with obesity, as a consequence, hyperholesterolaemia and triple-vessel disease. At the same time, postinfarction cardiosclerosis, renal dysfunction, and haemodynamically significant lesions of lower-extremity arteries were encountered in the group of unstable angina pectoris.

Surgical revascularization for acute coronary syndromes: a report from the North Rhine-Westphalia surgical myocardial infarction registry

OBJECTIVES

The aim of this was to analyse current outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndromes (ACSs), including ST-elevation or non-ST-elevation ACS (non-ST-segment elevation myocardial infarction) or unstable angina.

METHODS

Patients (n = 2432) undergoing CABG for ACS between January 2010 and December 2017 were prospectively entered into a surgical myocardial infarction registry in North Rhine-Westphalia, Germany. Key end points were in-hospital all-cause mortality (IHM) and major adverse cardio-cerebral events (MACCE). Predictors for IHM and MACCE were analysed by multivariable logistic regression.

RESULTS

Patients (78% males) were referred for CABG for unstable angina (25%), non-ST-segment elevation myocardial infarction (50%), and ST-segment elevation myocardial infarction (25%). The mean patient age was 68 ± 11 years, logistic EuroSCORE was 19 ± 18% and three-vessel and left main stem diseases were diagnosed in 81% and 45% of patients, respectively. On-pump CABG with cardiac arrest or beating heart was performed in 92% and 2%, respectively, with only 6% off-pump surgery and 6% multiple arterial revascularization (3.1 ± 1.0 grafts, 93% left internal thoracic artery). Emergency CABG was performed in 23% of patients (42% in ST-segment elevation myocardial infarction; P < 0.001). The total IHM and MACCE rates were 8.1% and 17.5% and were highest in ST-segment elevation myocardial infarction patients with 12.6% and 28.5%, respectively (P < 0.001). Key predictors for IHM and MACCE were female gender, elevated troponin, left ventricular ejection fraction, inotropic support, logistic EuroSCORE, cardiopulmonary bypass and aortic clamp time and the need for emergency CABG.

CONCLUSIONS

Surgical myocardial revascularization in patients with ACS is still linked to substantial in-hospital mortality. Emergency CABG for patients with ACS was associated with poorer outcomes.

Impact of Delay in Surgery on Outcome in Patients Undergoing Cardiac Revascularisation Surgery

BACKGROUND

Diagnosis of critical coronary artery disease, including after acute coronary syndrome presentation (ACS), represents an important indication for early coronary artery bypass graft (CABG) surgery. The study aims to investigate the influence of time from diagnosis to CABG on outcomes and document barriers to early revascularisation.

METHODS

All patients 18 years and older with an acute presentation due to ACS or critical coronary artery disease who were considered to require urgent inpatient cardiac surgery between January 2016-February 2019 were included in the study. The primary endpoints were 30-day all-cause mortality or readmission, 1-year all-cause mortality, all-cause readmission. The secondary endpoint was the rate of complications while waiting for surgery. The time duration between diagnostic coronary angiography and surgery was considered as the time interval.

RESULTS

Of 266 eligible patients, 251 underwent surgical revascularisation with 15 (6%) not undergoing surgery due to preoperative complications (n=12) or due to perceived prohibitively high surgical risk (n=3). The majority (85%) were male (mean age 67 years), 37% of patients had diabetes and 71% had hypertension. Non-ST elevation myocardial infarction was documented in 51% of the patients. The median time between diagnosis and inpatient CABG was 7 days (IQR 5-11). Thirty-five per cent (35%) of patients experienced complications while awaiting surgery. Of the 266 patients, 140 patients (53% - cohort 1) underwent surgery within 7 days. The cohort 1 rate of complications was lower than in cohort 2 (surgery after 7 days) (24 vs 47%, p<0.001). Moreover, 1-year mortality was less in cohort 1 (2 vs 8%, p=0.029).

CONCLUSION

In patients requiring urgent inpatient CABG, delay for more than 7 days is associated with a higher rate of in-hospital complications and worse 30 day and 12-month outcomes.

Trends in Utilization and Safety of In-Hospital Coronary Artery Bypass Grafting During a Non-ST-Segment Elevation Myocardial Infarction

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p <0.001). High, 26.4%, complication rate was driven mainly by cardiac and pulmonary complications. The mortality rate declined from 3.6% in 2003 to an average of 2.4% during 2010 to 2015. Older age, female gender, heart failure, and delayed CABG timing were independent predictors of adverse outcomes. In conclusion, utilization of in-hospital CABG as the primary revascularization strategy in patients with NSTEMI remained steady over the years. These data reveal the raising prevalence of co-morbidities during the study. High complication rate was recorded; however, the mortality declined over the years to about 2.4%. Delaying CABG was associated with small but statistically significant worsening in outcomes.

Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North-Rhine-Westphalia Surgical Myocardial Infarction Registry

Background

Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and ST‐segment–elevation myocardial infarction (STEMI).

Methods and Results

Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score.

Conclusions

Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.

Impact of troponin I level on coronary artery bypass grafting outcomes

PURPOSE

The effect of preoperative cardiac troponin level on outcomes after coronary artery bypass grafting (CABG) is unclear. We investigated the impact of preoperative cardiac troponin I (cTnI) level as well as the time interval between maximum cTnI and surgery on CABG outcomes.

METHODS

All patients who underwent isolated CABG at our institution between 2009 and 2016 and had preoperative cTnI level available were identified using our Society of Thoracic Surgeons registry. Receiver operating characteristic (ROC) analysis was performed to identify a cTnI threshold level. Subjects were divided into groups based on this value and outcomes compared.

RESULTS

A total of 608 patients were included. ROC analysis identified 5.74 µg/dL as the threshold value associated with worse postoperative outcomes. Patients with peak cTnI >5.74 µg/dL underwent CABG approximately 1 day later, had twice the risk of adverse postoperative events, and had 2.8 day longer postoperative length of stay than those with peak cTnI ≤5.74 µg/dL. cTnI level was not associated with mortality or 30-day readmission. Time interval between peak cTnI and surgery did not affect outcomes.

CONCLUSION

Elevated preoperative cTnI level beyond a certain threshold value is associated with adverse postoperative outcomes but is not a marker for increased mortality. Time from peak cTnI does not affect postoperative outcomes or mortality and may not need to be considered when deciding timing of CABG.

Revascularization following non-ST elevation myocardial infarction in multivessel coronary disease

BACKGROUND

The optimal revascularization approach for patients with multivessel coronary artery disease (MVCAD) is controversial. We sought to investigate outcomes in patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for non-ST elevation myocardial infarction (NSTEMI).

METHODS

Adult patients with MVCAD and NSTEMI undergoing either CABG or PCI at a single institution between 2011 and 2018 were included. Multivariable analysis was utilized to determine independent predictors of death, major adverse cardiac and cerebrovascular events (MACCE), and readmissions. A subanalysis examined patients undergoing complete revascularization.

RESULTS

A total of 2001 patients were included, of whom 1480 (74.0%) underwent CABG. CABG was associated with a lower risk-adjusted hazard for death (hazard ratio, 0.59, P < .001) and with improved survival at 1 year (92.0 vs 81.8%, P < .001) and 5 years (80.7 vs 63.3%, P < .001). Additionally, freedom from MACCE (P < .001) was greater in the CABG group and cumulative readmission, rates of MI, and rates of repeat revascularization were lower with CABG (each P < .001). Among patients undergoing complete revascularization, overall survival (1 year: 92.7 vs 83.9%, P = .010; 5 years: 81.1 vs 69.4%, P < .001) and freedom from MACCE (1 year: 92.3 vs 75.2%, P < .001; 5 years: 81.7 vs 61.4%, P < .001) remained higher for the CABG group; cumulative incidence of readmission was also decreased in those undergoing CABG (P < .001).

CONCLUSIONS

In this real-world analysis of patients with MVCAD presenting with NSTEMI, revascularization with CABG resulted in improved survival with lower rates of MACCE and readmission as compared to PCI, which persisted when accounting for complete revascularization.

[Coronary artery bypass grafting in non-ST-segment elevation acute myocardial infarction]

AIM

The study was aimed at comparatively assessing the immediate results of coronary artery bypass grafting operations without artificial circulation performed in non-ST-segment elevation acute myocardial infarction and chronic ischaemic heart disease.

PATIENTS AND METHODS

The main group with non-ST-segment elevation acute myocardial infarction enrolled a total of 101 patients undergoing coronary artery bypass grafting without artificial circulation. The patients' age varied from 47 to 87 years, median 66.0 years (60.0; 71.0). The indication for the operation was persistent myocardial ischaemia on the background of carried out therapy with impossibility of performing percutaneous coronary intervention due to anatomy of coronary arteries and peculiarities of their pathology. The comparison group of chronic ischaemic heart disease was composed of 108 patients undergoing elective coronary artery bypass grafting without artificial circulation. The patients' age varied from 40 to 92 years, median - 60.0 years (58.0; 68.0). The patients with acute myocardial infarction had a significantly greater (p<0.05) number of coronary arteries measuring in diameter 2.5 mm and more, with significant occlusive and stenotic lesions, as well as a higher total SYNTAX score. The patients undergoing elective surgery were found to have an initially higher (p<0.05) left ventricular ejection fraction.

RESULTS

In the group of acute myocardial infarction the waiting times for coronary artery bypass grafting varied from 2 to 8 days, median of waiting - 4.0 days (4.0; 5.0). The lethality rate (p<0.05) in the group of acute myocardial infarction amounted to 3.0% (3 cases) and in the group of chronic ischaemic heart disease to 0.9% (1 case). Twenty-one (20.8%) operations were carried out within the first 72 hours, with eighty surgical interventions (79.2%) performed after 72 hours from the onset of the disease. All 3 (3.8%) lethal outcomes were observed after coronary artery bypass grafting procedures performed later than 72 hours from the onset of acute myocardial infarction (p>0.05). The total number of complications (p>0.05) amounted to 18 (17.8%) and 10 (9.3%) in the group of acute myocardial infarction and in the group of chronic ischaemic heart disease, respectively.

CONCLUSION

The immediate results of delayed coronary artery bypass grafting procedures without artificial circulation for acute myocardial infarction and chronic ischaemic heart disease were statistically comparable (p>0.05) by the lethality and complication rates. Lethality in the group of non-ST-segment elevation acute myocardial infarction din not depend on the time of operation after the onset of the disease.

Late clinical outcomes of unselected patients with diabetic mellitus and multi-vessel coronary artery disease

BACKGROUND

The Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multi-Vessel Disease (FREEDOM) clinical trial randomized only a proportion of screened patients with diabetes mellitus (DM) and multi-vessel disease (MVD).

METHODS AND RESULTS

We determined late rates of death, non-fatal myocardial infarction (MI) and stroke in all 430 patients with DM who had MVD identified on angiographic screening for the FREEDOM Trial, which recruited from June 2006 -March 2010 at Liverpool Hospital, Sydney, Australia. Mortality at 6 years [median] was 23% among 192 FREEDOM-eligible patients and 26% among 238 FREEDOM-ineligible patients, of whom 139 [58%] had prior. CABG (mortality 31%). Overall, 196 (45%) had percutaneous coronary intervention (PCI), 127 (30%) underwent coronary artery bypass grafting (CABG) (who were 4 years younger; p = 0.003), and 107 (25%) had neither procedure of whom 80 were considered unsuitable for revascularization. Mortality was 26% post-PCI 16%, post-CABG and 33% among those who did not undergo revascularization (p = 0.01). On multivariable analyses, factors associated with late mortality were older age, hypertension and not undergoing CABG (all p < 0.05). Factors associated with late MI were presented with an acute coronary syndrome, whereas patients that underwent treatment with either PCI or CABG had less late MI (all p < 0.05).

CONCLUSION

Among consecutive diabetic patients with MVD, at a median of 6-years CABG was associated with better survival and fewer non-fatal MI outcomes compared to PCI.

Association between high-sensitivity cardiac troponin I measured at emergency department and complications of emergency coronary artery bypass grafting

High-sensitivity cardiac troponin I (hs-cTnI) is a widely used biomarker to identify ischemic chest pain in the Emergency Department (ED), but the clinical impact on emergency coronary artery bypass grafting (eCABG) remains undetermined. We aimed to evaluate the clinical impact of hs-cTnI measured at the ED by comparing outcomes of eCABG in patients with non–ST-segment–elevation acute coronary syndrome (NSTE-ACS) which comprises unstable angina (UA) and non–ST-segment–elevation myocardial infarction (NSTEMI). From January 2012 to March 2016, 242 patients undergoing eCABG were grouped according to serum hs-cTnI level in the ED. The primary endpoint was major cardiovascular cerebral event (MACCE) defined as a composite of all-cause death, myocardial infarction, repeat revascularization, and stroke. The incidence of each MACCE composite, in addition to postoperative complications such as acute kidney injury, reoperation, atrial fibrillation, and hospital stay duration were also compared. Patients were divided into two groups: UA [<0.04 ng/mL, n = 102] and NSTEMI [≥0.04 ng/mL, n = 140]. The incidence of MACCE did not differ between the two groups. Postoperative acute kidney injury was more frequent in the NSTEMI group after adjusting for confounding factors (6.9% vs. 23.6%; odds ratio, 2.76; 95% confidence interval, 1.09–6.99; p-value = 0.032). In-hospital stay was also longer in the NSTEMI group (9.0 days vs. 15.4 days, p-value = 0.008). ECABG for UA and NSTEMI patients showed comparable outcomes, but hs-cTnI elevation at the ED may be associated with immediate postoperative complications.

Early surgical myocardial revascularization in non-ST-segment elevation acute coronary syndrome

BACKGROUND

In non-ST-elevation myocardial infarction (NSTEMI) there is no consensus regarding optimal time point for coronary artery bypass grafting (CABG). Recent findings suggest that long-term outcomes are improved in early-revascularized NSTEMI patients. However, it has been stated that early surgery is associated to increased operative risk. In this study, we wanted to elucidate if early CABG in non-ST-elevation acute coronary syndrome can be performed safely.

METHODS

We performed a monocentric-prospective observational study within a 2-year interval. A total of 217 consecutive patients (41 female, age 68.9±10.2, ES II 6.62±8.56) developed NSTEMI and underwent CABG. Patients were divided into two groups according to the time point of coronary artery bypass after symptom onset (group A: <72 h; group B: >72 h). Endpoints included 6-month mortality and incidence of MACE (death, stroke or re-infarction).

RESULTS

There were no differences regarding mortality between both groups (30 days: group A 2.4% vs. group B 3.7%; P=0.592; 6 months: 8.4% vs. 6.0%; P=0.487). Incidence of MACE in the 6-month follow-up was also similar in both groups (group A: 9.6% vs. 9.7%, P=0.982). Regression analysis revealed as independent risk factors for mortality in the entire cohort ES II OR 1.045 (95% CI: 1.004-1.088). ES II remained an independent prognostic factor in group A OR 1.043 (95% CI: 1.003-1.086) and group B OR 1.032 (95% CI: 1.001-1.063).

CONCLUSIONS

Early revascularized patients showed a higher level of illness. However, results of early CABG were comparable to those following delayed revascularization. Moreover, EuroSCORE II was determined as independent risk factors for mortality.

Revascularization Strategies for Non-ST-Elevation Myocardial Infarction

PURPOSE OF REVIEW

Non-ST-elevation myocardial infarction (NSTEMI) is an urgent medical condition that requires prompt application of simultaneous pharmacologic and non-pharmacologic therapies. The variation in patient clinical characteristics coupled with the multitude of treatment modalities makes optimal and timely management challenging. This review summarizes risk stratification of patients, the role and timing of revascularization, and highlights important considerations in the revascularization approach with attention to individual patient characteristics.

RECENT FINDINGS

The early invasive management of NSTEMI has fostered a reduction in future ischemic events. Risk calculators are helpful in determining which patients should receive early invasive management. As many patients have multivessel disease, identifying the true culprit lesion can be challenging. Special attention should be given to those at the highest risk, such as diabetics, patients with renal failure, and those with left main disease. In patients with acute coronary syndrome, the decision and mode of revascularization should carefully integrate the patient's clinical characteristics as well as the complexity of the coronary anatomy.

Urgent Revascularization Strategies in Patients With Diabetes Mellitus and Acute Coronary Syndrome

The prevalence of diabetes mellitus (DM) is rising globally and in Canada. Besides being a risk factor for the development of coronary artery disease, DM is also a marker of poor prognosis in patients with acute coronary syndrome (ACS), increasing the risks for ischemic and bleeding complications. Patients with DM have a high prevalence of multivessel coronary artery disease (MVD) and robust evidence has supported coronary artery bypass surgery (CABG) as the optimal revascularization strategy in the setting of stable ischemic heart disease. In the acute scenario, particularly in patients with non-ST-segment elevation (NSTE) ACS (NSTE-ACS), there are many uncertainties regarding the best revascularization strategy. Most guidelines suggest an invasive and timely approach (that is, performing coronary catheterization within 72 hours after the onset of the NSTE-ACS) and make recommendations about choosing between percutaneous coronary intervention (PCI) or CABG on the basis of data for patients with stable ischemic heart disease. Recent observational and subgroup analyses suggest that CABG might be the preferential method of revascularization for patients with DM and MVD also in the NSTE-ACS setting; however, dedicated randomized clinical trials are lacking. Finally, in patients who present with an ST-segment elevation myocardial infarction, the initial revascularization method of choice is generally PCI, instead of fibrinolysis or CABG, and DM status most often does not influence this decision. The management of residual MVD after primary PCI for ST-segment elevation myocardial infarction, however, remains controversial.

Early and Long-Term Outcomes in Patients Undergoing Cardiac Surgery Following Iatrogenic Injuries During Percutaneous Coronary Intervention

Background Iatrogenic coronary artery injuries during percutaneous coronary interventions ( PCI ) often require emergent surgical management. Our study evaluated the early and long-term outcomes in patients undergoing surgical treatment of iatrogenic PCI complications and identified the predictors of operative and long-term mortality. Methods and Results Pre-, intra- and post-operative data and hospital outcomes of 168 consecutive patients undergoing cardiac surgical procedures for iatrogenic complications following PCI between December 1999 and July 2015, were prospectively collected in our computerized database. Logistic and Cox regression analyses were used to identify the independent predictors of operative and long-term mortality. The mean age was 68.5±10.2 years and 35.7% were females. PCI complications included left anterior descending (38.7%), right coronary (29.2%), circumflex (13.1%), left main coronary artery injuries (19.0%), and acute myocardial infarction (66.7%), Type A aortic dissection (7.7%), cardiac tamponade (17.9%), and cardiogenic shock ( CS ) (46.4%). Operative mortality for corrective surgery was 20.8% and was independently predicted by critical preoperative state (odds ratio: 3.5; P=0.01). The 5- and 10-year survival for all patients was 63.9±4.0% and 49.6±5.0%, which improved remarkably in hospital survivors (79.0±4.0% and 64.0±6.0%). Risk factors for long-term mortality were critical preoperative state (hazard ratio: 3.5; P<0.0001) and coronary artery occlusion during PCI (hazard ratio: 2.6; P=0.002). The 5- and 10-year freedom from major adverse cardiac and cerebrovascular events was 59.7±4.0% and 41.9±5.0%. Conclusions Iatrogenic injuries after PCI or coronary angiography requiring surgical correction are associated with a high operative and long-term mortality. Patients developing acute coronary artery occlusion have a more guarded long-term prognosis. Hospital survivors, however, have a superior long-term survival.

Institution of localized high-frequency electrical stimulation targeting early myocardial infarction: Effects on left ventricle function and geometry

BACKGROUND

Although strategies have focused on myocardial salvage/regeneration in the context of an acute coronary syndrome and a myocardial infarction (MI), interventions targeting the formed MI region and altering the course of the post-MI remodeling process have not been as well studied. This study tested the hypothesis that localized high-frequency stimulation instituted within a formed MI region using low-amplitude electrical pulses would favorably change the trajectory of changes in left ventricle geometry and function.

METHODS

At 7 days following MI induction, pigs were randomized for localized high-frequency stimulation (n = 5, 240 bpm, 0.8 V, and 0.05 ms pulses) or unstimulated (n = 6). Left ventricle geometry and function were measured at baseline (pre-MI) and at 7, 14, 21, and 28 days post-MI using echocardiography. MI size at 28 days post-MI was determined by histochemical staining and planimetry.

RESULTS

At 7 days post-MI and before randomization to localized high-frequency stimulation, left ventricular ejection fraction and end-diastolic volume was equivalent. However, when compared with 7-day post-MI values, left ventricle end-diastolic volume increased in a time-dependent manner in the MI unstimulated group, but the relative increase in left ventricle end-diastolic volume was reduced in the MI localized high-frequency stimulation group. For example, by 28 days post-MI, left ventricle end-diastolic volume increased by 32% in the MI unstimulated group but only by 12% in the MI localized high-frequency stimulation group (P < .05). Whereas left ventricular ejection fraction appeared unchanged between MI groups, estimates of pulmonary capillary wedge pressure, a marker of adverse left ventricle performance and progression to failure, increased by 62% in the MI unstimulated group and actually decreased by 17% in the MI localized high-frequency stimulation group when compared with 7-day post-MI values (P < .05). MI size was equivalent between the MI groups, indicative of no difference in the extent of absolute myocardial injury.

CONCLUSIONS

The unique findings from this study are 2-fold. First, targeting the MI region following the resolution of the acute event using a localized stimulation approach is feasible. Second, localized stimulation modified a key parameter of adverse post-MI remodeling (dilation) and progression to heart failure. These findings demonstrate that the MI region itself is a modifiable tissue and responsive to localized electrical stimulation.

Is delayed surgical revascularization in acute myocardial infarction useful or dangerous? New insights into an old problem

OBJECTIVES

Haemodynamically stable patients admitted for coronary artery bypass grafting in acute myocardial infarction often undergo delayed surgery in order to avoid the risks of emergency surgery. However, initially stable patients undergoing delayed surgery may develop low cardiac output syndrome (LCOS) during the waiting period, which might be a major drawback of this strategy. We aim to define risk factors and clinical consequences of LCOS during the waiting period.

METHODS

A total of 530 consecutive patients with acute myocardial infarction (33% non-ST-segment elevation myocardial infarction and 67% ST-segment-elevation myocardial infarction) underwent isolated coronary artery bypass grafting between 2008 and 2013. Outcomes after either immediate (<48 h after onset of symptoms) or delayed (>48 h after onset of symptoms) therapy were compared. Predictors of preoperative development of LCOS were identified using multivariate regression analysis.

RESULTS

Of the 327 patients undergoing delayed therapy, 39 (12%) developed preoperative LCOS, resulting in increased mortality compared with patients who remained stable (21 vs 7.6%, P < 0.001). Immediate therapy resulted in similar mortality compared with delayed therapy (6.4 vs 7.6%; P = 0.68) and better 7-year survival (70 vs 55%; P < 0.001). Predictors of developing LCOS were reduced left ventricular function (odds ratio 4.4), renal impairment (odds ratio 3.0), acute pulmonary infection (odds ratio 3.4) and the extent of troponin elevation at admission (odds ratio 1.01 per increase by 1 µg/l).

CONCLUSIONS

In patients with acute myocardial infarction undergoing delayed coronary artery bypass grafting, preoperative LCOS is a relevant and dangerous condition that can be avoided by operating immediately or by carefully selecting patients to be delayed according to the risk parameters identified preoperatively.

Outcome of Stable Patients With Acute Myocardial Infarction and Coronary Artery Bypass Surgery Within 48 Hours: A Single-Center, Retrospective Experience

BACKGROUND

The optimal timing of coronary artery bypass grafting (CABG) in clinically stable patients with acute myocardial infarction who are unsuitable for percutaneous coronary intervention is unclear. We report our experience with early CABG in these patients.

METHODS AND RESULTS

Between January 2001 and May 2015, 766 patients with ST-segment-elevation myocardial infarction (STEMI, n=305) or non-STEMI (NSTEMI, n=461) not including cardiogenic shock underwent CABG within 48 hours at our department. STEMI patients were younger than non-STEMI patients (age 65 years [range: 58-72] versus 70 years [range: 62-75], P<0.001) with a lower EuroSCORE II (4.12 [range: 2.75-5.81] versus 4.58 [range: 2.80-7.74], P=0.009). STEMI patients had undergone preoperative percutaneous coronary intervention more often (20.3% versus 7.8%, P<0.001). Time to surgery was shorter in STEMI compared with non-STEMI patients (5.0 hours [range: 3.2-8.8] versus 11.7 hours [range: 6.4-22.0], P<0.001). No significant differences concerning arterial graft use (93.8% versus 94.8%, P=0.540) or complete revascularization (87.5% versus 83.4%, P=0.121) were observed. The rate of strokes did not differ between the groups (2.0% versus 3.9%, P=0.134). Thirty-day mortality was lower in STEMI patients (2.7% versus 6.6% P=0.018), especially when CABG was performed within 6 hours (1.8% versus 7.1%, P=0.041). Survival of STEMI and non-STEMI patients was 94% versus 88% after 1 year (P<0.001), 87% versus 73% after 5 years (P<0.001), and 74% versus 57% after 10 years (P<0.001). Independent predictors of 30-day and long-term mortality included preoperatively increased lactate values, age, atrial fibrillation, and reduced left ventricular function.

CONCLUSIONS

Stable STEMI patients showed a lower rate of perioperative complications and better survival compared with non-STEMI patients when CABG was performed within 48 hours.

Training in Coronary Artery Bypass Surgery: Tips and Tricks of the Trade

Coronary artery bypass is often the first procedure cardiac surgeons are confronted with during their residencies. This article discusses the surgical steps and the potential difficulties encountered during this procedure and how they can be solved. The "point of view" of an experienced surgeon is provided to the trainees and to the readers.

Temporal Trends in Predictors of Early and Late Mortality After Emergency Coronary Artery Bypass Grafting for Cardiogenic Shock Complicating Acute Myocardial Infarction

BACKGROUND

Cardiogenic shock after acute myocardial infarction is an indication for emergent coronary artery bypass grafting in patients not amenable to percutaneous coronary intervention. Our study aimed to evaluate and identify risk factors for early and long-term outcomes in such patients.

METHODS

A total of 508 patients who underwent coronary artery bypass grafting for cardiogenic shock complicating acute myocardial infarction between January 2000 and June 2014 were divided into 3 time cohorts: 2000 to 2004 (n=204), 2005 to 2009 (n=166), and 2010 to 2014 (n=138). Predictors of in-hospital mortality for each time cohort and long-term mortality for all patients were identified by logistic and Cox regression analyses, respectively.

RESULTS

Mean age was 68.3±9.8 years. Of the 508 patients, 78.5% had 3-vessel and 47.1% had left main disease. Left ventricular function <30% was observed in 44.1% of patients, with 30.4%, 37.9%, 52.9%, and 3.1% requiring preoperative resuscitation, ventilation, intra-aortic balloon pump, and extracorporeal membrane oxygenation support, respectively. Overall in-hospital mortality was 33.7%; declined from 42.2% to 30.7% to 24.6%, respectively, for the 3 time cohorts (P=0.02); and was independently predicted by serum lactate >4 mmol/L (odds ratio [OR], 4.78; 95% confidence interval, 2.88-7.95; P<0.0001), ST-segment-elevation myocardial infarction (OR, 2.10; 95% confidence interval, 1.36-3.26; P=0.001), age >75 years (OR, 2.01; 95% confidence interval, 1.06-3.85; P=0.03), and left ventricular ejection fraction <30% (OR, 1.83; 95% confidence interval, 1.15-2.91; P=0.01). Cumulative survival was 42.6±2.0% and 33.4±2.0% at 5 and 10 years, respectively, and correspondingly improved to 64.3±3.0% and 49.8±3.0% in hospital survivors. Serum lactate >4 mmol/L (OR, 2.2; P<0.0001), incremental age (OR, 1.05; P<0.0001), New York Heart Association class IV (OR, 1.33; P=0.02), diabetes mellitus (OR, 1.39; P=0.005), and preoperative inotropic (OR, 2.61; P=0.001) and extracorporeal membrane oxygenation (OR, 1.68; P=0.05) support predicted late mortality.

CONCLUSIONS

Emergency coronary artery bypass grafting in patients with acute myocardial infarction complicated by cardiogenic shock is associated with a high in-hospital mortality, which showed a significant decline with time. Hospital survivors have good long-term outcomes, which demonstrate the beneficial effect of surgical revascularization. Preoperative serum lactate >4 mmol/L is a strong predictor of both early and late mortality.

Current outcomes of off-pump coronary artery bypass grafting: evidence from real world practice

Coronary artery bypass grafting (CABG) can be performed conventionally using cardiopulmonary bypass (CPB) and aortic clamping or on a beating heart (BH) without the use of CPB, the so-called off-pump CABG. Some surgeons, who are proponents of off-pump CABG, preferentially use this technique for the majority of operations, whereas others use it only in certain situations which warrant avoidance of CPB. Ever since the conception of off-pump CABG, the never-ending debate about which technique of CABG is safe and efficacious continues to date. Several randomized controlled trials (RCTs) have been conducted that have either favored on-pump CABG or have failed to show a significant difference in outcomes between the two techniques. However, these RCTs have been fraught with claims that they do not represent the majority of patients undergoing CABG in real world practice. Therefore, assessment of the benefits and drawbacks of each technique through observational and registry studies would be more representative of patients encountered in daily practice. The present review examines various retrospective studies and meta-analyses of observational studies that compare the early and long-term outcomes of off- and on-pump CABG, which assesses their safety and efficacy. Additionally, their outcomes in older patients, females, and those with diabetes mellitus, renal dysfunction, presence of ascending aortic disease, and/or acute coronary syndrome (ACS) have also been discussed separately. The general consensus is that early results of off-pump CABG are comparable to or in some cases better than on-pump CABG. However, on-pump CABG provides a survival benefit in the long term according to a majority of publications in literature.

Cardiac surgery 2015 reviewed

For the year 2015, almost 19,000 published references can be found in PubMed when entering the search term "cardiac surgery". The last year has been again characterized by lively discussions in the fields where classic cardiac surgery and modern interventional techniques overlap. Lacking evidence in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery has been added. As in the years before, CABG remains the gold standard for the revascularization of complex stable triple-vessel disease. Plenty of new information has been presented comparing the conventional to transcatheter aortic valve implantation (TAVI) demonstrating similar short- and mid-term outcomes at high and low risk, but even a survival advantage with transfemoral TAVI at intermediate risk. In addition, there were many relevant and interesting other contributions from the purely operative arena. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While the article does not have the expectation of being complete and cannot be free of individual interpretation, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

Indications, algorithms, and outcomes for coronary artery bypass surgery in patients with acute coronary syndromes

For patients with a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), guideline recommendations and treatment pathways focus on revascularization for definitive treatment if the patient is an appropriate candidate. Despite the widespread use of revascularization for NSTE-ACS, most patients undergo a percutaneous coronary intervention, whereas a minority of patients undergo coronary artery bypass grafting. Focusing specifically on the USA, the contemporary utilization, preoperative and perioperative considerations, and outcomes of NSTE-ACS patients undergoing coronary artery bypass grafting have not been comprehensively reviewed.