The EXCEL Trial: The Surgeons' Perspective

Clinical Updates in Coronary Artery Disease: A Comprehensive Review

Despite significant goals achieved in diagnosis and treatment in recent decades, coronary artery disease (CAD) remains a high mortality entity and continues to pose substantial challenges to healthcare systems globally. After the latest guidelines, novel data have emerged and have not been yet considered for routine practice. The scope of this review is to go beyond the guidelines, providing insights into the most recent clinical updates in CAD, focusing on non-invasive diagnostic techniques, risk stratification, medical management and interventional therapies in the acute and stable scenarios. Highlighting and synthesizing the latest developments in these areas, this review aims to contribute to the understanding and management of CAD helping healthcare providers worldwide.

Coronary Artery Surgery: Past, Present, and Future

Coronary artery bypass grafting (CABG) is the most commonly performed and studied major cardiac operation worldwide. An understanding of the evolution of CABG, including the early days of cardiac surgery, the first bypass operation, continuous improvements in techniques, and streamlining of the operation, is important to inform current trends and future innovations. This article will examine how CABG evolved (from techniques to conduits), describe current trends in the field, and explore what lies on the horizon for the future of CABG.

Predicting Determinants for Conversion of Off-Pump Coronary Revascularization to On-Pump Surgery: A Retrospective Analysis

A global consensus has not yet been reached regarding the preference for off-pump versus on-pump coronary revascularization. Although the coronary trial indicates that the secondary endpoint outcomes favor on-pump surgery, the cost-effectiveness and significantly lower immediate and early complications in off-pump surgery make it favorable for the Indian population. To analyze patients who underwent coronary revascularization, specifically coronary artery bypass grafting (CABG), a retrospective five-year study was conducted. During the given duration, a total of 652 patients underwent CABG. The study revealed a positive correlation between diabetes, high body surface area (BSA), and preexisting renal dysfunction as strong predictors for converting off-pump coronary artery bypass surgery (OPCABG) to on-pump surgery coronary artery bypass surgery (ONCABG). Preoperative electrocardiographic (ECG) changes and the use of intra-aortic balloon pulsation (IABP) as a mechanical assist device were strongly associated with the incidence of conversion from OPCABG to ONCABG. Tight left main disease and ostial coronary disease indicate a progressive dysfunction during off-pump surgery, necessitating early conversion to on-pump surgery to avoid complications. The on-pump group had more adverse outcomes in regard to renal and neurological dysfunction, which can be attributed to pump-induced dysfunction. In such scenarios, a surgeon's preparedness to convert an OPCABG to an ONCABG can be swift and efficient. In anticipation of increased pump-related complications in the ONCABG group, a measured approach can be implemented to avoid adverse postoperative outcomes in high-risk patients.

Minimally invasive off-pump anaortic coronary artery bypass (MACAB)

BACKGROUND

Minimally invasive direct coronary artery bypass has enabled coronary artery bypass graft to compete with the appeal of less invasive percutaneous coronary procedures. Favorable results of coronary artery bypass surgery performed without the use of cardiopulmonary bypass and without touching the aorta (anOPCAB) have enabled the development and use of minimally invasive methods.

METHODS

Between 2016 and 2021, 112 patients underwent multivessel coronary bypass surgery performed using a minimally invasive method through a small thoracotomy in the left chest with off-pump, anaortic, and all-arterial grafts (Minimally Invasive Off-Pump Anaortic Coronary Artery Bypass [MACAB]). Patient data were collected and retrospectively analyzed. Eight series from the literature using the multivessel mini-OPCAB and MACAB technique were also evaluated.

RESULTS

Collectively, from the literature, 2729 patients underwent an average of 2.4 bypasses with an early mortality rate of 0.7% and a stroke rate of 0.16%. In our MACAB case series, 112 patients underwent an average of 2.9 bypasses with a mortality rate of 1.8% and a stroke rate of 0%.

CONCLUSION

MACAB can be performed safely by experienced surgeons and reduces neurological injury and surgical trauma and may be a good alternative for multivessel stenting. Simulation systems are essential for its dissemination, and teams dedicated to coronary surgery-with subspecialty expertise-are necessary to achieve good outcomes.

Recent Evidence on Advances in PCI Treatment for Left Main Coronary Artery Disease

Revascularization therapy significantly improves the outcomes of patients with left main coronary artery disease (LMCAD), compared with medical therapy alone. For many years, coronary artery bypass grafting (CABG) has been the primary and standard treatment strategy. However, with advances in percutaneous coronary intervention (PCI) techniques and improvements in patients' outcomes, there is growing evidence supporting PCI for LMCAD. In this review, we aim to integrate the available evidences on advances in PCI treatment for LMCAD and provide guidance for further clinical practice.

Coronary Stenting: Reflections on a 35-Year Journey

Stenting was introduced as a therapy for coronary artery disease 35 years ago, and is currently the most commonly performed minimally invasive procedure globally. Percutaneous coronary revascularization, initially with plain old balloon angioplasty and later with stenting, has dramatically affected the outcomes of acute myocardial infarction and acute coronary syndromes. Coronary stenting is probably the most intensively studied therapy in medicine on the basis of the number of randomized clinical trials for a broad range of indications. Continuous improvements in stent materials, design, and coatings concurrent with procedural innovations have truly been awe-inspiring. The story of stenting is replete with high points and some low points, such as the initial experience with stent thrombosis and restenosis, and the more recent disappointment with bioabsorbable scaffolds. History has shown rapid growth of stent use with expansion of indications followed by contraction of some uses in response to clinical trial evidence in support of bypass surgery or medical therapy. In this review we trace the constantly evolving story of the coronary stent from the earliest experience until the present time. Undoubtedly, future iterations of stent design and materials will continue to move the stent story forward.

A Risk Score for Predicting Long-Term Mortality Following Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) comprises 15-30% of all bypass grafting surgeries. The currently available perioperative scores such as Euroscore and STS score do not specifically predict long-term mortality after off-pump procedures. The neutrophil-to-lymphocyte ratio (NLR) is one of the new, easily accessible markers of inflammation with proven predictive value in cardiovascular diseases. We aimed to develop the first risk score for long-term mortality after OPCAB and to determine if the perioperative value of NLR predicts long-term mortality in OPCAB patients.

METHODS

In total, 440 consecutive patients with multivessel stable coronary artery disease undergoing OPCAB were recruited. Differential leukocyte counts were obtained by a routine hematology analyzer. Data regarding mortality during a median follow-up time of 5.3 years were obtained from the Polish National Health Service database. An independent population of 242 patients served as a validation cohort.

RESULTS

All-cause mortality was influenced by different clinical risk factors. In multivariate regression analysis, chronic obstructive pulmonary disease, stroke history, post-operative NLR and LVEF were independent predictors of mortality. Combing all independent predictors predicted long-term all-cause mortality with 68.5% sensitivity and 71.5% specificity (AUC = 0.704, p < 0.001). After weighing these variables according to their estimates in a multivariate regression model, we developed a score to predict mortality in patients undergoing OPCAB (PREDICT-OPCAB Score, ranging from 0 to 10). Patients with a high score were at higher risk of mortality within the median 5.3 years of follow-up (score 0-3: 8.3%; 4-6: 27.0%; 7-10: 40.0%; p < 0.001 for score 0-3 vs. 4-6 and 7-10). This association was confirmed in the validation cohort.

CONCLUSIONS

We developed and validated the first simplified risk score to predict mortality following OPCAB based on easily accessible clinical factors. This risk score can be used when obtaining a patient's informed consent and as an aid in determining treatment.