1
|
Stevens LM, Chartrand-Lefebvre C, Mansour S, Béland V, Soulez G, Forcillo J, Basile F, Prieto I, Noiseux N. Anterolateral territory coronary artery bypass grafting strategies: a non-inferiority randomized clinical trial: the AMI-PONT trial. Eur J Cardiothorac Surg 2023; 63:ezad060. [PMID: 36805638 PMCID: PMC10133400 DOI: 10.1093/ejcts/ezad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/09/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVES The main objective was to assess whether a composite coronary artery bypass grafting strategy including a saphenous vein graft bridge to distribute left internal mammary artery outflow provides non-inferior patency rates compared to conventional grafting surgery with separated left internal mammary artery to left anterior descending coronary graft and aorto-coronary saphenous vein grafts to other anterolateral targets. METHODS All patients underwent isolated grafting surgery with cardiopulmonary bypass and received ≥2 grafts/patients on the anterolateral territory. The graft patency (i.e. non-occluded) was assessed using multislice spiral computed tomography at 1 year. RESULTS From 2012 to 2021, 208 patients were randomized to a bridge (n = 105) or conventional grafting strategy (n = 103). Patient characteristics were comparable between groups. The anterolateral graft patency was non-inferior in the composite bridge compared to conventional grafting strategy at 1 year [risk difference 0.7% (90% confidence interval -4.8 to 6.2%)]. The graft patency to the left anterior descending coronary was no different between groups (P = 0.175). Intraoperatively, the bridge group required shorter vein length for anterolateral targets (P < 0.001) and exhibited greater Doppler flow in the mammary artery pedicle (P = 0.004). The composite outcome of death, myocardial infarction or target vessel reintervention at 30 days was no different (P = 0.164). CONCLUSIONS Anterolateral graft patency of the composite bridge grafting strategy is non-inferior to the conventional grafting strategy at 1 year. This novel grafting strategy is safe, efficient, associated with several advantages including better mammary artery flow and shorter vein requirement, and could be a valuable alternative to conventional grafting strategies. Ten-year clinical follow-up is underway. TRIAL REGISTRATION ClinicalTrials.gov: NCT01585285.
Collapse
Affiliation(s)
- Louis-Mathieu Stevens
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
| | - Carl Chartrand-Lefebvre
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Samer Mansour
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
- Division of Cardiology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Gilles Soulez
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Jessica Forcillo
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
| | - Fadi Basile
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Ignacio Prieto
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Nicolas Noiseux
- Division of Cardiac Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
- CHUM Research Centre (CRCHUM), Montreal, QC, Canada
| |
Collapse
|
2
|
Dallan LRP, Dallan LAO, Lisboa LAF, Mejia OAV, Platania F, Rodrigues RDC, Dallan LAP, Jatene FB. Transit‐time flow measurement parameters after protamine infusion in CABG surgeries. J Card Surg 2022; 37:3492-3506. [DOI: 10.1111/jocs.16948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/03/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Luis Roberto P. Dallan
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Luis Alberto O. Dallan
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Luiz Augusto F. Lisboa
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Omar A. V. Mejia
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Fernando Platania
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Renan de Carvalho Rodrigues
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Luis Augusto P. Dallan
- Department of Cardiovascular Medicine, Harrington Heart and Vascular Institute University Hospitals Cleveland Medical Center Cleveland Ohio USA
| | - Fabio B. Jatene
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| |
Collapse
|
3
|
Halfwerk FR, Spoor P, Mariani S, Hagmeijer R, Grandjean JG. Intraoperative transit time flow measurements during off-pump coronary artery bypass surgery: The impact of coronary stenosis on competitive flow. J Card Surg 2022; 37:305-313. [PMID: 34676586 PMCID: PMC9298124 DOI: 10.1111/jocs.16103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/08/2021] [Accepted: 10/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Combining preoperative angiography findings with intraoperative transit time flow measurements (TTFM) may improve patency of coronary artery bypass grafts. Nevertheless, graft flow might be impaired by native coronary flow based on the severity of stenoses, with inferior long-term outcomes. This study investigates the impact of left anterior descending artery (LAD) stenosis on competitive flow measured in left internal mammary artery (LIMA) grafts during off-pump coronary artery bypass grafting. METHODS Fifty patients were included in this prospective single-center cohort study. LAD stenosis was assessed with quantitative coronary analysis (QCA) and stratified into three groups based on its severity. TTFM of LIMA grafts were performed with LAD open and temporarily occluded. Change in mean graft flow after LAD snaring was the primary endpoint. Secondary endpoints included further TTFM parameters, clinical outcomes, and competitive flow index (CFI), defined as the ratio of mean graft flow with open or closed LAD. RESULTS Mean LAD stenosis as objectified with QCA was 58 ± 15%. Mean LIMA graft flow increased from 20 ml/min with open LAD to 30 ml/min with snared LAD (p < .001). TTFM cut-off values for graft patency improved in 26%-42% of patients after LAD occlusion. Median CFI was 0.66 (IQR: 0.56-0.82). Postoperative myocardial infarction occurred in 2.0% of patients, 120-day mortality was 0%, and 2-year mortality was 6.0%. CONCLUSIONS Routine snaring of the LAD with CFI calculation during coronary artery bypass grafting is useful to detect significant competitive flow in LIMA grafts, potentially preventing unnecessary intraoperative graft revisions.
Collapse
Affiliation(s)
- Frank R. Halfwerk
- Department of Cardio‐Thoracic Surgery, Thoraxcentrum TwenteMedisch Spectrum TwenteEnschedeThe Netherlands
- Department of Biomechanical Engineering, Faculty of Engineering TechnologyUniversity of TwenteEnschedeThe Netherlands
| | - Pien Spoor
- Department of Cardio‐Thoracic Surgery, Thoraxcentrum TwenteMedisch Spectrum TwenteEnschedeThe Netherlands
| | - Silvia Mariani
- Department of Cardio‐Thoracic Surgery, Thoraxcentrum TwenteMedisch Spectrum TwenteEnschedeThe Netherlands
- Department of Cardio‐Thoracic Surgery, Heart and Vascular CentreMaastricht University Medical Centre (MUMC)MaastrichtThe Netherlands
| | - Rob Hagmeijer
- Department of Engineering Fluid Dynamics, Faculty of Engineering TechnologyUniversity of TwenteEnschedeThe Netherlands
| | - Jan G. Grandjean
- Department of Cardio‐Thoracic Surgery, Thoraxcentrum TwenteMedisch Spectrum TwenteEnschedeThe Netherlands
- Department of Biomechanical Engineering, Faculty of Engineering TechnologyUniversity of TwenteEnschedeThe Netherlands
| |
Collapse
|
4
|
Ramírez JK, Nafeh-Abi-Rezk M, Tamargo-Barbeito TO, Colao-Jiménez Y, García-Nocetti DF, Contreras-Arvizu JA. FluxCABG: flujometría intraoperatoria en la cirugía de revascularización miocárdica como factor pronóstico de eventos cardiacos mayores. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
|
5
|
Thuijs DJFM, Bekker MWA, Taggart DP, Kappetein AP, Kieser TM, Wendt D, Di Giammarco G, Trachiotis GD, Puskas JD, Head SJ. Improving coronary artery bypass grafting: a systematic review and meta-analysis on the impact of adopting transit-time flow measurement. Eur J Cardiothorac Surg 2020; 56:654-663. [PMID: 30907418 PMCID: PMC6751409 DOI: 10.1093/ejcts/ezz075] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/18/2019] [Accepted: 02/11/2019] [Indexed: 12/11/2022] Open
Abstract
![]()
Despite there being numerous studies of intraoperative graft flow assessment by transit-time flow measurement (TTFM) on outcomes after coronary artery bypass grafting (CABG), the adoption of contemporary TTFM is low. Therefore, on 31 January 2018, a systematic literature search was performed to identify articles that reported (i) the amount of grafts classified as abnormal or which were revised or (ii) an association between TTFM and outcomes during follow-up. Random-effects models were used to create pooled estimates with 95% confidence intervals (CI) of (i) the rate of graft revision per patient, (ii) the rate of graft revision per graft and (iii) the rate of graft revision among grafts deemed abnormal based on TTFM parameters. The search yielded 242 articles, and 66 original articles were included in the systematic review. Of those articles, 35 studies reported on abnormal grafts or graft revisions (8943 patients, 15 673 grafts) and were included in the meta-analysis. In 4.3% of patients (95% CI 3.3–5.7%, I2 = 73.9) a revision was required and 2.0% of grafts (95% CI 1.5–2.5%; I2 = 66.0) were revised. The pooled rate of graft revisions among abnormal grafts was 25.1% (95% CI 15.5–37.9%; I2 = 80.2). Studies reported sensitivity ranging from 0.250 to 0.457 and the specificity from 0.939 to 0.984. Reported negative predictive values ranged from 0.719 to 0.980 and reported positive predictive values ranged from 0.100 to 0.840. This systematic review and meta-analysis showed that TTFM could improve CABG procedures. However, due to heterogeneous data, drawing uniform conclusions appeared challenging. Future studies should focus on determining the optimal use of TTFM and assessing its diagnostic accuracy.
Collapse
Affiliation(s)
- Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Margreet W A Bekker
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - David P Taggart
- Department of Cardiovascular Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| | - Teresa M Kieser
- Division of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre, University of Duisburg-Essen, Duisburg, Germany
| | - Gabriele Di Giammarco
- Department of Cardiac Surgery, Università degli Studi "G. D'Annunzio" Chieti-Pescara, Chieti, Italy
| | - Gregory D Trachiotis
- Department of Cardiothoracic Surgery, Veterans Affairs Medical Centre, Washington, DC, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Centre, Rotterdam, Netherlands
| |
Collapse
|
6
|
Bienz M, Drullinsky D, Stevens LM, Bracco D, Noiseux N. Microcirculatory response during on-pump versus off-pump coronary artery bypass graft surgery. Perfusion 2015; 31:207-15. [PMID: 26091812 DOI: 10.1177/0267659115590481] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The use of cardiopulmonary bypass (CPB) during coronary artery bypass graft surgery (CABG) is associated with a systemic inflammatory response, resulting in altered microcirculation. The aim of this study was to evaluate whether beating heart surgery can preserve the microcirculation. METHODS Sublingual microcirculation was characterized by a Sidestream Darkfield Imaging Microscope during off-pump (OPCABG) and on-pump (ONCABG) surgery. Microcirculatory parameters were evaluated during eight precise perioperative time points. RESULTS The quality of the microcirculation decreased during early ONCABG. OPCABG resulted in a significantly better microcirculation compared to ONCABG for three of six parameters during surgery. However, by the end of surgery and postoperatively, the microcirculatory parameters were no different between the groups. CONCLUSIONS While the results do not show a marked preservation of the microcirculation during and after OPCABG compared to ONCABG, they coincide with the body temperature fluctuations of each group during and after surgery. Our work suggests that active warming could impact the microcirculation parameters.
Collapse
Affiliation(s)
- Marc Bienz
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - David Drullinsky
- Department of Surgery, Division of Cardiac Surgery, McGill University Hospital Center (MUHC), Montreal, Quebec, Canada
| | - Louis-Mathieu Stevens
- Department of Surgery, Division of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - David Bracco
- Department of Anesthesia, MUHC, Montreal, Quebec, Canada
| | - Nicolas Noiseux
- Department of Surgery, Division of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| |
Collapse
|