Does preoperative screening with computed tomography of the chest decrease risk of stroke in patients undergoing coronary artery bypass grafting

Background

Stroke is one of the most feared complications post coronary artery bypass with aortic calcifications being the commonest source of embolic stroke. The aim of our study was to determine the clinical impact and usefulness of routine use of plain chest computerised tomography to screen for aortic calcification on incidence of postoperative stroke in coronary artery bypass grafting (CABG) patients.

Methods

This is a retrospective case-control study that included four hundred and five patients who underwent primary isolated CABG and had preoperative plain chest computerised tomography as a screening for aortic calcification. Aortic calcification was classified according to the area involved (ascending, arch, arch vessels and descending aorta) and the pattern of calcification. Patients were divided into two groups according to the incidence of postoperative stroke and the aortic calcification distribution was compared between the two groups. Stroke predictors were studies using univariate and multivariate regression analysis.

Results

Fourteen patients (3.5%) developed postoperative stroke. There was no difference in preoperative and operative characteristics between patients who developed postoperative stroke and those who did not, except for the history of preoperative stroke or transient ischemic attack (TIA) that was higher in the group who developed postoperative stroke (50.00% vs. 6.19%, P<0.001). Patients who developed postoperative stroke had higher percentage of aortic root calcification (78.57% vs. 64.18%), ascending aortic calcification (28.57% vs. 19.07%) and descending aortic calcification (85.71% vs. 73.71%) but none of them reached statistical significance. History of preoperative stroke or TIA was the only significant predictor of postoperative stroke using both univariate and multivariate regression models.

Conclusions

Our study showed the importance of preoperative computed tomography (CT) scan of the chest as a screening tool as it detected a high prevalence of aortic calcification in our patients. However, its impact on prevention of postoperative stroke needs to be investigated further in future prospective studies.

Results of Surgical Ablation for Atrial Fibrillation in Patients with Rheumatic Heart Disease

Background

There is conflicting evidence regarding the success of the Maze procedure to restore sinus rhythm in patients with rheumatic heart disease. Hence, the aim of our study was to describe the results of surgical ablation for atrial fibrillation in patients with rheumatic heart disease undergoing cardiac surgery.

Methods

This is a retrospective study that included adult patients with rheumatic heart disease who underwent surgical ablation for atrial fibrillation. The ablation lesions were performed using monopolar radiofrequency ablation in all patients.

Results

Fifty-seven consecutive patients were included in the study. Cox Maze IV was performed in 44 patients (77%), while left-sided surgical ablation was performed in 10 patients (17%) and pulmonary vein isolation in 3 patients (5%). The percentage of patients who were in sinus rhythm on discharge, at 1-month, at 3-months, 6-months and 12-months follow up were 56%, 54%, 52%, 56% and 46% respectively. Complete heart block occurred in 21 patients (44%), but only 15 of them (26%) required permanent pacemaker insertion. Freedom from composite endpoint of death, stroke, and readmission for heart failure was 78% at one-year follow up.

Conclusion

Despite the suboptimal rates of sinus rhythm at the intermediate and long term follow up, surgical ablation of atrial fibrillation in patients with rheumatic heart disease should continue to be performed. Continuation of Class III antiarrhythmic medications and early intervention for recurrent atrial fibrillation is crucial to the success of this procedure and for maintenance of higher rates of sinus rhythm at intermediate and long-term follow up.

Surgical revascularization in stable coronary artery disease with ventricular dysfunction: a single-center cohort study

PURPOSE

Stress-gated myocardial perfusion scintigraphy (MPS) is used for prognosis in stable coronary artery disease (CAD). We sought to assess coronary artery bypass grafting (CABG) outcomes in stable coronary artery disease patients who had myocardial perfusion scintigraphy and left ventricular (LV) dysfunction.

METHODS

Stable CAD patients who underwent CABG (2012-2019) and had stress-gated MPS were identified retrospectively. Based on the post-stress LV ejection fraction, a total of 130 patients were divided into a control group (51%) and LV dysfunction group (49%).

RESULTS

Patients with left ventricular dysfunction had significantly more mean summed stress score (22.1 ± 9 Vs. 12.5 ± 8; P ≤ 0.001) and summed resting score (14.6 ± 8 Vs. 3.7 ± 4; P ≤ 0.001) compared to the control group respectively. They also had a greater risk for developing low cardiac output syndrome after surgery (OR: 2.9, 95% CI 1.1-6.6, P=0.033). At 4.7 years, freedom from cardiac death was not statistically significant between the left ventricular dysfunction and control groups, respectively (90.2% vs. 95.6%; P=0.157). Cardiac death was not influenced by either ventricular dysfunction at the time of surgery (HR: 2.6, 95% CI 0.64-10.6, P=0.182) nor by having percent ischemic myocardium > 10% (HR: 0.86, 95% CI 0.23-3.24, P=0.826).

CONCLUSION

Significant myocardial ischemia and ventricular dysfunction before complete surgical revascularization did not influence the risk of cardiac-related deaths on long-term follow-up. This might be related to the improved survival after CABG in patients with myocardial ischemia and left ventricular dysfunction.