Congenital Absence of Pericardium: A Case Report and Technical Considerations in Cardiac Surgery

This case report describes a rare instance of left-sided congenital pericardial agenesis (CPA) encountered during coronary artery bypass grafting (CABG) in a 77-year-old male. In this unique case, the presence of an unusual strip of left pericardium containing the phrenic nerve posed significant surgical challenges. Special attention was required for the graft lay, ensuring adequate filling of the heart during assessment before closure, as well as emphasis on the need for generous graft length. Additionally, the evaluation of graft positioning prior to cardiopulmonary bypass was crucial. Despite these complexities, CABG was successfully performed with no complications to note. This case underscores the importance of adaptability in surgical technique to manage the unique challenges posed by CPA, leading to a positive outcome despite the atypical cardiac anatomy.

Evaluate the Quality of Life in Patients With Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft

Introduction Globally, coronary heart disease is the most imperative cause of premature death. However, timely management with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) can improve the quality of life (QoL) and reduce mortality. The objective of this study was to evaluate the QoL between the patients who received PCI and CABG for the treatment of coronary heart disease. Materials and methods This was a retrospective observational study. Patients who underwent PCI or CABG at least three months before or more at enrollment were purposefully selected. Results A total of 156 patients were enrolled, 78 in each group. Health-related QoL was assessed by using the SF-36 scale for PCI or CABG procedures. The mean ± SD scores of QoL for PCI and CABG were 78.95 ±10.14 and 78.17 ± 10.92, respectively. Of the patients, 72.43% felt better after treatment, 17.95% felt the same as before treatment, and 9.62% felt worse than before treatment in both groups. Among CABG patients, 38.46% felt significantly better after treatment compared to PCI (33.97%) (p=0.048). Moreover, more CABG patients (6.41%) felt significantly worse than PCI patients (3.21%) after treatment (p=0.048). Male patients were significantly more in the CABG group (89.74%) compared to the PCI group (75.64%). In contrast, female patients had more PCI (24.36%) compared to CABG patients (10.26%) (p=0.020). Conclusion Subjective perceptions of physical and mental well-being improved significantly from before treatment to at least three months after treatment, and an enhanced health-related QoL was noticed for medical intervention (PCI) and surgical approach (CABG).

Feasibility and Safety of Concomitant Laparoscopic Cholecystectomy With Open-Heart Surgery: A Systematic Review and Our Early Clinical Experience

Significant valvular or coronary artery disease may co-exist in patients presenting with symptomatic cholelithiasis. Isolated laparoscopic cholecystectomy in these cases is often associated with cardiac complications. Addressing the cardiac condition first may result in flaring up of cholecystitis during postoperative recovery and is associated with adverse outcomes. Open-heart surgery followed by laparoscopic cholecystectomy during a single operative setting is an option in these situations. The aim of our study is to review the published articles for this strategy and to share our initial experience with two such patients. PubMed, OVID Medline, and Cochrane library database were used, and we searched these databases using Medical Subject Headings (MeSH) terms and keywords from the inception date until August 1, 2023, and did not restrict our search to any language, study type, sample size, or publication date. All the publications reporting concomitant laparoscopic cholecystectomy and open-heart surgery were identified and a systematic review was carried out. Our first case underwent coronary artery bypass grafting and laparoscopic cholecystectomy. The second patient underwent a double valve replacement and laparoscopic cholecystectomy. Both the patients made an uneventful recovery, and are alive and doing well. Concomitant open-heart surgery and laparoscopic cholecystectomy in certain situations may be necessary and can be performed safely.

Late-Onset Chylothorax After Coronary Artery Bypass Grafting

Chylothorax, the presence of lymph in the pleural cavity, is a significant post-cardiac surgery complication. Historically linked to left internal mammary artery (LIMA) harvesting, its occurrence in cases without LIMA usage is uncommon. This paper details a case of chylothorax in an 84-year-old female patient who underwent coronary artery bypass grafting (CABG) without LIMA harvesting. Three months post-surgery, she manifested symptoms of exertional shortness of breath and diminished breath sounds on the left side. Diagnostic measures, including echocardiography and chest X-rays, revealed a pronounced left-sided pleural effusion. Diagnostic thoracocentesis yielded a milky fluid, and laboratory analysis confirmed its chylous nature. Therapeutic interventions comprised chest tube insertion, drainage of the milky fluid, dietary modifications, and the performance of talc pleurodesis after a fatty food-provocation test resulted in increased fluid collection. The patient's journey highlights the challenges of diagnosing and managing post-cardiosurgical chylothorax. The paper emphasizes the importance of early detection and appropriate interventions to prevent complications associated with a heightened mortality risk.

Caught in the Act: A Recurrent Tamponade After Coronary Artery Bypass Grafting With Culprit Lesion Identified on Computed Tomography Angiogram

Delayed cardiac tamponade after cardiac surgery is a rare complication with significant diagnostic challenges. The recurrence of cardiac tamponade physiology after initial intervention creates another degree of difficulty in the management of already medically complex patients. We present the case of a 65-year-old male who underwent four-vessel coronary artery bypass grafting that was complicated by the delayed presentation of cardiac tamponade requiring mediastinal exploration. Following this he developed a recurrence of cardiac tamponade with bleeding from a vein graft identified on multiphase spiral computed tomography angiography.

Chronic Total Occlusion of the Left Main Coronary Artery With Preserved Left Ventricular Systolic Function Presenting as a Chronic Coronary Syndrome: A Case Report and Brief Review

The incidence of lesions involving the left main coronary artery (LMCA) during coronary angiography is approximately 5% to 8%. It usually presents with acute coronary syndrome and can be fatal. Total occlusion of the LMCA is rare, often accompanied by myocardial infarction and cardiogenic shock. We present an LMCA chronic total occlusion case in a 60-year-old female patient with chronic coronary syndrome. In our case, the LMCA was selectively visualized, and it was found to be occluded. The right coronary artery fed the entire left system through the collateral network. The patient had no risk of coronary artery disease other than hypertension. Successful coronary artery bypass grafting was performed without any complications.

Assessing the Patient Outcomes and Performance of a Cardiothoracic and Vascular Surgery (CTVS) Unit During Its First Two Years in a Tier-2 City in India: A Comprehensive Audit and Analysis

This detailed article presents a comprehensive overview of the initial two-year experience in establishing a new cardiothoracic vascular surgery (CTVS) facility in a tier-2 city in India. The article discusses various aspects of setting up and operating a specialized healthcare facility. The first two years of developing the CTVS facility were included in the study period. The manpower included one cardiothoracic vascular surgeon, one cardiac anesthesiologist, two perfusionists, and two physician assistants, along with four other ancillary staff to assist in the smooth functioning of the operation theater. The CTVS recovery staff included 15 nursing officers. There was only one modular operation theater reserved for cardiothoracic vascular surgeries, along with a five-bed recovery room (CTVS intensive care unit). One-hundred-seventy-two procedures were done, including 122 open heart surgeries, 36 vascular procedures, and 14 thoracic procedures. The majority of patients were discharged by the seventh day postoperatively. Overall complication and mortality rates were 8% and 4.6%, respectively. This article also discusses relevant hospital policy, challenges faced, and future recommendations for similar endeavors. The findings highlight the successful implementation of the facility and its impact on providing specialized cardiac care to the local population.

The Quality of Coronary Artery Bypass Grafting Videos on YouTube

Objective  YouTube (YouTube LLC, San Bruno, California, United States), one of the most accessed sites on the internet, has become a widespread source of healthcare information for patients. Videos about coronary artery bypass grafts (CABG) have accrued tens of millions of views on the platform, yet their educational quality is unknown. This study investigates the educational landscape of videos regarding CABG procedures on YouTube. Methods YouTube was queried for "Coronary Artery Bypass Graft Surgery" and "Coronary Artery Bypass Graft Procedure". After applying exclusion criteria, 73 videos were assessed. Two independent reviewers rated the material with the Global Quality Scale (GQS) (5 = high quality, 0 = low quality) to judge educational value. A ratio of view count to days since upload was applied to assess video popularity. Source, modality, and date of upload were recorded for each video as well. Results An average GQS score of 2.94 was found, indicating poor educational quality of the 73 YouTube videos on CABG procedures. Videos uploaded by physicians (56/73; 76.7%) had a significantly higher average GQS score than those uploaded by non-physicians (p<0.001). When content was grouped by delivery method, physician-led presentations (24/73 or 32.9%) produced the highest average GQS score of 3.35; conversely, patient-friendly delivery methods (18/73 or 24.7%) yielded the lowest average GQS score of 2.36 (p<0.001). Neither the view ratio nor the days since upload significantly correlated with the educational quality of the video. Conclusion Although CABG videos are readily available on YouTube, they often contain considerable biases and misleading information. With online sources for healthcare education now commonplace, physicians must be aware of the vast quantities of low-quality videos patients often encounter when weighing different treatment options. Further analysis of CABG videos on YouTube may allow physicians to ameliorate this gap by producing videos that are not only high quality but highly viewed on the platform.

A Case of Cutibacterium acnes Pericardial Effusion After Coronary Artery Bypass Surgery

Cutibacterium acnes is a gram-positive, anaerobic rod commonly found on the skin and mucosal membrane. It is mostly associated with its role in acne formation, but here we present a case of purulent pericarditis secondary to C. acnes after coronary artery bypass graft surgery (CABG). A 58-year-old male presented for CABG after a coronary angiogram showed severe multivessel disease. The procedure was performed successfully. He had minimal complications until postop day seven, when he developed a fever and hypoxia. The transthoracic echo (TTE) was largely unrevealing. Due to further declining status the following day, a transesophageal echo (TEE) was performed and revealed a loculated pericardial effusion not visualized on TTE. This was subsequently drained, and fluid cultures grew C. acnes. The patient received five weeks of antibiotic therapy, which improved his condition.

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.

Comparative Evaluation of Dexmedetomidine and Magnesium Sulfate for Prevention of Postoperative Atrial Fibrillation in Patients of Coronary Artery Bypass Surgeries

Introduction The main goal of this study is to compare the effects of dexmedetomidine and magnesium sulfate on preventing atrial fibrillation (AF) after off-pump coronary artery bypass graft (CABG) surgeries. AF is a type of irregular heartbeat that often occurs after heart surgery and can cause serious complications. We want to see which drug is more effective in reducing the risk of AF in patients who have had CABG surgeries without using a heart-lung machine.  Materials and methods This was a randomized clinical study, conducted on patients of ASA classes III and IV who were the candidates for off-pump coronary artery bypass graft surgeries, which were conducted in the cardiac operating room from the period October 2020 to April 2021, at the Department of Anaesthesia, Jawaharlal Nehru Medical College, Sawangi, Meghe. All patients were aged between 30 and 85 years and with a left ventricular ejection fraction of above 40%. Results When the two groups were compared, the incidence of arrhythmias was more in group D (a group that received injection dexmedetomidine infusion), predominantly AF with an incidence of 50% more as compared to group M (a group that received injection magnesium sulfate infusion). When hemodynamic parameters were compared, events of bradycardia and hypotension were significantly higher in group D as compared to group M. The heart rate (HR), when compared between the two groups intraoperatively from the duration before induction of anesthesia till during sternum closure, has a significant p-value (0.0001). Similarly, when the mean arterial pressure (MAP) was compared between the two groups intraoperatively, significant hypotension was noted in group D (p-value = 0.0001). Postoperatively, in the intensive care unit when the HR and MAP were compared for 48 hours, bradycardia and hypotension were noted, but drastic changes in the mean values of the HR and MAP were not seen in both groups D and M. Conclusion When comparing the antiarrhythmic properties of the study drugs, it was observed that intraoperative and postoperative arrhythmias were less with magnesium sulfate as compared with dexmedetomidine. It was also found that there were higher events of hypotension and bradycardia in the dexmedetomidine group as compared to the magnesium sulfate group.

The Role of Vitamin D Supplementation Before Coronary Artery Bypass Grafting in Preventing Postoperative Atrial Fibrillation in Patients With Vitamin D Deficiency or Insufficiency: A Systematic Review and Meta-Analysis

This study aims to evaluate the role of preoperative vitamin D supplementation before coronary artery bypass grafting (CABG) surgery in preventing postoperative atrial fibrillation (POAF) in vitamin D deficient or insufficient patients. Three randomized controlled trials (RCTs) comprising 448 subjects were selected after a detailed search was conducted on PubMed, Cochrane CENTRAL, Scopus, and Embase in December 2022. Analysis was run using RevMan (version 5.4.1; Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). The analysis collected risk ratio (RR) and 95% confidence interval (CI) data from the relevant studies, which were then pooled using a random effects model. A significance level of less than 0.05 (p<0.05) was considered significant. Our analysis showed that compared with the standard of care, preoperative vitamin D supplementation in vitamin D deficient and insufficient patients effectively reduced POAF after CABG surgery (RR=0.6, 95% CI=0.4-0.9, P=0.01). There was no significant difference in the duration of hospitalization between the vitamin D supplementation group compared with the control following CABG (mean difference -0.85, 95% CI -2.13 to 0.43, P = 0.19). This meta-analysis shows that preoperative vitamin D supplementation in vitamin D deficient and insufficient patients undergoing CABG can reduce the rate of POAF. As POAF is associated with many complications, providing vitamin D supplementation to individuals with a vitamin D deficiency undergoing CABG can improve long-term cardiovascular outcomes following surgery.

Coronary Artery Bypass Graft Surgery for Spontaneous Coronary Artery Dissection in Early Pregnancy: Medical and Ethical Decision-Making Issues

Spontaneous coronary artery dissection (SCAD) in young females is a rare condition that typically occurs during the postpartum period.Even more rare is when SCAD occurs during the antepartum phase of pregnancy. This scenario can have catastrophic outcomes for both the mother and the unborn child. Due to its infrequency, there is minimal information on how to treat these patients effectively while keeping both the mother and the unborn child as safe as possible. We present a case of a 36-year-old multiparous Caucasian female brought in by an ambulance for sudden-onset left-sided chest pain radiating to her left shoulder, arm, and back. The initial laboratory tests were significant for a B-type natriuretic peptide (BNP) level of 190.82 pg/mL (the normal range is less than 100 pg/mL) and a troponin level of 3.98 ng/mL (the normal range is less than 0.04 ng/mL), which peaked to 18.39 ng/mL in less than 24 hours. Electrocardiogram (EKG) showed sinus tachycardia of 103 beats per minute (bpm) and anterolateral ST-T changes suggestive of ischemia. Human chorionic gonadotropin (hCG) was 32 mIU/mL (the normal range is less than 5 mIU/mL), which may indicate early pregnancy. Echocardiogram (ECHO) showed left anterior descending (LAD) artery territory wall motion abnormalities, which included the akinesis of the apical, middle, and apical anterior septum and the hypokinesis of the basal anteroseptal segment. Her calculated ejection fraction was 38.4% with no valvular abnormalities. Cardiac catheterization showed severe diffuse LAD disease in the proximal segment with the middle LAD and diagonal branch subtotally occluded. The right coronary artery (RCA) had severe disease. Cardiothoracic surgery was consulted for a coronary artery bypass graft (CABG). The procedure performed was a three-vessel coronary artery bypass graft, which included the following: left internal mammary artery (LIMA) to middle LAD, saphenous vein graft (SVG) to distal LAD, and SVG to diagonal. This case report aims to provide additional information to the database of SCAD in pregnant females undergoing coronary artery bypass graft surgery.

Mycotic Pseudoaneurysm Formation at the Cannulation Site in the Ascending Aorta

The formation of mycotic pseudoaneurysms in the ascending aorta is a rare but sometimes fatal complication after open-heart surgery, requiring cardiopulmonary bypass (CPB). There has been little cited about this rare complication. We present a case of a 51-year-old man who developed a mycotic pseudoaneurysm in the ascending aorta at a previous aortic cannulation site nine years after coronary artery bypass surgery. The patient presented to the emergency department with two weeks of worsening substernal chest pain and was found to have pseudoaneurysm in the anterior wall of the ascending aorta on chest computed tomography angiography (CTA) during his chest pain workup. The patient's blood cultures grew methicillin-susceptible Staphylococcus aureus (MSSA). During the hospital course, the patient's respiratory status worsened, and repeat CTA revealed enlargement of the pseudoaneurysm arising from the anterior proximal arch of the aorta. Chest X-ray obtained because of hypoxia demonstrated widening of the upper mediastinum, which appeared increased compared with the previous exam. Because of concern for rupture of an aneurysm, the patient was taken to the operating room for redo sternotomy and repair of the pseudoaneurysm with femoral artery cannulation for cardiopulmonary bypass. The patient completed eight weeks of IV nafcillin, and rifampin was added to decrease biofilm formation.

Spontaneous Coronary Artery Dissection of an Anomalous Right Coronary Artery in a Young Male

Spontaneous coronary artery dissection (SCAD) is a tear in the coronary artery layers that presents clinically as an acute coronary syndrome (ACS), ventricular arrhythmias, or sudden cardiac death (SCD). It is uncommon for young healthy males with no comorbid conditions to have SCAD. We report an interesting case of SCAD in an anomalous right coronary artery (RCA) in a young 33-year-old male. The patient presented with episodes of midsternal chest pain and had elevated troponins on laboratory workup. A left heart catheterization revealed anomalous RCA, originating from the left aortic sinus. The left heart catheterization also demonstrated a SCAD of the anomalous RCA. Cardiothoracic surgery was consulted, and the patient had placement of saphenous vein graft to the proximal RCA. While this patient's presentation of ACS in the setting of SCAD is relatively common, it was atypical due to gender and lack of precipitating stressors. One of the risk factors this patient did have was the anomalous RCA arising from the left aortic sinus. There is scarce literature involving guidance for therapeutic intervention for RCA ostial lesion, let alone an anomalous one. Although coronary artery bypass grafting (CABG) remains the most clinically sound decision, in this case, further development of guidelines for RCA lesions would aid in decision-making.

Unexpected Evolution After Multivessel Coronary Artery Bypass Grafting in a Patient With Kawasaki Disease

Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is an acute vasculitis that frequently affects medium-sized blood vessels. The disease is usually self-limiting and most commonly affects children under five years of age. It often affects the coronary arteries and is the leading cause of acquired heart disease in developed countries. We report the case of a teenage boy who had a long-standing diagnosis of Kawasaki disease, underwent coronary artery bypass grafting surgery, and had a complicated medical course following the surgery.

Giant Coronary Artery Aneurysms

We present the case of a patient with giant coronary artery aneurysm. He has underlying severe coronary atherosclerosis and concomitant aneurysms of the abdominal aorta and popliteal artery. Our patient was treated surgically in the past due to underlying severe atherosclerosis. Despite bypass, his coronary aneurysms continued to enlarge. There is a lack of randomized trials regarding management to guide the decision-making process. Our case describes the work-up and treatment of a patient with giant coronary artery aneurysm requiring urgent orthopedic surgery.

Incidence and Causes of Reintubation Other Than Reopening of the Chest in Post-Cardiac Surgical Patients in a Tertiary Care Hospital

Objective

To determine the incidence of endotracheal reintubation, excluding surgical reopening, in post-cardiac surgical patients in a tertiary care hospital.

Material and methods

A retrospective descriptive analysis of 408 patients who underwent different cardiac surgeries during this period. Post-operative extubation was performed when patients fulfilled the preset criteria for extubation, which include consciousness (awake and aware), stable vital signs, acceptable arterial blood gases, acceptable respiratory mechanics, a maximum inspiratory force greater than 20-25 cm H₂O, chest tube drainage less than 100 ml per hour, normal temperature and electrolytes. The total number of patients who were reintubated within 72 hours of extubation was noted. The criteria for reintubation included altered conscious level with Glasgow Coma Score (GCS) of less than 8, respiratory failure, unstable hemodynamics, and arrhythmias such as ventricular tachycardia (VT) and fibrillation. All of the information was collected retrospectively on a specifically prepared form. Data was entered and evaluated in Statistical Package for the Social Sciences.

The research was piloted in the Cardiac Intensive Care Unit (CICU) of Northwest General Hospital and Research Center, Hayatabad, Peshawar from December 2018 to March 2020.

Results

Out of 408 patients who had cardiac surgeries, only nine (2.2%) were reintubated after initial extubation. The average time for which patients remained on the ventilator was 8 ± 2 hours. The reasons for reintubation were recorded. Among those reintubated, eight patients (88.88%) had undergone coronary artery bypass grafting (CABG) whereas one patient (11.11%) had undergone mitral valve replacement (MVR). In three (33.33%) patients, stroke (hemiplegia in two and global brain ischemia in one) with low GCS was the primary cause of reintubation. Arrhythmias - which included VT, ventricular fibrillation (VF), and supraventricular tachyarrhythmias (SVT) - were responsible for three (33.33%) cases of reintubation. Respiratory failure - with a partial pressure of oxygen in arterial blood less than 60 mmHg, along with tachypnea - was responsible for reintubation in two (22.22%) patients. In one (11.11%) patient who had MVR, cardiac arrest was the underlying reason; the cause of arrest could not be retrieved from the retrospective data. Notably, as a common variable, five (62.5%) out of the eight reintubated CABG patients had a poor left ventricular function. 

Conclusion

Causes of reintubation were primarily cardiac (arrhythmias) and neurological, followed by respiratory causes in our center. Patients with poor left ventricular function and diffuse coronary artery disease appear to have a higher incidence of reintubation which can lead to extended CICU and hospital stay, elevated mortality, and higher costs.

Non-ST-Segment Myocardial Infarction Resulting From Thrombotic Saphenous Vein Graft Aneurysm

Acute coronary syndromes from coronary emboli are rare, but well described in the literature. Saphenous vein grafts (SVG), used in coronary artery bypass grafting surgery, are vessels prone to atherosclerotic occlusion and aneurysmal dilation. Descriptive cases of embolization of these atherosclerotic lesions are lacking. Aneurysmal dilation of SVG conduits provides an area of stagnated flow that can harbor thrombi with embolic potential. This case describes a patient with non-ST-segment myocardial infarction possibly resulting from SVG aneurysm thrombus embolism.

Weighting composite endpoints in clinical trials: essential evidence for the heart team

BACKGROUND

Coronary revascularization trials often use a composite endpoint of major adverse cardiac and cerebrovascular events (MACCE). The usual practice in analyzing data with a composite endpoint is to assign equal weights to each of the individual MACCE elements. Noninferiority margins are used to offset effects of presumably less important components, but their magnitudes are subject to bias. This study describes the relative importance of MACCE elements from a patient perspective.

METHODS

A discrete choice experiment was conducted. Survey respondents were presented with a scenario that would make them eligible for the Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial three-vessel disease cohort. Respondents chose among pairs of procedures that differed on the 3-year probability of MACCE, potential for increased longevity, and procedure/recovery time. Conjoint analysis derived relative weights for these attributes.

RESULTS

In all, 224 respondents completed the survey. The attributes did not have equal weight. Risk of death was most important (relative weight 0.23), followed by stroke (0.18), potential increased longevity and recovery time (each 0.17), myocardial infarction (0.14), and risk of repeat revascularization (0.11). Applying these weights to the SYNTAX 3-year endpoints resulted in a persistent, but decreased margin of difference in MACCE favoring coronary artery bypass graft surgery compared to percutaneous coronary intervention. When labeled only as "procedure A" and "procedure B," 87% of respondents chose coronary artery bypass graft surgery over percutaneous coronary intervention. When procedures were labeled as "coronary stent" and "coronary bypass surgery," only 73% chose coronary artery bypass graft surgery. Procedural preference varied with demographics, sex, and familiarity with the procedures.

CONCLUSIONS

The MACCE elements do not carry equal weight in a composite endpoint, from a patient perspective. Using a weighted composite endpoint increases the validity of statistical analyses and trial conclusions. Patients are subject to bias by labels when considering coronary revascularization.