Background This study examines if bilateral internal thoracic artery (BITA) grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting, in the modern era, in ...which diabetes mellitus and obesity are more prevalent. Methods The Society of Thoracic Surgeons database at a single large academic center was reviewed for all consecutive isolated coronary artery bypass grafting patients with two or more distal anastomoses from January 1, 2002, through December 31, 2010. Propensity-adjusted logistic and Cox regression models were used to estimate the effect of BITA on short-term outcomes and long-term survival for diabetic and nondiabetic patients. Results A total of 3,527 coronary artery bypass grafting operations (812 BITA, 2,715 SITA) were performed. Fewer BITA than SITA patients had diabetes (28.6% vs 44.7% p < 0.001). There was no significant difference in 30-day rates of death, stroke, or myocardial infarction between nondiabetic patients who had BITA vs SITA, or between diabetic patients who had BITA vs SITA. BITA grafting conferred a 35% reduction (95% confidence interval, 12% to 52%, p = 0.006) in the long-term hazard of death equally for nondiabetic and diabetic patients ( p = 0.93). Deep sternal wound infection was more common among diabetic than among nondiabetic patients (1.5% vs 0.7%), but was similar within nondiabetic (1.0% vs 0.6%) and diabetic patients (1.7% vs 1.5%) who had BITA vs SITA. Overall, BITA and SITA patients had similar rates of deep sternal wound infection (1.2% vs 1.0%). Conclusions BITA grafting confers a long-term survival advantage and should be performed whenever suitable coronary anatomy exists and patient risk factors allow an acceptable risk of deep sternal wound infection.
Background It is unknown whether purported benefits of off-pump coronary artery bypass grafting are patient-specific within the Society of Thoracic Surgeons National Cardiac Database or dependent on ...center volume or operating surgeon. Methods The Society of Thoracic Surgeons National Cardiac Database was queried for all patients undergoing nonemergency, isolated coronary artery bypass between January 1, 2005, and December 31, 2010, who had Predicted Risk of Mortality scores and participant/surgeon identifiers. Of these 876,081 patients (“all sites”), 210,469 underwent surgery at participant sites that had performed more than 300 off-pump and 300 on-pump coronary artery bypass operations during the 6-year study period (“high-volume sites”). Operative mortality, stroke, acute renal failure, mortality or morbidity, and prolonged postoperative length of stay were analyzed with conditional logistic models for all sites and for high-volume sites, stratified by participant center and surgeon, and adjusted for 30 variables that comprise the Society of Thoracic Surgeons coronary artery bypass grafting risk models. Results Off-pump coronary artery bypass was associated with a significant reduction in risk of death, stroke, acute renal failure, mortality or morbidity, and postoperative length of stay compared with on-pump coronary artery bypass after adjustment for 30 patient risk factors in the overall sample. This held true within high-volume centers. In the overall sample, there was a significant ( P < .05) interaction between off-pump coronary artery bypass and Predicted Risk of Mortality for death, stroke, acute renal failure, and mortality or morbidity. Conclusions Off-pump coronary artery bypass was associated with reduced adverse events compared with on-pump coronary artery bypass after adjustment for 30 patient risk factors and center and surgeon identity. Patients with higher Predicted Risk of Mortality scores had the largest apparent benefit.
Background Hybrid coronary revascularization (HCR) combines a minimally invasive (3-cm anterolateral thoracotomy), sternal-sparing, off-pump left internal mammary artery–left anterior descending ...(LIMA-LAD) coronary artery anastomosis with percutaneous coronary intervention (PCI) to non-LAD coronary arteries. We compared outcomes of HCR versus traditional off-pump coronary artery bypass grafting (OPCAB) for the treatment of multivessel coronary artery disease (CAD). Methods Between October 8, 2003 and April 23, 2010, 147 patients with multivessel coronary disease were treated with HCR at a US academic center. These were matched 4:1 to 588 contemporaneous patients treated with multivessel OPCAB by sternotomy using an optimal matching algorithm with 8 preoperative variables: age, gender, ejection fraction, presence of diabetes, myocardial infarction (MI), number of diseased vessels, left main coronary artery disease, and Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) score. In-hospital major adverse events (MACCE) and the need for repeated revascularization during follow-up were compared between groups. All-cause mortality was determined using the Social Security Death Index (SSDI). Results Matching produced groups with similar coronary anatomy and statistically similar preoperative risk factors. The incidence of MACCE was similar between groups (3/147 HCR versus 12/588 OPCAB). During a median 3.2 years of follow up, the need for repeated revascularization was higher for HCR than for OPCAB (18/147 12.2% versus 22/588 3.7%; p < 0.001). The incidence of blood transfusion was higher for the OPCAB group. Estimated 5-year survival was similar between groups (OPCAB, 84.3% versus HCR, 86.8%; p = 0.61). Conclusions Hybrid coronary revascularization is a minimally invasive treatment for multivessel CAD. Although repeated revascularization was greater with HCR, both in-hospital and midterm outcomes were comparable with those of traditional OPCAB. Further investigation into the comparative effectiveness of this alternative strategy is warranted.
We evaluated the influence of transit-time flow measurement with epicardial and epiaortic high-frequency ultrasound in patients undergoing coronary artery bypass grafting procedure.
The Registry for ...Quality Assessment with Ultrasound Imaging and Transit-time Flow Measurement in Cardiac Bypass Surgery study is a multicenter, prospective study among 7 international centers performing coronary artery bypass grafting procedures. The primary end point was any change in the planned surgical procedure. Major secondary end points consisted of the rate and reason for surgical changes related to the aorta, in situ conduits, coronary targets, and completed grafts, and the rate of in-hospital mortality and major morbidity.
Between April 2015 and December 2017, 1046 patients were enrolled. Of those, 1016 were included in the final analyses. Mean age was 65.9 years, 14.0% were women, and diabetes was present in 39.6%. Off-pump procedures were performed in 39.6% and bilateral internal thoracic arteries in 30.5%. The primary end point occurred in 25.2% of patients (n = 256) and in 77% (197 out of 256) this was based on transit-time flow measurement and/or high-frequency ultrasound. Surgical changes were related to the aorta in 9.9%, to in situ conduits in 2.7%, and the coronary targets in 22.6%. Graft revision occurred in 7.8%, including revisions of the proximal and/or distal anastomosis in 6.6%. In-hospital adverse event rates were 0.6% for mortality, 1.0% for cerebrovascular events, and 0.3% for myocardial infarction.
Surgical changes related to the aorta, conduits, coronary targets, and anastomosis were made in 25% of patients. This was associated with low operative mortality and low major morbidity. Transit-time flow measurement and high-frequency ultrasound may improve the quality, safety, and efficacy of coronary artery bypass grafting procedures and should be considered as a routine procedural aspect.
Changes to the planned surgical strategy were made in 25.2% of cases with few complications. Display omitted
The burden oral anticoagulation is a limitation of mechanical valve prostheses.
The aim of this study was to test whether patients could be safely managed with dual-antiplatelet therapy (DAPT) ...(aspirin 325 mg and clopidogrel 75 mg) or lower warfarin after On-X mechanical aortic valve replacement (mAVR).
PROACT (Prospective Randomized On-X Anticoagulation Trial) (n = 576) is a multicenter (41 sites) noninferiority trial. From June 2006 through February 2014, 201 patients ≥18 years of age without thromboembolic risk factors undergoing mAVR were randomized to receive DAPT (n = 99) or standard warfarin plus aspirin (n = 102) 3 months after mAVR (low-risk arm). From June 2006 through October 2009, 375 patients with 1 or more thromboembolic risk factors were also randomized to lower intensity warfarin plus aspirin (international normalized ratio 1.5 to 2.0; n = 185) or standard warfarin plus aspirin (international normalized ratio 2.0 to 3.0; n = 190) 3 months after mAVR (high-risk arm).
The low-risk arm was terminated for excess cerebral thromboembolic events (3.12% per patient-year vs. 0.29% per patient-year, p = 0.02) in the DAPT group at up to 8.8-year follow-up (631.6 patient-years), with no differences in bleeding or all-cause mortality. High-risk arm patients experienced significantly lower major (1.59% per patient-year vs. 3.94% per patient-year, p = 0.002) and minor (1.27% per patient-year vs. 3.49% per patient-year, p = 0.002) bleeding up to 8.7-year follow-up (2,035.2 patient-years), with no differences in thromboembolism (0.42% per patient-year vs. 0.09% per patient-year, p = 0.20) and all-cause mortality.
DAPT was associated with higher rates of thromboembolism and valve thrombosis compared with control in the low-risk arm. International normalized ratios were safely maintained at 1.5 to 2.0 in high-risk patients, without differences in mortality or thromboembolic complications. (Randomized On-X Anticoagulation Trial PROACT; NCT00291525)
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Objective The purpose of this study was to determine whether the incidence of postoperative stroke could be reduced by eliminating aortic clamping during coronary artery bypass grafting. Methods From ...2002 to 2013, 12,079 patients underwent primary, isolated coronary artery bypass grafting at a single US academic institution. Aortic manipulation was completely avoided by using in situ internal thoracic arteries for inflow in 1552 patients (12.9%) (no-touch), a clampless facilitating device for proximal anastomoses in 1548 patients (12.8%), and aortic clamping in 8979 patients (74.3%). These strategies were assessed in a logistic regression model controlling for relevant variables. Results The overall incidence of postoperative stroke was 1.4% (n = 165), with an unadjusted incidence of 0.6% (n = 10) in the no-touch group, 1.2% (n = 18) in the clampless facilitating device group, and 1.5% (n = 137) in the clamp group ( P < .01 for no-touch vs clamp). The ratio of observed to expected stroke rate increased as the degree of aortic manipulation increased, from 0.48 in the no-touch group, to 0.61 in the clampless facilitating device group, and to 0.95 in the clamp group. Aortic clamping was independently associated with an increase in postoperative stroke compared with a no-touch technique (adjusted odds ratio, 2.50; P < .01). When separated by cardiopulmonary bypass use, both the off-pump partial clamp and the on-pump crossclamp techniques increased the risk of postoperative stroke compared with no-touch (adjusted odds ratio, 2.52, P < .01; and adjusted odds ratio, 4.25, P < .001, respectively). Conclusions A no-aortic touch technique has the lowest risk for postoperative stroke for patients undergoing coronary artery bypass grafting. Clamping the aorta during coronary artery bypass grafting increases the risk of postoperative stroke, regardless of the severity of aortic disease.
Coronary revascularization is accomplished either by percutaneous coronary intervention (PCI), with low risk of immediate complications, or coronary artery bypass graft (CABG), with improved ...long-term, event-free survival attributable to use of the left internal mammary artery graft. Hybrid coronary revascularization (HCR) combines both. The left internal mammary artery graft is done by sternal-sparing approaches or by robotic-assisted, endoscopic surgery. HCR reduces bleeding, ventilator time, and length of stay compared with traditional CABG. Compared with PCI, HCR offers the durability and survival advantages of the left internal mammary artery. The large-scale National Heart, Lung, and Blood Institute-sponsored, randomized Hybrid Trial (Hybrid Coronary Revascularization Trial) was initiated to examine whether HCR is superior to multivessel PCI. However, enrollment was suboptimal, triggering premature study discontinuation. HCR integrates the positive features of both PCI and CABG, albeit requiring 2 procedures rather than 1. Adequately powered randomized trials are required to evaluate the outcomes and cost-effectiveness of HCR compared with CABG and multivessel PCI alone.
The prognostic implications of periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remain controversial. We examined ...the 3-year rates of mortality among patients with and without PMI undergoing left main coronary artery intervention randomized to PCI with everolimus-eluting stents vs. CABG in the large-scale, multicentre, prospective, randomized EXCEL trial.
By protocol, PMI was defined using an identical threshold for PCI and CABG creatinine kinase-MB (CK-MB) elevation >10× the upper reference limit (URL) within 72 h post-procedure, or >5× URL with new Q-waves, angiographic vessel occlusion, or loss of myocardium on imaging. Cox proportional hazards modelling was performed controlling for age, sex, hypertension, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and chronic obstructive pulmonary disease (COPD). A total of 1858 patients were treated as assigned by randomization. Periprocedural MI occurred in 34/935 (3.6%) of patients in the PCI group and 56/923 (6.1%) of patients in the CABG group odds ratio 0.61, 95% confidence interval (CI) 0.40-0.93; P = 0.02. Periprocedural MI was associated with SYNTAX score, COPD, cross-clamp duration and total procedure duration, and not using antegrade cardioplegia. By multivariable analysis, PMI was associated with cardiovascular death and all-cause death at 3 years adjusted hazard ratio (HR) 2.63, 95% CI 1.19-5.81; P = 0.02 and adjusted HR 2.28, 95% CI 1.22-4.29; P = 0.01, respectively. The effect of PMI was consistent for PCI and CABG for cardiovascular death (Pinteraction = 0.56) and all-cause death (Pinteraction = 0.59). Peak post-procedure CK-MB ≥10× URL strongly predicted mortality, whereas lesser degrees of myonecrosis were not associated with prognosis.
In the EXCEL trial, PMI was more common after CABG than PCI, and was strongly associated with increased 3-year mortality after controlling for potential confounders. Only extensive myonecrosis (CK-MB ≥10× URL) was prognostically important.
Background The impact of the degrees of renal dysfunction (RD) after aortic valve replacement (AVR) has not been well described. The purpose of this study was to compare patients undergoing AVR with ...a range of renal function from normal to dialysis-dependence. Methods A retrospective review of 2,408 patients undergoing AVR with or without coronary artery bypass graft surgery (CABG) from January 1996 to March 2009 was performed. Glomerular filtration rate (GFR) was estimated for patients using the Modification of Diet in Renal Disease formula. Multivariable logistic and Cox regression methods were used to determine the independent association of GFR with outcomes. Adjusted odds ratios were calculated for in-hospital outcomes, and Kaplan-Meier curves were created to estimate long-term survival. Results In all, 1,512 patients (62.8%) had isolated AVR, and 896 (37.2%) underwent AVR plus CABG. Preoperative RD was common among all patients: 1,148 of 2,408 (47.7%) with mild RD (GFR 60 to 90 mL · min−1 · 1.73 m−2 ), 644 of 2,408 (26.7%) moderate RD (GFR 30 to 59 mL · min−1 · 1.73 m−2 ), 59 of 2,408 (2.5%) severe RD (GFR 15 to 30 mL · min−1 · 1.73 m−2 ), and 114 (4.7%) with kidney failure (GFR <15) or requiring dialysis. In-hospital mortality generally rose with RD, from 2.9% for patients with no RD to 15.8% for patients with severe RD, and 17.3% for patients requiring dialysis. Patients with severe RD or preoperative dialysis were associated with significantly poorer outcomes. Adjusted long-term survival is progressively worse across levels of RD, as was postoperative length of stay ( p < 0.001). Conclusions Preoperative RD is common among the AVR population and is associated with diminished long-term survival. The association between RD and worse outcomes after AVR surgery has significant clinical implications.
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