Background Use of one or more arterial grafts to revascularize two-vessel and three-vessel coronary artery disease has been shown to improve coronary artery bypass graft surgery (CABG) survival. Yet, ...the presumed long-term survival benefits of all-arterial CABG have not been quantified. Methods We compared propensity-adjusted 12-year survival in two contemporaneous multivessel primary CABG cohorts with all patients receiving 2 or more grafts: (1) all-arterial cohort (n = 612; 297 three-vessel disease 49%); and (2) single internal thoracic artery (ITA) plus saphenous vein (SV) cohort (n = 4,131; 3,187 three-vessel disease 77%). Results Early (30-day) deaths were similar for the all-arterial and ITA/SV cohorts (8 1.30% versus 69 1.67%) whereas late mortality was substantially greater for the ITA/SV cohort (85 13.9% versus 1,216 29.4%; p < 0.0001). The risk-adjusted 12-year survival was significantly better for all-arterial (with a risk ratio RR = 0.60; 95% confidence interval CI: 0.48 to 0.75; p < 0.001), but this benefit was true only for three-vessel disease (RR = 0.58; 95% CI: 0.43 to 0.78; p < 0.001) and not for two-vessel disease (RR = 0.97; 95% CI: 0.66 to 1.43; p = 0.89). The all-arterial survival benefit was also true for varying risk subcohorts: no diabetes mellitus (RR = 0.50; 95% CI: 0.37 to 0.69), diabetes mellitus (RR = 0.77; 95% CI: 0.56 to 1.07), ejection fraction 40% or greater (RR = 0.60; 95% CI: 0.45 to 0.78), and ejection fraction less than 40% (RR = 0.62; 95% CI: 0.40 to 0.98). Lastly, the multivariate analysis indicated a strong long-term effect of completeness of revascularization, particularly for all-arterial patients, so that compared with patients with two grafts, survival was significantly better when three grafts (RR = 0.54; 95% CI: 0.33 to 0.87) or four grafts (RR = 0.40; 95% CI: 0.21 to 0.76) were completed. Conclusions All-arterial revascularization is associated with significantly better 12-year survival compared with the standard single ITA with saphenous vein CABG operation, in particular for triple-vessel disease patients. The completeness of revascularization of the underlying coronary disease is critical for maximizing the long-term benefits of arterial-only grafting.
Background Increasing the number of arterial grafts for coronary artery bypass grafting (CABG) has been linked to improved late survival. Currently, it is not known if these long-term benefits are ...also true when sequential radial artery (RA) grafts are the primary means to maximizing arterial revascularization. Methods We compared late survival of 532 consecutive patients receiving sequential RA grafts (sequential RA group: 438 men; 462 with three-vessel disease) with that of a 4,131 contemporaneous internal thoracic artery (ITA) with saphenous vein (SV) multivessel CABG cohort (conventional group). Graft failure rates were determined from symptom-driven repeat angiography films in 122 sequential RA patients performed 2 to 4,317 days after surgery. Median survival sequential RA follow-up was 5.3 years (range, 0.5 to 12.3). Results The sequential RA patients received a total of 1,181 RA grafts (538 sequential 30 triple and 75 single) along with 636 SV and 533 ITA. Overall RA graft failure (80 of 272; 29%) was intermediate to that for ITA (7 of 121; 5.8%; p < 0.001) and vein (54 of 133, 41.6%; p = 0.032) grafts. Sequential versus nonsequential RA failure did not differ (77 of 252 31% versus 3 of 20 15%; p = 0.202), while failure of the proximal (36 of 123; 29%) and distal (40 of 129; 31%) components of sequential RA grafts were essentially identical. A total of 69 deaths (6 operative; 1.1%) have occurred in the sequential RA cohort. Unadjusted 10-year sequential RA cohort survival was 76.2% overall, and 79.0% for the 454 primary isolated CABG subgroup. The risk-adjusted 10-year survival using a logit propensity score was substantially better for the sequential RA cohort versus the conventional CABG cohort (risk ratio 95% confidence interval 0.61 0.44 to 0.85; p = 0.003). Conclusions Sequential RA grafting is a safe method for maximizing arterial revascularization and is associated with excellent 10-year survival that seems to be superior to conventional or ITA/SV CABG results. Also, the similar proximal and distal sequential RA patency mitigates concerns of a clinically significant effect of increased vasoreactivity of distal segments of RA conduits.
Objective Perioperative infection of an aortic graft is one of the most devastating complications of vascular surgery, with a mortality rate of 10% to 30%. The rate of amputation of the lower limbs ...is generally >25%, depending on the graft material, the location of the graft and infection, and the bacterial virulence. In vitro studies suggest that an antibiotic-impregnated graft may help prevent perioperative graft infection. In a pilot animal study, we tested a locally developed technique of bonding Dacron aortic grafts with three antimicrobial agents to evaluate the ensuing synergistic preventive effect on direct perioperative bacterial contamination. Methods We surgically implanted a 6-mm vascular knitted Dacron graft in the infrarenal abdominal aorta of six Sinclair miniature pigs. Two pigs received unbonded, uninoculated grafts; two received unbonded, inoculated grafts; and two received inoculated grafts that were bonded with chlorhexidine, rifampin, and minocycline. Before implantation, the two bonded grafts and the two unbonded grafts were immersed for 15 minutes in a 2-mL bacterial solution containing 1 to 2 × 107 colony-forming units (CFU)/mL of Staphylococcus aureus (ATCC 29213). Two weeks after graft implantation, the pigs were euthanized, and the grafts were surgically excised for clinical, microbiologic, and histopathologic study. Results The two bonded grafts treated with S aureus showed no bacterial growth upon explant, whereas the two unbonded grafts treated with S aureus had high bacterial counts (6.25 × 106 and 1.38 × 107 CFU/graft). The two control grafts (unbonded and untreated) showed bacterial growth (1.8 × 103 and 7.27 × 103 CFU/graft) that presumably reflected direct, accidental perioperative bacterial contamination; S cohnii ssp urealyticus and S chromogenes , but not S aureus , were isolated. The histopathologic and clinical data confirmed the microbiologic findings. Only pigs that received unbonded grafts showed histopathologic evidence of a perigraft abscess. Conclusions Our results suggest that bonding aortic grafts with this triple antimicrobial combination is a promising method of reducing graft infection resulting from direct postoperative bacterial contamination for at least 2 weeks. Further studies are needed to explore the ability of this novel graft to combat one of the most feared complications in vascular surgery.
Background Coronary artery bypass grafting with concomitant coronary endarterectomy (CABG/CE) is used in patients with severe coronary atherosclerosis to revascularize otherwise ungraftable targets. ...This study investigates the efficacy of arterial versus vein grafting for CABG/CE surgery. Methods We reviewed our experience in 288 CABG/CE patients (63 ± 10 years, 207 men). A total of 1,056 grafts (275 internal thoracic artery ITA 26%; 221 radial 21%, 560 vein 53%) were constructed including 325 (31%) placed to CE targets. Results Eighteen of 288 patients died in-hospital (6.3%). Unadjusted one-year and five-year survival for the 270 discharged patients was 95.2% and 83.0%, respectively. Survival (0 to 7 years) was significantly better for patients with radial (n = 154) versus no-radial (n = 134) artery grafting ( p = 0.021). Multivariate Cox regression analysis associated increased number of arterial grafts (hazard ratio HR = 0.64 0.44 to 0.92; HR 95% confidence interval) to improved survival, while RCA endarterectomy (HR = 1.8 1.0 3.3; p = 0.054) was associated with worse survival. Repeat angiography (495 days median) in 68 patients encompassed 78 CE (38 vein, 24 ITA, and 16 radial) and 162 non-CE (84 vein, 40 ITA, and 38 radial) grafts. Graft failure was similar ( p = 0.37) for radial (10 of 54 19%) and ITA (7 of 64 11%), and worst for vein (50 of 122 41%; p < 0.001). For CE targets, graft failure was worse for vein (55% vs 35%; p = 0.05) and unchanged for arterial (13% vs 15%; p = 0.88) grafts. Conclusions Combined CABG/CE is associated with good long-term outcomes. Increased arterial grafting achieved by radial artery utilization confers a survival benefit in this high-risk population. The latter is probably derived from superior radial versus vein graft patency.
Objective We investigated whether use of radial artery versus saphenous vein grafts during coronary artery bypass grafting reoperations is associated with a significant long-term survival benefit. ...Methods We reviewed a series of 347 consecutive coronary artery bypass grafting reoperations (1996–2007; 270 78% male patients; age, 65.3 ± 9.2 years). Internal thoracic artery grafts were used in 248 (71%) patients at the time of the first coronary artery bypass grafting operation and in 154 (44%) patients at reoperation. Patients were grouped based on whether a functional radial artery graft was present after coronary artery bypass grafting reoperation (radial artery cohort, n = 203 59%) or not (saphenous vein cohort, n = 144 41%). Median time to reoperation was similar for the radial artery (10.3 years) and saphenous vein (10.1 years) cohorts ( P = .55). Angiographic data were used to ascertain the number and type of grafts that remained functional from initial coronary artery bypass grafting. Survival data (≤12 years) were time segmented based on multiphase hazard modeling at 90 days, and late survival was then analyzed by using proportional hazard Cox regression, with risk adjustment based on a radial artery–use propensity score computed from 48 covariates, including time to reoperation, month of surgical intervention, and total arterial and vein grafts after reoperation. Propensity-matched and propensity quintile comparisons were also done. Results Follow-up was similar for the radial artery versus saphenous vein cohorts (5.7 ± 3.4 vs 5.8 ± 4.0 years, P = .86), and 112 (50 in the radial artery and 62 in the saphenous vein cohorts) deaths were documented. Early mortality (≤90 days) did not differ for the radial artery (7.4%) and saphenous vein (12.5%) cohorts ( P = .14). Unadjusted late outcomes were superior for the radial artery versus saphenous vein cohorts, with survival of 97.3% versus 92.9%, 84.9% versus 77.2%, and 74.1% versus 60.3% at 1, 5, and 10 years, respectively. Propensity-adjusted radial artery survival was superior, with a hazard ratio of 0.58 ( P = .04), and this result was confirmed in a propensity-matched comparison. Conclusions We conclude that the use of radial artery as opposed to saphenous vein grafting for reoperative coronary artery bypass grafting, either with or without concomitant internal thoracic artery grafts, is associated with a substantial improvement in late survival. This benefit is likely derived from the increased overall number of arterial grafts.
Stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). Whether left subclavian artery (LSA) coverage and LSA revascularization affect stroke rate is debated. Whether ...patients with aneurysms or dissections undergoing TEVAR have higher stroke rates is also debated. We report a systematic review of 63 studies comprising more than 3,000 patients. We conclude that stroke risk after TEVAR is increased by LSA coverage, and that LSA revascularization reduces stroke risk. LSA revascularization may lower the rate of posterior stroke. TEVAR for aneurysm is associated with increased stroke risk compared to TEVAR for dissection.
Abstract Pediatric heart failure (HF) is an important cause of morbidity and mortality in childhood. This article presents guidelines for the recognition, diagnosis, and early medical management of ...HF in infancy, childhood, and adolescence. The guidelines are intended to assist practitioners in office-based or emergency room practice, who encounter children with undiagnosed heart disease and symptoms of possible HF, rather than those who have already received surgical palliation. The guidelines have been developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and are accompanied by practical Recommendations for their application in the clinical setting, supplemented by online material. This work does not include Recommendations for advanced management involving ventricular assist devices, or other device therapies.
Reply Schwann, Thomas A., MD; Zacharias, Anoar, MD; Riordan, Christopher J., MD ...
The Annals of thoracic surgery,
2008, Letnik:
85, Številka:
5
Journal Article
Abstract Objective Postoperative myocardial infarction remains a serious complication in cardiac surgery. The incidence and impact of this condition in acute type A aortic dissection are poorly ...understood. Methods A total of 1445 patients with acute type A aortic dissection who underwent surgery were enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2013. Individuals with preoperative myocardial infarction at hospital presentation and a history of myocardial infarction were excluded. Patients with postoperative myocardial infarction (n = 38, 2.6%) were compared with those without postoperative myocardial infarction (n = 1407, 97.4%). Results The postoperative myocardial infarction group was more often of white race (100% vs 90%, P = .043) with bicuspid aortic valve (15.6% vs 4.5%, P = .015). Imaging demonstrated more aortic root involvement (75.8% vs 49.5%, P = .003), pericardial effusion (65.5% vs 44.1%, P = .022), and coronary artery compromise (27.3% vs 10.2%, P = .022). Patients with postoperative myocardial infarction were more frequently hypotensive or in shock during surgery (42.9% vs 25.5%, P = .021). Patients with postoperative myocardial infarction were more likely to have undergone root replacement (54.5% vs 33.3%, P = .011), coronary artery bypass grafting (28.6% vs 7.4%, P < .001), or aortic valve replacement (40.0% vs 23.8%, P = .027), and less likely to have had complete arch replacement (2.8% vs 14.0%, P = .050). Median circulatory arrest time was higher in postoperative myocardial infarction (60 vs 38 minutes, P = .024). In-hospital mortality (57.9% vs 16.3%, P < .001) and Kaplan–Meier estimates of 5-year mortality ( P = .007) were distinctly higher in postoperative myocardial infarction. Conclusions Postoperative myocardial infarction is a devastating complication of type A aortic dissection repair. It is associated with bicuspid aortic valve, root involvement, pericardial effusion, and extent of surgical repair. Patients with postoperative myocardial infarction have higher serious postoperative complications, in-hospital mortality, and 5-year mortality rates than those without postoperative myocardial infarction.
By amalgamating recent communication and control technologies, computing and data analytics techniques, and modular manufacturing, Industry 4.0 promotes integrating cyber–physical worlds through ...cyber–physical systems (CPS) and digital twin (DT) for monitoring, optimization, and prognostics of industrial processes. A DT enables interaction with the digital image of the industrial physical objects/processes to simulate, analyze, and control their real-time operation. DT is rapidly diffusing in numerous industries with the interdisciplinary advances in the industrial Internet of things (IIoT), edge and cloud computing, machine learning, artificial intelligence, and advanced data analytics. However, the existing literature lacks in identifying and discussing the role and requirements of these technologies in DT-enabled industries from the communication and computing perspective. In this article, we first present the functional aspects, appeal, and innovative use of DT in smart industries. Then, we elaborate on this perspective by systematically reviewing and reflecting on recent research trends in next-generation (NextG) wireless technologies (e.g., 5G-and-Beyond networks) and design tools, and current computational intelligence paradigms (e.g., edge and cloud computing-enabled data analytics, federated learning). Moreover, we discuss the DT deployment strategies at different communication layers to meet the monitoring and control requirements of industrial applications. We also outline several key reflections and future research challenges and directions to facilitate industrial DT’s adoption.
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