Graft failure occurs in a sizeable proportion of coronary artery bypass conduits. We herein review relevant current evidence to give an overview of the incidence, pathophysiology, and clinical ...consequences of this multifactorial phenomenon. Thrombosis, endothelial dysfunction, vasospasm, and oxidative stress are different mechanisms associated with graft failure. Intrinsic morphological and functional features of the bypass conduits play a role in determining failure. Similarly, characteristics of the target coronary vessel, such as the severity of stenosis, the diameter, the extent of atherosclerotic burden, and previous endovascular interventions, are important determinants of graft outcome and must be taken into consideration at the time of surgery. Technical factors, such as the method used to harvest the conduits, the vasodilatory protocol, the storage solution, and the anastomotic technique, also play a major role in determining graft success. Furthermore, systemic atherosclerotic risk factors, such as age, sex, diabetes mellitus, hypertension, and dyslipidemia, have been variably associated with graft failure. The failure of a coronary graft is not always correlated with adverse clinical events, which vary according to the type, location, and reason for failed graft. Intraoperative flow verification and secondary prevention using antiplatelet and lipid-lowering agents can help reducing the incidence of graft failure.
Despite the success of current therapies for acute myocardial infarction (MI), many patients still develop adverse cardiac remodeling and heart failure. With the growing prevalence of heart failure, ...a new therapy is needed that can prevent remodeling and support tissue repair. Herein, we report on injectable recombinant human collagen type I (rHCI) and type III (rHCIII) matrices for treating MI. Injecting rHCI or rHCIII matrices in mice during the late proliferative phase post-MI restores the myocardium's mechanical properties and reduces scar size, but only the rHCI matrix maintains remote wall thickness and prevents heart enlargement. rHCI treatment increases cardiomyocyte and capillary numbers in the border zone and the presence of pro-wound healing macrophages in the ischemic area, while reducing the overall recruitment of bone marrow monocytes. Our findings show functional recovery post-MI using rHCI by promoting a healing environment, cardiomyocyte survival, and less pathological remodeling of the myocardium.
Dialysis-dependent renal failure occurs infrequently after cardiac surgery but leads to substantial morbidity and mortality. In contrast, milder degrees of acute kidney injury (AKI), based on small ...increases in serum creatinine, occur frequently but the independent impact of mild AKI on outcome remains unclear.
Between January 2010 and December 2012, 3,869 consecutive patients undergoing cardiac surgery comprised the study cohort. Acute kidney injury was defined according to the AKI Network criteria as stage I, II, or III. A nonparsimonious multivariable logistic regression model including preoperative and intraoperative variables was constructed to determine a propensity score for the development of stage I AKI followed by a greedy matching algorithm to create 1:1 propensity-matched pairs.
The incidence of stage I AKI in the entire cohort was 22.4%. Stage I AKI patients were more likely to be older; to have diabetes mellitus, hypertension, preoperative renal dysfunction, and poorer left ventricle function; and to require more urgent surgery and longer cardiopulmonary bypass. After propensity matching, the 833 matched pairs were similar in terms of all of the above characteristics (all p > 0.5). Within the matched cohort, AKI patients had higher mortality (2.6% versus 1.2%, p = 0.01), higher incidence of neurologic dysfunction (15.2% versus 8.1%, p < 0.001), and longer duration of mechanical ventilation (41.7 ± 125.0 versus 19.3 ± 58.6 hours, p < 0.001). Intensive care unit stay (5.2 ± 10.7 versus 2.7 ± 3.8 days, p < 0.0001), and hospital length of stay (17.9 ± 20.1 versus 14.7 ± 18.3 days, p = 0.0007) was significantly longer for matched AKI patients.
Patients with even mild degrees of AKI have increased mortality and morbidity compared with their matched counterparts. Interventions that prevent or mitigate AKI after cardiac surgery can yield substantial clinical benefit.
Objective Minimally invasive coronary artery bypass grafting is safe and widely applicable, and may be associated with fewer transfusions and infections, and better recovery than standard coronary ...artery bypass grafting. However, graft patency rates remain unknown. The Minimally Invasive Coronary Artery Bypass Grafting Patency Study prospectively evaluated angiographic graft patency 6 months after minimally invasive coronary artery bypass grafting. Methods In this dual-center study, 91 patients were prospectively enrolled to undergo minimally invasive coronary artery bypass grafting via a 4- to 7-cm left thoracotomy approach. The left internal thoracic artery, the ascending aorta for proximal anastomoses, and all coronary targets were directly accessed without endoscopic or robotic assistance. The study primary outcome was graft patency at 6 months, using 64-slice computed tomography angiography. Secondary outcomes included conversions to sternotomy and major adverse cardiovascular events (Clinical Trial Registration Unique identifier: NCT01334866 ). Results The mean age of patients was 64 ± 8 years, the mean ejection fraction was 51% ± 11%, and there were 10 female patients (11%) in the study. Surgeries were performed entirely off-pump in 68 patients (76%). Complete revascularization was achieved in all patients, and the median number of grafts was 3. There was no perioperative mortality, no conversion to sternotomy, and 2 reopenings for bleeding. Transfusion occurred in 24 patients (26%). The median length of hospital stay was 4 days, and all patients were followed to 6 months, with no mortality or major adverse cardiovascular events. Six-month computed tomography angiographic graft patency was 92% for all grafts and 100% for left internal thoracic artery grafts. Conclusions Minimally invasive coronary artery bypass grafting is safe, feasible, and associated with excellent outcomes and graft patency at 6 months post-surgery.
SUMMARY
The primary hypothesis of the ROMA trial is that in patients undergoing primary isolated non-emergent coronary artery bypass grafting, the use of 2 or more arterial grafts compared with a ...single arterial graft (SAG) is associated with a reduction in the composite outcome of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization.
The secondary hypothesis is that in these patients, the use of 2 or more arterial grafts compared with a SAG is associated with improved survival. The ROMA trial is a prospective, unblinded, randomized event-driven multicentre trial comprising at least 4300 subjects. Patients younger than 70 years with left main and/or multivessel disease will be randomized to a SAG or multiple arterial grafts to the left coronary system in a 1:1 fashion. Permuted block randomization stratified by the centre and the type of second arterial graft will be used. The primary outcome will be a composite of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary outcome will be all-cause mortality. The primary safety outcome will be a composite of death from any cause, any stroke and any myocardial infarction. In all patients, 1 internal thoracic artery will be anastomosed to the left anterior descending coronary artery. For patients randomized to the SAG group, saphenous vein grafts will be used for all non-left anterior descending target vessels. For patients randomized to the multiple arterial graft group, the main target vessel of the lateral wall will be grafted with either a radial artery or a second internal thoracic artery. Additional grafts for the multiple arterial graft group can be saphenous veins or supplemental arterial conduits. To detect a 20% relative reduction in the primary outcome, with 90% power at 5% alpha and assuming a time-to-event analysis, the sample size must include 845 events (and 3650 patients). To detect a 20% relative reduction in the secondary outcome, with 80% power at 5% alpha, the sample size must include 631 events (and 3650 patients). To be conservative, the sample size will be set at 4300 patients. The primary outcome will be tested according to the intention-to-treat principle. The primary analysis will be a Cox proportional hazards regression model, with the treatment arm included as a covariate. If non-proportional hazards are observed, alternatives to Cox proportional hazards regression will be explored.
Visual estimation is the most commonly used method to evaluate the degree of coronary artery stenosis prior to coronary artery bypass grafting. In interventional cardiology, the use of fractional ...flow reserve (FFR) to guide revascularization decisions has become routine. We investigated whether the preoperative FFR measurement of coronary lesions is associated with anastomosis function 6 months after surgical revascularization using a multiarterial grafting strategy.
In this prospective double-blind study, 67 patients were enrolled from two institutions in Europe and Canada. From these patients, 199 coronary lesions were assessed visually and with FFR at the time of the preoperative angiogram. All patients received coronary revascularization using multiple arterial grafts. A post-operative 6-month angiogram was performed to assess anastomosis functionality using a described angiographic method. The primary outcome was the association between preoperative FFR values and anastomosis function 6 months after surgery. Preoperative FFR was significantly associated with 6-months anastomotic function for all conduits and for all targets (P < 0.001). An FFR value of ≤0.78 was associated with an anastomotic occlusion rate of 3%.
We found a significant association between the preoperative FFR measurement of the target vessel and the anastomotic functionality at 6 months, with a cut-off of 0.78. Integration of FFR measurement into the preoperative diagnostic workup before multiarterial coronary surgical revascularization leads to improved anastomotic graft function.
NCT02527044.
Background Mitral annuloplasty with either a partial band or complete ring is an integral part of mitral valve repair for degenerative disease. The affect of annuloplasty type on outcomes has not ...been well described. The objective of our study was to compare echocardiographic and functional characteristics of patients who underwent mitral repair with either a complete ring or a partial band. Methods We evaluated 107 patients who underwent mitral repair of myxomatous degeneration at our institution by stress echocardiography, 6-minute walk testing, and short form-36 questionnaire. These assessments were performed 4.3 ± 2.2 years following mitral repair by a single surgeon. A band was used in 65 patients (61%) and a ring in 42 patients (39%). Parametric and nonparametric tests were used in the analyses. Results The labeled band and ring size used for repair were 30.7 ± 2.8 mm and 30.4 ± 2.1 mm, respectively ( P = .6). The resting mean mitral gradient and valve area were 3.7 ± 1.9 mm Hg and 2.3 ± 0.6 cm2 for patients who received a band and 5.8 ± 2.6 mm Hg and 1.8 ± 0.5 cm2 for patients who received a ring (both P < .001). Distance traversed on 6-minute walk testing was 471 ± 77 m in the band group and 443 ± 107 m in the ring group ( P = .1). At peak exercise, the mean mitral gradient (15.3 ± 8.2 mm Hg vs 10.6 ± 4.8 mm Hg; P < .001) and right ventricular systolic pressure (52.6 ± 14.2 mm Hg vs 45.8 ± 9.5 mm Hg; P = .004) were higher for patients who received a ring versus a band. Ring patients reported lower levels of energy ( P = .02) and general health ( P = .007) on short form-36 assessment. Conclusions Annuloplasty using a complete ring may be associated with a higher mitral valve gradient at rest and at peak exercise in certain patients. These patients may also have worse quality of life. In view of these findings, we recommend careful consideration of annuloplasty type and size at the time of mitral repair of organic disease.
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