Abstract
OBJECTIVES
This study sought to evaluate the long-term differences in survival between multiple arterial grafts (MAG) and single arterial grafts (SAG) in patients who underwent coronary ...artery bypass grafting (CABG) in the SYNTAX study.
METHODS
The present analysis included the randomized and registry-treated CABG patients (n = 1509) from the SYNTAX Extended Survival study (SYNTAXES). Patients with only venous (n = 42) or synthetic grafts (n = 1) were excluded. The primary end point was all-cause death at the longest follow-up. Multivariable Cox regression was used to adjust for differences in baseline characteristics. Sensitivity analysis using propensity matching with inverse probability for treatment weights was performed.
RESULTS
Of the 1466 included patients, 465 (31.7%) received MAG and 1001 (68.3%) SAG. Patients receiving MAG were younger and at lower risk. At the longest follow-up of 12.6 years, all-cause death occurred in 23.6% of MAG and 40.0% of SAG patients adjusted hazard ratio (HR) 0.74, 95% confidence interval (CI) (0.55–0.98); P = 0.038, which was confirmed by sensitivity analysis. MAG in patients with the three-vessel disease was associated with significant lower unadjusted and adjusted all-cause death at 12.6 years adjusted HR 0.65, 95% CI (0.44–0.97); P = 0.033. In contrast, no significance was observed after risk adjustment in patients with the left main disease, with and without diabetes, or among SYNTAX score tertiles.
CONCLUSIONS
In the present post hoc analysis of all-comers patients from the SYNTAX trial, MAG resulted in markedly lower all-cause death at 12.6-year follow-up compared to a SAG strategy. Hence, this striking long-term survival benefit of MAG over SAG encourages more extensive use of multiple arterial grafting in selected patients with reasonable life expectancy.
Trial registration
SYNTAXES ClinicalTrials.gov reference: NCT03417050; SYNTAX ClinicalTrials.gov reference: NCT00114972.
Whether coronary artery bypass grafting (CABG) should be performed with multiple arterial grafts (MAG) in patients requiring bypass surgery remains fiercely debated.
Background:The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain ...unproven.Methods and Results:Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III−IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively.Conclusions:BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.
Long-term outcome of the in situ versus free internal thoracic artery as the second arterial graft Marzouk, Mohamed; Kalavrouziotis, Dimitri; Grazioli, Valentina ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
December 2021, 2021-12-00, 20211201, Letnik:
162, Številka:
6
Journal Article
Recenzirano
Odprti dostop
The study objective was to determine the impact on outcome associated with using the second internal thoracic artery as a free compared with an in situ graft among patients who received the first ...internal thoracic artery as an in situ internal thoracic artery to the left anterior descending artery.
Among 2600 patients who underwent bilateral internal thoracic artery with an in situ internal thoracic artery to the left anterior descending artery, the second internal thoracic artery was used as a free graft bilateral internal thoracic artery in 136 patients and as an in situ graft (in situ bilateral internal thoracic artery) in 2464 patients. One-to-many propensity score matching was performed to produce a cohort of 134 patients with a second free graft internal thoracic artery matched to 2359 patients with a second in situ internal thoracic artery. Early and long-term outcomes including survival, hospital readmission, and repeat revascularization up to a maximum of 25.8 years were compared.
There were no differences between the 2 matched groups' preoperative baseline characteristics and early adverse events. Long-term survival at 5, 10, and 15 years was significantly higher among patients with an in situ bilateral internal thoracic artery compared with patients with a free graft bilateral internal thoracic artery (hazard ratio free graft bilateral internal thoracic artery vs in situ bilateral internal thoracic artery, 1.53; 95% confidence interval, 1.14-2.10; P = .004). However, the long-term risk of readmission to the hospital for cardiovascular reasons and need for repeat revascularization were not significantly different between the 2 matched groups.
In a small, propensity-matched cohort of patients undergoing coronary artery bypass grafting, the use of a second in situ internal thoracic artery was associated with an increase in late survival compared with the use of a second internal thoracic artery as a free graft. However, the risk of late hospital readmission and the need for repeat revascularization were similar.
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We sought to identify the trends in bilateral internal thoracic artery use and determine the degree to which the survival advantage of bilateral internal thoracic artery revascularization persists ...among perceived “high-risk” patients, compared with the use of left internal thoracic artery alone.
A retrospective review was conducted of patients who underwent isolated coronary artery bypass grafting for multivessel coronary artery disease at the Mayo Clinic between January 2000 and December 2015. Propensity score matching was performed between patients with bilateral internal thoracic artery and left internal thoracic artery alone grafts (1011 matched pairs). Effect of bilateral internal thoracic artery use on survival in “high-risk” patients (ejection fraction <40%, body mass index ≥30, age ≥70 years, diabetes, chronic lung disease, cerebrovascular accident) was evaluated.
A total of 6468 isolated coronary artery bypass grafts were performed (5431 using left internal thoracic artery alone, 1037 using bilateral internal thoracic artery). There was an increasing trend in bilateral internal thoracic artery use (P value for linear trend = .005), with the percentage of coronary artery bypass grafting cases with bilateral internal thoracic artery doubling over the last 4 years (13% in 2012 to 27% in 2015). Propensity-matched comparisons showed a survival advantage for bilateral internal thoracic artery (hazard ratio, 0.81; 95% confidence interval, 0.66-0.99; P = .043). Risk of deep sternal wound infection, although higher in the bilateral internal thoracic artery group, was not significant (1.2% vs 0.5%; P = .088). None of the “high-risk” subsets of patients showed an adverse effect of bilateral internal thoracic artery on survival.
Bilateral internal thoracic artery use in coronary artery bypass grafting is increasing over time. There is a consistent survival benefit with bilateral internal thoracic artery use, extending to patients with higher-risk comorbidities, suggesting the need for further expansion in use of this technique.
Hemodialysis access has been considered as a support for end-stage renal patients. We measured the hemodynamic changes of the distal part of the upper extremity immediately after providing the AVGs ...in each method mentioned above and then compared the results. This method is a novel one and hasn’t been used in any other studies before. We studied 32 patients referred to the vascular surgery department of Rasht Razi Hospital between 2019-2020 (using the Convenient Sampling method). This study is a case-control study. Out of 32 patients referred to the vascular surgery department of the hospital, 68.8% were male, and their mean age was 53.41±12.75 years, ranging from 28 to 78 years. Changes in distal arterial hemodynamics of the upper limb before and after clamping in dialysis venoarterial loop versus straight grafts are different in studied patients (P<0.05). The mean hemodynamic changes before and after clamping in loop venoarterial grafts (19.5000) are less than straight grafts. In dialysis patients who do not have any superficial vein suitable for venous, arterial fistula, surgical placement of artificial grafts in the upper limb is appropriate. Based on the results of this study, the loop method seems to have lesser ischemic Complications and can be applied to dialysis patients.
The development of vascular bioengineering has led to a variety of novel treatment strategies for patients with cardiovascular disease. Notably, combining biodegradable scaffolds with autologous cell ...seeding to create tissue-engineered vascular grafts (TEVG) allows for in situ formation of organized neovascular tissue and we have demonstrated the clinical viability of this technique in patients with congenital heart defects. The role of the scaffold is to provide a temporary 3-dimensional structure for cells, but applying TEVG strategy to the arterial system requires scaffolds that can also endure arterial pressure. Both biodegradable synthetic polymers and extracellular matrix-based natural materials can be used to generate arterial scaffolds that satisfy these requirements. Furthermore, the role of specific cell types in tissue remodeling is crucial and as a result many different cell sources, from matured somatic cells to stem cells, are now used in a variety of arterial TEVG techniques. However, despite great progress in the field over the past decade, clinical effectiveness of small-diameter arterial TEVG (<6mm) has remained elusive. To achieve successful translation of this complex multidisciplinary technology to the clinic, active participation of biologists, engineers, and clinicians is required. (Circ J 2014; 78: 12–19)
Diltiazem has been used during the perioperative period in patients undergoing coronary artery bypass grafting (CABG) to prevent arterial graft spasm. However, its long-term outcome effects remain ...unclear.
Patient records obtained from the Society of Thoracic Surgeons and the Geisinger Clinic electronic health records between October 2008 and October 2018 were screened. Adult patients who had isolated CABG with cardiopulmonary bypass were included. Cohorts of patients who received diltiazem (DILT) and those who did not (non-DILT) were matched by propensity scores based on age, gender, surgical year, Society of Thoracic Surgeons mortality and morbidity scores, and number of arterial grafts. Incidence rate ratios (IRRs) were estimated for DILT vs non-DILT on short-term adverse outcomes. Long-term survival over time was compared between DILT vs non-DILT using Kaplan–Meier curves.
Among the 1004 patients included in the analyses, IRRs for the DILT group relative to the non-DILT group were: 30-day all-cause mortality, IRR: 2.33, 95% confidence interval (CI): 0.91–5.96, P=0.07; postoperative myocardial ischaemia, IRR: 1.10, 95% CI: 0.60–2.02, P=0.75; new onset atrial fibrillation, IRR: 1.06, 95% CI: 0.78–1.43, P=0.73; stroke/transient ischaemic attack, IRR: 0.76, 95% CI: 0.17–3.38, P=0.71. For long-term survival, Kaplan–Meier curves stratified by diltiazem revealed no differences in survival rates between DILT and non-DILT groups.
For patients undergoing on-pump CABG, perioperative diltiazem therapy did not show significant short- or long-term outcome advantages over those who did not receive diltiazem.
OBJECTIVES
Despite long-term survival benefits, the increased risk of sternal complications limits the use of bilateral internal thoracic artery (BITA) grafts for myocardial revascularization. The ...aim of the present study was both to analyse the risk factors for deep sternal wound infection (DSWI), which complicates routine BITA grafting and to create a DSWI risk score based on the results of this analysis.
METHODS
BITA grafts were used as skeletonized conduits in 2936 (70.6%) of 4160 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution from 1 January 1999 to 2013. The outcomes of these BITA patients were reviewed retrospectively and a risk factor analysis for DSWI was performed.
RESULTS
A total of 129 (4.4%) patients suffered from DSWI. Two multivariable analysis models were created to examine preoperative factors either alone or combined with intraoperative and postoperative factors. Female gender, obesity, diabetes, poor glycaemic control, chronic lung disease and urgent surgical priority were the predictors of DSWI common to both models. Two (preoperative and combined) models of a new scoring system were devised to predict DSWI after BITA grafting. The preoperative model performed better than five of six scoring systems for sternal wound infection that were considered; the combined model performed better than three considered scoring systems.
CONCLUSIONS
A weighted scoring system based on risk factors for DSWI was specifically created to predict DSWI risk after BITA grafting. This scoring system outperformed the existing scoring systems for sternal wound infection after coronary bypass surgery. Prospective studies are needed for validation.
Background
Blood glucose level variability has been associated with increased risk of complication in the postoperative setting of cardiovascular surgery. Although interesting for optimization of ...blood glucose management in this context, continuous blood glucose (CBG) devices can have a limited reliability in this context, in particular because of the use of paracetamol. The aim of this study was to evaluate the reliability of Dexcom G6®, a recently developed continuous glucose monitoring device.
Methods
We performed a prospective, observational, non-randomized, single-centre study comparing Dexcom G6® CBG level monitoring with the standard methods routinely used in this context. The standard blood glucose values were paired to the time corresponding values measured with Dexcom G6®. Agreement between the two methods and potential correlation in case of paracetamol use were calculated.
Results
From May 2020 to August 2021, 36 out of 206 patients operated for isolated coronary artery bypass grafting were enrolled; 673 paired blood glucose level were analyzed. Global agreement (ρc) was 0.85 (95% C.I.: 0.84–0.86), intensive care unit agreement was 0.78 (95%C.I.: 0.74–0.82) and ward agreement was 0.91 (95%C.I.: 0.89–0.93). In the diabetic population, it was 0.87 (95%C.I.: 0.85–0.90). When paracetamol was used, the difference was 0.02 mmol/l (95%C.I.: 0.29–0.33).
Conclusions
Dexcom G6® provides good blood glucose level accuracy in the postoperative context of cardiac surgery compared to the standard methods of measurements. The results are particularly reliable in the ward where the need for repeated capillary glucose measurements implies patient discomfort and time-consuming manipulations for the nursing staff.
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