Atrial fibrillation (AF) is a relatively common comorbidity among patients referred for coronary artery bypass grafting (CABG) and is associated with poorer prognosis. However, little is known about ...how surgical technique influences survival in this population.
The current analysis aimed to determine whether total arterial revascularization (TAR) is associated with improved long-term outcomes in patients with preoperative AF.
We analyzed patients' data from the HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) registry. The registry, to date, involves five tertiary high-volume centers in Poland. Between 2006 and 2019, 4746 patients presented with preoperative AF and multivessel coronary artery disease and underwent CABG. We identified cases of TAR and used propensity score matching to determine non-TAR controls. Median follow-up was 4.1 years (interquartile range IQR, 1.9-6.8 years).
Propensity matching resulted in 295 pairs of TAR vs. non-TAR. The mean (standard deviation SD) number of distal anastomoses was 2.5 (0.6) vs. 2.5 (0.6) (P = 0.94) respectively. Operative and 30-day mortality was not different between TAR and non-TAR patients (hazard ratio HR and 95% confidence intervals CIs, 0.17 (0.02-1.38); P = 0.12 and 0.74 0.40-1.35; P = 0.33, respectively). By contrast, TAR was associated with nearly 30% improved late survival: HR, 0.72 (0.55-0.93); P = 0.01. This benefit was sustained in subgroup analyses, yet most pronounced in low-risk patients ( < 70 years old; EuroSCORE II < 2; no diabetes) and when off-pump CABG was performed.
TAR in patients with preoperative AF is safe and associated with improved survival, with particular survival benefits in younger low-risk patients undergoing off-pump CABG.
The aim of the study was to analyse the early and long-term outcomes of a consecutive series of patients who underwent sequential coronary artery bypass grafting (CABG) and to compare them with a ...matched population of totally arterial revascularized patients.
From January 1994 to December 1996, 209 patients underwent total arterial myocardial revascularization at our institution arterial (ART) group. In the same period, 2097 patients underwent CABG with left internal thoracic artery on left anterior descending and great saphenous vein on the right and circumflex branches sequentially sequential vein (SV) group. The propensity score methodology was used to obtain risk-adjusted outcome comparisons between the two groups (209 vs 243 patients in the ART group and SV group, respectively).
In-hospital mortality was 1% in the ART group and 0.4% in the SV group (P = 0.86). Mean follow-up was 14 ± 4 years. Long-term survival was comparable among the two study groups actuarial 5- and 15-year survival rates were 97 vs 93% and 82 vs 79% in the ART group and the SV group, respectively (P = 0.29). At follow-up, recurrence of angina (17 vs 18%; P = 0.99), acute myocardial infarction (MI) (3 vs 5%; P = 0.72) and repeated percutaneous coronary intervention (19 vs 21%; P = 0.69) were similar in the ART group compared with the SV group. In the Cox regression analysis, type of revascularization was not an independent predictor of any long-term outcomes (death or major adverse cardiac events). In asymptomatic patients, exercise stress test at follow-up was comparable between the two groups (P = 0.14).
Sequential vein CABG appears to have good early and long-term clinical outcomes. Also, early and long-term incidence of acute MI was not significantly higher in the SV group. However, further studies with a larger population are warranted in order to confirm the present results.
OBJECTIVES
Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an ...increased risk of sternal complications. In the present study, early and long-term outcomes of the routine use of left-sided BITA grafting in insulin-dependent diabetic patients were reviewed retrospectively.
METHODS
Among the 2701 consecutive patients who underwent isolated BITA grafting at the authors' institution from 1999 throughout 2012, 188 (mean age: 67 ± 9 years) were insulin-dependent diabetic patients. The mean expected operative risk, calculated according to the European System for Cardiac Operative Risk Evaluation II, was 11 ± 10.8%.
RESULTS
There were 6 (3.2%) hospital deaths. Prolonged invasive ventilation (17.6%), multiple transfusion (16.5%), deep sternal wound infection (DSWI, 11.7%) and acute kidney injury (10.6%) were the most frequent major postoperative complications. Chronic lung disease (P = 0.08), low cardiac output (P = 0.039), multiple transfusion (P = 0.034) and mediastinal re-exploration (P = 0.071) were risk factors for DSWI. The mean follow-up was 5.7 ± 3.6 years. The 10-year non-parametric estimates of overall survival, freedom from cardiac and cerebrovascular death, and major adverse cardiac and cerebrovascular events were 57.7 95% confidence interval (CI): 45.1–66.2, 83.6 (95% CI: 76.6–90.7) and 55.4% (95% CI: 44.7–66.1), respectively. Predictors of decreased late survival were old age (P = 0.013), chronic lung disease (P = 0.004), renal impairment (P = 0.009) and left ventricular dysfunction (P = 0.035).
CONCLUSIONS
Left-sided BITA grafting may be performed routinely even in insulin-dependent diabetic patients. The increased rates of postoperative complications do not prevent low early mortality and good long-term outcomes.
To analyse the survival of patients who had undergone bilateral internal thoracic artery grafting versus those with single internal thoracic artery grafting from the available literature. Moreover, ...this study will review the available literature regarding which of the two techniques seems to be the safest with long-term survival and reduced mortality rates.
A literature search of the databases was conducted to retrieve studies that fall under the study design of cohort and randomized controlled clinical trials in English from January 2015 to July 2021. Finally, seven studies were selected: four cohort studies and three other from a randomized trial.
The cohort studies revealed that bilateral internal thoracic artery grafting is associated with lower mortality rates and better long-term survival outcomes than single internal thoracic artery grafting, while the ART randomized controlled clinical trials showed that there is no significant difference in mortality rates between both the coronary artery bypass grafting techniques. However, all studies concluded that bilateral internal thoracic artery grafting is associated with a higher frequency of deep sternal wound infections.
The discrepancy in results between the cohort studies and randomized controlled clinical trial remains persistent. However, the stated advantages of bilateral internal thoracic artery grafting are not strong enough to convince surgeons to alter their practice and the wide magnitude of expectations from the ART study was reckoned as inadequate. This may well be due to the presence of limited criteria for bilateral internal thoracic artery grafting in identifying the impact on survival of extended arterial revascularization, and there is a new colossal expectation from the ongoing randomized trial based on multiple arterial grafting versus single arterial grafting.
Bilateral internal thoracic artery (BITA) grafting is underused in women.
Outcomes of 798 consecutive women with multivessel coronary disease who underwent isolated coronary surgery (1999–2016) using ...BITA (n=530, 66.4%) or single internal thoracic artery (SITA) grafting (n=268, 33.6%) were reviewed retrospectively. Differences between BITA and SITA cohort were adjusted by propensity score matching. For both series, late survival was estimated with the Kaplan-Meier method.
One-to-one propensity score matching resulted in 247 BITA/SITA pairs with similar baseline characteristics and risk profile. According to the propensity matching, BITA grafting was associated with a trend towards reduced in-hospital mortality (3.2% vs. 5.7%, p=0.19). However, BITA women had an increased chest tube output (p=0.0076) as well as higher rates of any (13% vs. 5.3%, p=0.003) and deep sternal wound infections (9.3% vs. 4.9%, p=0.054), this translating in a longer in-hospital stay (10 vs. 9days, p=0.029). Test for interaction showed that body mass index >30kg/m2 and extracardiac arteriopathy were associated with a higher risk of deep sternal wound infection in BITA than in SITA women (23.4% vs. 13.7%, p<0.001 and 23.9% vs. 3.4%, p=0.001, respectively). Freedom from all-cause death and cardiac or cerebrovascular death were improved in BITA cohort, even though the differences were not quite significant (p=0.16 and 0.076, respectively).
When routinely performed, BITA grafting does not increase in-hospital mortality in women and could improve long-term survival. However, its use should be avoided in obese women with extracardiac arteriopathy because of increased risk of deep sternal wound infection.
Coronary artery bypass grafting is the most commonly performed cardiac surgical procedure. Conduit selection is crucial to achieving early optimal outcomes, with graft patency being likely the main ...driver to long-term survival. We present a review of current evidence on the patency of arterial and venous bypass conduits and of differences in angiographic outcomes.
Background:
Hypothenar hammer syndrome (HHS) is traditionally treated with venous bypass grafting, but controversy has arisen as arterial grafts have become more available.
Methods:
A retrospective ...review of all patients undergoing ulnar artery bypass grafting for HHS with an arterial graft from 2008 to 2017 was performed. We also review the literature for patency rates and discuss the scenarios that favor different graft choices.
Results:
Six patients were included in our series. Five had primary surgery and 1 had revision surgery for HHS. Five arterial grafts were from the deep inferior epigastric artery and 1 was from the lateral circumflex femoral artery. The proximal anastomotic site was the ulnar artery for all: n = 6. The distal anastomosis site was the palmar arch and common digital artery (CDA) of the ring/small finger and CDA of the middle/ring finger: n = 3; the palmar arch and the CDA of the ring/small finger: n = 3. All patients were symptom-free at follow-up and had a patent ulnar artery on Allen’s testing or angiogram.
Conclusion:
Patency rates of arterial grafts for HHS appear to be excellent and this small series and may offer an alternative to traditional venous grafts and end-to-end arterial anastomoses. We suggest using arterial perforator grafts from free flap donor sites. These have well-described anatomy, are easily harvested, and carry minimal donor site morbidity. Lateral circumflex femoral artery graft is favored in patients requiring a single distal anastomosis, who have a ventral hernia, or who are obese. Deep inferior epigastric artery graft is preferred when multiple distal targets or versatile configurations are needed, in thin patients, or in female patients.
There is a clinical need for a functional tissue-engineered blood vessel because small-caliber arterial graft (<5 mm) applications are limited by the availability of suitable autologous vessels and ...suboptimal performances of synthetic grafts. This study presents an analysis of the mechanical properties of tissue-engineered vascular constructs produced using a novel single-step self-assembly approach. Briefly, the tissue-engineered vascular media were produced by culturing smooth muscle cell in the presence of sodium l-ascorbate until the formation of a cohesive tissue sheet. This sheet was then rolled around a tubular support to create a media construct. Alternatively, the tissue-engineered vascular adventitia was produced by rolling a tissue sheet obtained from dermal fibroblasts or saphenous vein fibroblasts. The standard self-assembly approach to obtain the two-layer tissue-engineered vascular constructs comprising both media and adventitia constructs consists of two steps in which tissue-engineered vascular media were first rolled on a tubular support and a tissue-engineered vascular adventitia was then rolled on top of the first layer. This study reports an original alternative method for assembling tissue-engineered vascular constructs comprising both media and an adventitia in a single step by rolling a continuous tissue sheet containing both cell types contiguously. This tissue sheet was produced by growing smooth muscle cells alongside fibroblasts (saphenous vein fibroblasts or dermal fibroblasts) in the same culture dish separated by a spacer, which is removed later in the culture period. The mechanical strength assessed by uniaxial tensile testing, burst pressure measurements, and viscoelastic behavior evaluated by stepwise stress relaxation tests reveals that the new single-step fabrication method significantly improves the mechanical properties of tissue-engineered vascular construct for both ultimate tensile strength and all the viscoelastic moduli.
Despite good outcomes, the use of the radial artery as a coronary graft is not widespread. Concerns regarding its low versatility and the risk of hand ischaemia, as well as the lack of reliable ...information regarding the best storage solution of the graft, and regarding the treatment for preventing spasms have limited its use. In this manuscript, the (numerous) benefits and (few) drawbacks of the proximal inflow for the radial artery from the in situ right internal thoracic artery proximal stump are discussed. Outcomes are reported from a limited series of patients undergoing totally arterial myocardial revascularization using this composite graft and both internal thoracic arteries.
OBJECTIVES
Coronary artery bypass grafting (CABG) has historically demonstrated higher hospital mortality in women compared with men. The influence of gender on long-term outcomes has not been ...clearly defined.
METHODS
A retrospective analysis of 4584 consecutive CABG patients was conducted: 3647 men (1761 single internal mammary artery, SIMA; 1886 bilateral IMA, BIMA) and 937 women (608 SIMA and 329 BIMA). Propensity-score analysis and optimal matching algorithms were used to create matched groups for baseline risk factors between men and women (SIMA: 602 men and 602 women; BIMA: 328 men and 328 women). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8 years) was 96.7% complete.
RESULTS
Hospital mortality was higher in unmatched female vs male patients (SIMA 36/608; 5.9 vs 72/1761; 4.1%; BIMA 11/329; 3.3 vs 47/1886; 2.5%; P = 0.010). However, in the matched groups the increased hospital mortality for females approached statistical significance in the SIMA but not in the BIMA patients. (SIMA male 21/602, 3.5%; female 35/602, 5.8%; P = 0.055; BIMA male 12/328; 3.7%; female 11/328; 3.4%; P = 0.832). When propensity matched for baseline variables, the female SIMA patients experienced prolonged survival compared with their male counterparts. (male vs female, 20-year survival 17.0 ± 2.0 vs 26.4 ± 2.3%; median 10.4 vs 11.4; P = 0.043.) However, long-term survival between the matched male and the female BIMA patients was comparable (male vs female, 20-year survival 31.3 ± 3.6 vs 30.1 ± 3.6%; median 13.7 vs 13.7; P = 0.790).
CONCLUSIONS
When liberally applied, BIMA grafting ameliorates both the increased perioperative mortality in female patients and the reduced long-term survival of male patients, effectively reversing the negative influence of gender on both short- and long-term outcomes of CABG surgery.
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