Contemporary Coronary Artery Bypass Grafting vs Multivessel Percutaneous Coronary Intervention

Advancing the Treatment Paradigm for Multivessel Coronary Artery Disease: Hybrid Coronary Revascularization

OBJECTIVE

The purpose of this study was to examine the longitudinal safety and efficacy of hybrid coronary revascularization (HCR) in a large cohort of patients with multivessel coronary artery disease (CAD).

METHODS

From 2009 to 2020, 561 consecutive patients (median age 64.0 years, predicted risk of mortality 1.3% ± 1.8%, 403 with 2-vessel disease and 158 with 3-vessel disease) underwent a planned HCR procedure with a robot-assisted off-pump left internal mammary artery to left anterior descending (LIMA-LAD) coronary artery bypass graft (CABG) combined with percutaneous coronary intervention (PCI) of non-LAD vessels. Multivariable regression analysis was used to identify risk factors for short-term and longer-term outcomes.

RESULTS

Operative mortality and stroke occurred in 4 (0.7%) and 5 patients (0.9%), respectively. Postoperative angiography revealed LIMA patency in 415 of 425 patients (98%). Median follow-up was 4.5 years and was 93% complete. Repeat revascularization occurred in 44 patients (8%) at a median of 2.7 years. Freedom from repeat revascularization and survival at 5 years was similar between patients with 2-vessel and 3-vessel disease (P = 0.73 and P = 0.19, respectively). Completely revascularized patients had 5-year survival of 91% versus 64% for incompletely revascularized patients (hazard ratio = 3.8, P < 0.001). Age (P = 0.03), renal failure (P < 0.001), and history of myocardial infarction (P = 0.01) were risk factors for late adverse events.

CONCLUSIONS

HCR is a safe and effective minimally invasive alternative to conventional CABG or multivessel PCI with a low incidence of late repeat revascularization and mortality. HCR can be safely applied to carefully selected patients with either 2-vessel or 3-vessel CAD; however, incomplete revascularization may result in lower long-term survival.

Does the Coronary Artery Bypass Grafting Impact the Survival of Men and Women Equally Compared to General Population? Results from KROK Registry and Polish Central Statistical Office

Objective: The aim of this study was to evaluate the impact of coronary bypass surgery (CABG) on long-term mortality, comparing survival rates to those of the general population in Poland. Methods: The study was based on the Polish National Register of Cardiothoracic Surgical Procedures (KROK). Between January 2009 and December 2019, 133,973 patients underwent CABG. The study included all patients who underwent primary CABG. After excluding reoperations and patients with missing key data, there were 132,760 remaining patients who participated in the study. In order to compare patients who underwent CABG with the general population, data from Polish life expectancy tables from the Central Statistical Office (CSO) were used. Results: In the general population (GP), there is a consistent decrease in survival for both women and men throughout the entire observation period. The decline in survivability is more pronounced in the male group. Unlike the CABG group, which is at risk of perioperative mortality, there is no initial drop in survivability in the GP. The early mortality rate in CABG group within 30 days was significantly higher in the group of women than in men (3.51% compared to 2.19%, p < 0.001). The annual mortality rate was higher in the group of women (6.7% vs. 5.14%), and survival time was shorter (345.5 ± 0.4 vs. 351.2 ± 0.2 days, p < 0.001). However, the total mortality over a 13-year period of observation did not differ significantly between the groups (30.17% for women vs. 29.6% for men, p = 0.996) with survival time 10.08 ± 0.02 years in men vs. 10.06 ± 0.03 in women, p = 0.996. Conclusions: CABG surgery equalizes the probability of survival between genders. In long-term observation men have a greater survival benefit than women if compared to the predicted survival of the general population. These observations may provide a new perspective on the choice of revascularization strategy in relation to gender.

Comparing percutaneous coronary intervention and coronary artery bypass grafting for left main stenosis on the basis of current regional registry evidence

Objectives

There is an ongoing debate whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is the better choice for treatment of left main (LM) stenosis. We aimed to provide external validation for the recently reviewed guideline recommendations for invasive LM therapy by evaluating the impact of CABG or PCI on long-term survival from local reports of different regions in the world. We performed a systematic review and meta-analysis to address contemporary registry studies comparing PCI and CABG for patients with LM stenosis.

Methods

Three databases were assessed. Our primary end point was long-term all-cause mortality. Secondary end points were major adverse cardiovascular events (MACE), myocardial infarction, repeat revascularization, stroke, and periprocedural mortality. Reconstruction of time-to-event data was performed.

Results

A total of 2477 studies were retrieved. Seven studies with risk-adjusted populations were selected for the analysis. Four studies favored CABG and 3 studies showed no difference for the primary end point. Compared with PCI, patients who underwent CABG had lower risk of death (hazard ratio, 1.15; 95% confidence interval, 1.05-1.26, P < .01) and MACE (hazard ratio, 1.54; 95% confidence interval, 1.40-1.69, P < .01) during follow-up. Moreover, PCI was associated with more myocardial infarction, repeat revascularization, but less strokes when compared with CABG. There was no significant difference regarding periprocedural mortality. The MACE rate was lower after CABG in both early and late phase, which outweighs the higher rate of periprocedural stroke after CABG.

Conclusions

Regional registry evidence supports the current notion of superior long-term endpoints with CABG compared with PCI for the treatment of LM stenosis over time.

Predictive Performances of ACEF, ACEF II, Updated ACEF II, and EuroSCORE II Risk Scores in Patients Undergoing Isolated Off-pump Coronary Artery Bypass Grafting

OBJECTIVES

This study evaluated the performances of the age, creatinine, and ejection fraction (ACEF) I and II scores and compare them with that of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II score in patients who underwent isolated off-pump coronary artery bypass grafting (OPCABG). Additionally, this study was designed to externally validate the performance of the updated ACEF II score.

DESIGN

Retrospective observational study.

PARTICIPANTS

A total of 936 patients who underwent OPCABG between January 1, 2013, and December 31, 2022, at a tertiary teaching center were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Predicted operative mortality was calculated using a risk score model. The predictive performance of each score was evaluated using receiver operating characteristic curves and calibration plots. The ACEF II score demonstrated the highest C-statistic (area under the curve = 0.831, 95% confidence interval: 0.691-0.971), while the C-statistics for ACEF I, updated ACEF II, and EuroSCORE II were 0.793 (0.645-0.940), 0.698 (0.524-0.872), and 0.780 (0.606-0.954), respectively. The ACEF II score exhibited significantly better discriminative performance than the updated ACEF II score (p = 0.010); however, no significant differences were observed compared with the ACEF I and EuroSCORE II scores (p = 0.118 and 0.354, respectively).

CONCLUSIONS

ACEF I and II scores are reliable risk stratification models with performances comparable to the EuroSCORE II score in patients undergoing isolated OPCABG. However, the updated ACEF II score failed to demonstrate improved performance.

Techniques and Results of Multiple Arterial Bypass Grafting: Towards More "Curative" Coronary Revascularizations

Surgical coronary bypass has evolved continually, and most analyses currently favor performing coronary grafts with autologous living arterial conduits to obtain better long-term patencies and clinical outcomes. With bilateral internal mammary artery grafts and both radial arteries, 4 excellent arterial conduits exist for creating "all-arterial" revascularization in the majority of multivessel disease patients, including those with valve disorders. Using contemporary surgical techniques, it is possible to obtain greater than 95% overall early graft patencies that translate into better late outcomes, including improved survival, freedom from myocardial infarction, fewer percutaneous coronary interventions, and redo coronary bypass procedures. The overall goal is to revascularize the 2 most important coronary systems with internal mammary artery grafts, and the rest with radial arteries, depending on the anatomy, experience, and choice of the surgeon. Using highly validated management strategies, early postoperative complications, including the incidence of sternal infections, are extremely uncommon, and in many practices, multi-arterial grafts currently are used in the majority of multivessel patients, including those with concomitant valve disease. Because patencies and outcomes are significantly better than with saphenous vein bypass or percutaneous coronary interventions, referring physicians frequently favor multi-arterial bypass procedures as the primary therapy for patients with prognostically serious multivessel disease. Thus, coronary bypass using predominantly autologous arterial conduits should play an increasingly important role in the future management of severe coronary atherosclerosis.

Cardiac Surgery 2023 Reviewed

We reviewed the cardiac surgical literature for 2023. PubMed displayed almost 34,000 hits for the search term "cardiac surgery AND 2023." We used a PRISMA approach for a results-oriented summary. Key manuscripts addressed the mid- and long-term effects of invasive treatment options in patient populations with coronary artery disease (CAD), comparing interventional therapy (percutaneous coronary intervention [PCI]) with surgery (coronary artery bypass graft [CABG]). The literature in 2023 again confirmed the excellent long-term outcomes of CABG compared with PCI in patients with left main stenosis, specifically in anatomically complex chronic CAD, but even in elderly patients, generating further support for an infarct-preventative effect as a prognostic mechanism of CABG. For aortic stenosis, a previous trend of an early advantage for transcatheter (transcatheter aortic valve implantation [TAVI]) and a later advantage for surgical (surgical aortic valve replacement) treatment was also re-confirmed by many studies. Only the Evolut Low Risk trial maintained an early advantage of TAVI over 4 years. In the mitral and tricuspid field, the number of interventional publications increased tremendously. A pattern emerges that clinical benefits are associated with repair quality, making residual regurgitation not irrelevant. While surgery is more invasive, it currently generates the highest repair rates and longest durability. For terminal heart failure treatment, donor pool expansion for transplantation and reducing adverse events in assist device therapy were issues in 2023. Finally, the aortic diameter related to adverse events and technical aspects of surgery dominated in aortic surgery. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation, but provides up-to-date information for patient-specific decision-making.

Association of chronic poststernotomy pain and health-related quality of life: a prospective cohort study

PURPOSE

Chronic poststernotomy pain (CPSP) after cardiac surgery is multifactorial and impacts patient recovery. We aimed to evaluate the association between CPSP severity and health-related quality of life at six months after cardiac surgery.

METHODS

This was a single-centre prospective cohort study of patients who underwent cardiac surgery with median sternotomy between September 2020 and March 2021. Telephone interviews were conducted at six and 12 months postoperatively using the Short Form McGill Pain Questionnaire and the EQ-5D-5L. Strength of correlation was described using Spearman's correlation coefficient. Multivariable regression analysis was used to account for confounding variables.

RESULTS

A total of 252 patients responded to the six-month interview (response rate, 65%). The mean (standard deviation) age of respondents was 65 (13) yr. Twenty-nine percent of respondents (72/252) reported CPSP at six months, and 14% (41/252) reported more than mild pain (score ≥ 2/5). At 12 months, of the 89% (64/72) patients who responded, 47% (30/64) still reported pain. The strength of the correlation between pain scores and EQ-5D-5L was weak (Spearman's correlation coefficient, -0.3). Risk factors for CPSP at six months included higher pain score on postoperative day 1, history of chronic pain prior to surgery, and history of depression. Intraoperative infusion of dexmedetomidine or ketamine was associated with a reduced risk of CPSP at six months.

CONCLUSION

Chronic poststernotomy pain still affects patient recovery at six and 12 months after cardiac surgery. The severity of that pain is poorly correlated with patients' quality of life.

STUDY REGISTRATION

www.osf.io ( https://osf.io/52rsw ); registered 14 May 2022.