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Biancari F, Dalén M, Tauriainen T, Gatti G, Salsano A, Santini F, Feo MD, Zhang Q, Mazzaro E, Franzese I, Bancone C, Zanobini M, Mäkikallio T, Saccocci M, Francica A, Onorati F, El-Dean Z, Mariscalco G. Revascularization of Occluded Right Coronary Artery and Outcome After Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg 2023; 71:462-468. [PMID: 36736367 DOI: 10.1055/s-0043-1761625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The aim of the present study was to evaluate the results of isolated coronary artery bypass grafting (CABG) with or without revascularization of the occluded right coronary artery (RCA). METHODS Patients undergoing isolated CABG were included in a prospective European multicenter registry. Outcomes were adjusted for imbalance in preoperative variables with propensity score matching analysis. Late outcomes were evaluated with Kaplan-Meier's method and competing risk analysis. RESULTS Out of 2,948 included in this registry, 724 patients had a total occlusion of the RCA and were the subjects of this analysis. Occluded RCA was not revascularized in 251 (34.7%) patients with significant variability between centers. Among 245 propensity score-matched pairs, patients with and without revascularization of occluded RCA had similar early outcomes. The nonrevascularized RCA group had increased rates of 5-year all-cause mortality (17.7 vs. 11.7%, p = 0.039) compared with patients who had their RCA revascularized. The rates of myocardial infarction and repeat revascularization were only numerically increased but contributed to a significantly higher rate of MACCE (24.7 vs. 15.7%, p = 0.020) at 5 year among patients with nonrevascularized RCA. CONCLUSION In this multicenter study, one-third of totally occluded RCAs was not revascularized during isolated CABG for multivessel coronary artery disease. Failure to revascularize an occluded RCA in these patients increased the risk of all-cause mortality and MACCEs at 5 years.
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Affiliation(s)
- Fausto Biancari
- Hear and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Medicine, University of Helsinki, South-Karelia Central Hospital, Lappeenranta, Finland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery and Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tuomas Tauriainen
- Hear and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Marino, University of Genoa, Genoa, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Marino, University of Genoa, Genoa, Italy
| | - Marisa De Feo
- Department of Cardiothoracic Sciences, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Qiyao Zhang
- Department of Molecular Medicine and Surgery and Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Enzo Mazzaro
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Ilaria Franzese
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Ciro Bancone
- Department of Cardiothoracic Sciences, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Marco Zanobini
- Cardiovascular Department, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Timo Mäkikallio
- Department of Medicine, University of Helsinki, South-Karelia Central Hospital, Lappeenranta, Finland
| | - Matteo Saccocci
- Cardiac Surgery Unit, Poliambulanza Foundation, Brescia, Italy
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Zein El-Dean
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
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Ybarra LF, Rinfret S. Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions. Can J Cardiol 2022; 38:S42-S53. [PMID: 33075456 DOI: 10.1016/j.cjca.2020.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 12/30/2022] Open
Abstract
Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization.
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Affiliation(s)
- Luiz F Ybarra
- London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Stéphane Rinfret
- Division of Cardiology, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
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Fiddicke M, Fleissner F, Brunkhorst T, Kühn EM, Obed D, Boethig D, Ismail I, Haverich A, Warnecke G, Sommer W. Coronary artery bypass grafts to chronic occluded right coronary arteries. JTCVS OPEN 2021; 7:169-179. [PMID: 36003729 PMCID: PMC9390466 DOI: 10.1016/j.xjon.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/04/2021] [Indexed: 11/15/2022]
Abstract
Background The benefit of revascularizing chronically occluded coronary arteries remains debatable, and available long-term outcome reports are sparse. Current guidelines recommend revascularization of chronically occluded arteries only in patients with myocardial ischemia and/or symptoms associated with angina. We investigated outcome of patients with total chronic occlusion of the right coronary artery (RCA) receiving coronary artery bypass grafting (CABG) surgery with and without revascularization of the RCA. Methods We retrospectively analyzed all patients with chronically occluded RCAs receiving CABG with (group 1 = RCA-CABG; n = 487) and without (group 2 = No-RCA-CABG; n = 100) revascularization of the RCA. In total, 587 patients with complete follow-up of a minimum of 6 years were included (92%). Results In total, 82% in group 1 versus 86% in group 2 were male (P = .38). European System for Cardiac Operative Risk Evaluation II was comparable between both groups (4.35 ± 7.09% vs 4.80 ± 5.77%, P = .56) with no major differences regarding preoperative characteristics between groups. Patients in group 1 received 3.24 ± 0.79 distal anastomoses, whereas group 2 received 2.45 ± 0.83 distal anastomoses (P < .001). Although in-hospital mortality was comparable (2.9% in group 1 vs 5.0% in group 2, P = .27), long-term survival was significantly better in group 1 (P = .002). No difference in the incidence of further major adverse cardiac and cerebrovascular events was found. Conclusions Patients with a chronically occluded RCA undergoing CABG who did not receive an RCA graft showed a significantly reduced long-term survival. Given the herein presented data, revascularization of chronically occluded right arteries during CABG should be recommended whenever technically feasible.
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Affiliation(s)
- Maleen Fiddicke
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Felix Fleissner
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tonita Brunkhorst
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Eva M. Kühn
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Doha Obed
- Department of Plastic- and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Issam Ismail
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
- Address for reprints: Wiebke Sommer, MD, Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany.
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Schaefer A, Conradi L, Schneeberger Y, Reichenspurner H, Sandner S, Tebbe U, Nowak B, Stritzke J, Kastrati A, Schunkert H, von Scheidt M. Clinical outcomes of complete versus incomplete revascularization in patients treated with coronary artery bypass grafting: insights from the TiCAB trial. Eur J Cardiothorac Surg 2020; 59:ezaa330. [PMID: 33188598 DOI: 10.1093/ejcts/ezaa330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES In this post hoc analysis of the Ticagrelor in coronary artery bypass grafting (CABG) trial, we aimed to analyse patients treated with CABG receiving either complete revascularization (CR) or incomplete revascularization (ICR) independent from random allocation to either ticagrelor or aspirin. METHODS Of 1859 patients enrolled in the Ticagrelor in CABG trial, 1550 patients (83.4%) received CR and 309 patients (16.6%) ICR. Outcomes were evaluated regarding all-cause mortality, cardiovascular death, myocardial infarction (MI), repeat revascularization, stroke and bleeding within 12 months after CABG. RESULTS Baseline parameters revealed significant differences regarding clinical presentation (stable angina pectoris: CR 68.9% vs ICR 71.2%, instable angina pectoris: 14.1% vs 7.8%, non-ST elevation MI: 17.0% vs 21.0%, P ˂ 0.01), lesion characteristics (chronic total occlusion: CR 91.3% vs ICR 96.8%, P ˂ 0.01), operative technique [off-pump coronary artery bypass surgery (OPCAB): CR 3.0% vs ICR 6.1%, P ˂ 0.01] and number of utilized grafts (total number of grafts: 2.69/patient vs 2.49/patient, P ˂ 0.001). ICR patients displayed a significantly increased risk of repeat revascularization [hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.16-3.16; P < 0.01] and percutaneous coronary intervention (HR 1.95, 95% CI 1.13-3.35; P < 0.05) within 12 months after CABG. Higher risk for repeat revascularization in ICR patients was independent from random allocation to either ticagrelor or aspirin and persisted after adjustment for baseline imbalances. CONCLUSIONS Patients with ICR presented more stable at the time of admission, but received less grafts, highly likely due to a higher rate of chronic total occlusion lesions and performed OPCAB. Although mortality presented no difference between groups, our results suggest that patients benefit from CR with regard to prevention of repeat revascularization.
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Affiliation(s)
- Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Yvonne Schneeberger
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Sigrid Sandner
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Ulrich Tebbe
- Department of Cardiology, Angiology, and Intensive Care Medicine, District Hospital Lippe-Detmold, Detmold, Germany
| | - Bernd Nowak
- CCB, Cardiovascular Center Bethanien, Frankfurt am Main, Germany
| | - Jan Stritzke
- Lanserhof Sylt, Marienstein Privatklinik, List, Germany
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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