2018 ESC/EACTS Guidelines on myocardial revascularization

Myocardial Revascularization in Patients With 3 Vessel Coronary Artery Disease and Chronic Kidney Disease: Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention

Coronary artery disease (CAD) and chronic kidney disease (CKD) commonly co-exist. Superior outcomes with coronary artery bypass grafting(CABG) compared to percutaneous coronary intervention (PCI) have been identified in patients with 3 vessel CAD (TVD) and CKD but have been limited to mid-term follow-up. Herein, we analyzed the long-term outcomes of patients with TVD and CKD undergoing surgical versus percutaneous revascularization. 1,599 patients with CKD and TVD without STEMI or previous revascularization underwent coronary angiography between 2009 and 2018. The primary outcome was all-cause mortality. Secondary outcomes included rates of readmission for myocardial infarction (MI), stroke, repeat revascularization, and overall rehospitalization. 453 patients were included in the final analysis (PCI 373; CABG 80; median follow-up 9.3 years). All results are presented as CABG versus PCI. The rate of all-cause mortality at the longest follow-up (14.1 years) was significantly lower in patients who underwent CABG (68.9% vs 83.1%, p = 0.039, adjusted Hazard Ratio (aHR) 0.68, 95% confidence interval (CI) 0.47-0.98). Readmission rates for MI (10.2% vs. 28.4%, p = 0.009, aHR 0.37, 95% CI 0.17-0.77) and repeat revascularization (3.1% vs. 24.4%, p < 0.001, aHR 0.09, 95% CI 0.02-0.34) were also lower after CABG than after PCI. No significant difference was observed in the rates of readmission for stroke or all causes. In conclusion, in this retrospective single-center study, we confirmed that the previously described advantages of CABG over PCI in patients with CKD and TVD persist with extended long-term follow-up. CABG should be considered the gold standard approach to revascularization in this patient population.

Percutaneous Coronary Intervention or Minimally Invasive Coronary Bypass for Isolated Left Anterior Descending Artery Disease

The optimal revascularization strategy for isolated left anterior descending (LAD) artery disease, minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI), remains a subject of debate. This updated meta-analysis aimed to compare the long- term outcomes of MIDCAB versus PCI for patients with isolated LAD artery disease. Three databases were systematically searched to identify randomized controlled trials (RCTs) and adjusted studies. Primary outcomes included long-term survival and repeat target vessel revascularization (TVR). The secondary endpoint was long-term major adverse cardiovascular events (MACEs). Hazards ratios (HR) and Confidence Intervals (CI) were calculated for long-term outcomes and a random effects model was used. Sensitivity analyses included subgroups analysis of stent-type. Nine articles, comprising four RCTs, totaling 2,168 patients (MIDCAB=1,086 and PCI=1,080) were included. The weighted mean follow-up was 4.35±4.9 years. Long-term survival was comparable between MIDCAB and PCI (HR=0.76; 95% CI, 0.58-1.00; p=0.05). MIDCAB was associated with a significantly lower rate of repeat TVR (HR=0.35; 95% CI, 0.25-0.49; p<0.0001) and a reduced risk of MACEs (HR=0.59; 95% CI, 0.43-0.81; p<0.0001), although the difference was not evident in subgroup analysis comparing MIDCAB and PCI with drug-eluting stent (HR=0.66; 95% CI, 0.46-1.06; p=0.09). In conclusion, this meta-analysis of RCTs and adjusted studies shows that in patients with isolated LAD lesion, MIDCAB and PCI exhibit comparable long-term survival. However, MIDCAB is associated with a significantly reduced risk of long-term repeat TVR and MACEs compared to PCI.

Flow-Based Coronary Artery Bypass Graft Patency Metrics: Uncertainty Quantification Simulations to Guide Development

PURPOSE

Over time, transit time flow measurement (TTFM) has proven itself as a simple and effective tool for intra-operative evaluation of coronary artery bypass grafts (CABGs). However, metrics used to screen for possible technical error show considerable spread, preventing the definition of sharp cut-off values to distinguish between patent, questionable, and failed grafts. The simulation study presented in this paper aims to quantify this uncertainty for commonly used patency metrics, and to identify the most important physiological parameters influencing it.

METHODS

Uncertainty quantification was performed on a realistic multiscale numerical model of the coronary circulation, guided by Morris screening sensitivity analysis of a simpler, lumped-parameter model. Simulation results were qualitatively verified against results of a recent clinical study.

RESULTS

Correspondence with clinical study data is reasonable, especially considering that the model was not fitted in any way. Stenosis severity was confirmed to be an influential parameter. However, also cardiac period and graft diameter were observed to be important, particularly for mean flow rate and pulsatility index.

CONCLUSION

Metrics quantifying the flow waveform's diastolic dominance show the highest sensitivity to graft stenosis, and seem to be least affected by autoregulation. Among these, the novel diastolic resistance index shows the strongest sensitivity to stenosis severity.

SIGNIFICANCE

The approach used in this study is expected to benefit the development of improved patency metrics, by allowing medical engineers to include sensitivity and uncertainty in assessing, in-silico, the potential of novel metrics, thus enabling them to provide better guidance in the design of clinical studies.

Coronary artery disease with heavily calcified lesions - literature review of novel therapeutic methods

Coronary artery disease and atherosclerosis are a very significant and widespread problem in modern medicine. The development of current diagnostics and treatment of atherosclerotic lesions is moving towards minimally invasive methods. The purpose of this article is to present selected novel methods of treating coronary atherosclerosis, comparing their effectiveness, indications, contraindications, and possible complications. A literature review of selected treatment methods for calcified atherosclerotic lesions was conducted in the online databases of PubMed, PubMed Central, Google Scholar, and NCBI. It includes original and review papers. The main language of the articles was English. The search used keywords such as "coronary artery disease," "calcified atherosclerotic lesions," "rotational atherectomy," "intravascular lithotripsy," and "RotaTripsy," as well as related phrases. After analyzing the abstracts, the papers that most closely matched the stated topic were selected. Atherosclerosis is the leading cause of coronary heart disease incidence. Several risk factors, both non-modifiable and modifiable, predispose to its occurrence. Heavily calcified atherosclerotic plaques are associated with a higher risk of coronary artery disease consequences. Currently, methods such as CT coronary angiography and optical coherence tomography are used for diagnosis. Endovascular therapies are now recommended for the treatment of atherosclerosis with heavily calcified plaques. Rotational atherectomy, intravascular lithotripsy and RotaTripsy are promising methods for treating high-grade atherosclerosis with calcified deposits. However, especially in the case of RotaTripsy, further clinical studies are required to better evaluate the efficacy of this novel method.

No-touch vein grafts in coronary artery bypass surgery: a registry-based randomized clinical trial

BACKGROUND AND AIMS

No-touch saphenous vein harvesting may enhance graft patency and improve clinical outcomes after coronary artery bypass grafting (CABG).

METHODS

In this registry-based, randomized trial, patients undergoing CABG were randomly assigned to no-touch or conventional harvesting. The primary composite outcome was the proportion of patients with occluded/stenosed >50% vein graft on coronary computed tomography angiography, or who underwent percutaneous coronary intervention to a vein graft, or died. Secondary outcomes included clinical outcomes and leg wound complications.

RESULTS

A total of 902 patients were enrolled with a mean total number of distal vein anastomoses of 2.0 (SD 0.87). The primary endpoint occurred in 90/454 (19.8%) of patients randomized to no-touch and in 107/446 (24.0%) of patients randomized to the conventional technique [difference, -4.3 percentage points; 95% confidence interval (CI) -10.1-1.6; P = .15] at a mean follow-up time of 3.5 (SD 0.1) years. The composite of death, myocardial infarction, or repeat revascularization at 4.4 (SD 1.3) years occurred in 57/454 (12.6%) and 44/446 (9.9%) in the no-touch and conventional groups, respectively (hazard ratio 1.3; 95% CI, 0.87-1.93). Leg wound complications were more common in patients assigned to no-touch harvesting at 3 months [107/433 (24.7%) vs. 59/427 (13.8%); difference, 10.9 percentage points; 95% CI 5.7-16.1]. At 2 years, 189/381 (49.6%) vs. 91/361 (25.2%) had remaining leg symptoms (difference, 24.4 percentage points; 95% CI 17.7-31.1).

CONCLUSIONS

No-touch vein graft harvesting for CABG was not superior to conventional open harvesting in reducing vein graft failure or clinical events after CABG but increased leg wound complications. The primary outcome requires cautious interpretation due to a lower-than-expected number of primary events.

Sex-specific outcome after minimally invasive direct coronary artery bypass for single-vessel disease: a propensity score matching analysis

OBJECTIVE

To evaluate the influence of gender on surgical outcome in patients with single-vessel disease undergoing minimally invasive direct coronary artery bypass (MIDCAB).

METHODS

This retrospective, non-randomized study analyzed 471 patients who underwent MIDCAB between February 2012 and January 2021 through left lateral thoracic small incision in the Department of Cardiac Surgery of our hospital were selected. Data were collected on demographics, clinical characteristics, operative and postoperative outcomes, and follow-up mortality and morbidity. Propensity score matching (PSM) was used to match patients between the groups.

RESULTS

Before matching, female patients were older, had higher incidence of DM (40.2% Vs 27.3%, p = 0.013), higher LVEF (66.7 ± 8.0 Vs 63.6 ± 10.1, p<0.001) and smaller LVEDD (4.7 ± 0.5 Vs 5.1 ± 0.6, p = 0.001). After matching, the differences in baseline characteristics between both groups were eliminated. PS matching selected 103 matched pairs for final comparison. No significant differences were observed between both groups in terms of in-hospital mortality, the incidence of MACCE, incidence of perioperative MI, incidence of stroke, reoperation for bleeding. Female patients had longer length of stay compared to male patients (18.9 ± 14.3 Vs 15.5 ± 5.9, p = 0.027).

CONCLUSION

Female sex is not connected with higher risk of mortality or other major events in MIDCAB. Wound healing complications remain the leading attribute associated with female sex.

The effect of diabetes on long-term outcomes in patients following coronary artery bypass grafting

OBJECTIVES

Diabetes mellitus is a risk factor for coronary artery disease, but its role following coronary artery bypass grafting (CABG) is still unclear and few data on long-term outcomes are available. This study aimed to evaluate the impact of diabetes on long-term outcomes after CABG.

METHODS

The PRIORITY (PRedictIng long-term Outcomes afteR Isolated coronary arTery bypass surgerY) project is an observational cohort study merging 2 prospective multicentre studies on isolated CABG. Follow-up information was obtained through administrative databases and was truncated 10 years after the intervention. Baseline differences between patients with and without diabetes were balanced with inverse probability of treatment weighting.

RESULTS

The cohort consisted of 10 989 patients with complete follow-up information who underwent isolated CABG (diabetes 32.3%). Diabetes did not affect short-term mortality [odds ratio (OR) 0.90, 95% confidence interval (CI) 0.73-1.10] and repeat revascularization (OR 0.79, 95% CI 0.42-1.49), while it is related to lower incidence of 30-day major adverse cardiac and cerebrovascular events (OR 0.67, 95% CI 0.60-0.76), acute myocardial infarction (OR 0.60, 95% CI 0.51-0.70) and stroke (OR 0.47, 95% CI 0.28-0.77). Diabetic patients had a higher long-term risk for major adverse cardiac and cerebrovascular event [weighted hazard ratio (HR) 1.31, 95% CI 1.26-1.37], mortality (HR 1.45, 95% CI 1.37-1.53), as well as stroke (HR 1.38, 95% CI 1.25-1.53) and myocardial infarction (HR 1.39, 95% CI 1.26-1. 53). Diabetes had not been associated with an increased incidence of repeated revascularization up to 10 years (HR 1.04, 95% CI 0.96-1.12).

CONCLUSIONS

Diabetic patients had worse long-term outcomes. Diabetes may have a greater negative impact on micro-vasculopathy than grafts, as evidenced by the increased long-term incidence of myocardial infarction without affecting myocardial revascularization.

Carotid Ultrasound Assessment Prior to Coronary Artery Bypass Grafting - An Irish Cardiac Surgery Center's Experience

BACKGROUND

Carotid stenosis is a risk factor for cerebrovascular accident (CVA) following coronary artery bypass grafting (CABG). Guidelines recommend selective preoperative screening with Doppler ultrasound (US) but nonselective application is commonplace. Recent data has questioned the efficacy of perioperative carotid intervention, challenging the value of this practice. We thus aimed to analyze the utility of carotid US assessment prior to CABG in our institution.

METHODS

This was a retrospective review of all patients over 18 that underwent a nonemergency CABG in a single Irish cardiac surgery center from January 2019 to December 2022.

RESULTS

1161 subjects were included. 1084/1161 (93.36%) underwent US assessment. 41/1084 (3.8%) had ≥70% stenosis and 189/1084 (17.5%) had ≥50% stenosis. 32/1084 (2.95%) underwent confirmatory imaging and 7/1084 (0.64%) underwent carotid intervention. Postoperative CVA occurred in 18/1161 (1.55%) and ≥70% (P = 0.024) and ≥50%(P < 0.001) carotid stenosis were associated with same. Chronic kidney disease (odds ratio [OR] = 1.66,P = 0.01), decreasing hemoglobin (OR = 1.13,P = 0.019), increasing age (OR = 1.03,P = 0.011) and being a current (OR = 3.21,P < 0.001) or ex-smoker (OR = 1.82,P = 0.004) were risk factors for ≥50% carotid stenosis on logistic regression. Multivessel coronary artery disease (CAD) was not associated with carotid stenosis (P = 0.563). Of those that underwent carotid intervention, 0/7 (0%) suffered a CVA, but this protective effect failed to reach statistical significance for those with ≥70% (P = 1) or ≥50% (P = 1) carotid stenosis.

CONCLUSIONS

Carotid US screening altered the management of only a small proportion of CABG patients despite near universal application, challenging the effectiveness of this practice. Multivessel CAD was not associated with carotid stenosis despite European guidelines listing it as screening criteria. Predictive models must be developed using identified risk factors to enable targeted preoperative screening.

Direct Axillary Artery Cannulation as Standard Perfusion Strategy in Minimally Invasive Coronary Artery Bypass Grafting

OBJECTIVE

Cardiopulmonary bypass (CPB) via the right axillary artery (RAA) has become an alternative perfusion strategy, especially in complex aortic procedures. This study delineates our technique and outcome with direct axillary cannulation utilizing the Seldinger technique, which we adopted as the standard perfusion strategy in the sternum-sparing minimally invasive total coronary revascularization via left anterior thoracotomy (TCRAT) using CPB.

METHODS

From November 2019 to December 2023, a total of 413 consecutive patients underwent nonemergent isolated coronary artery bypass grafting (CABG) via left anterior minithoracotomy on CPB with peripheral cannulation via the RAA and cardioplegic cardiac arrest, using this technique as a default strategy in the daily routine. All patients had multivessel coronary artery disease. The primary outcome was intraoperative cannulation-related complications (bleeding, revision, ischemia, wound healing complications). The secondary outcome was cannulation-related events during follow-up (blood pressure differences, incidence of brachial plexus injury, clinical signs of circulatory problems of arm and hand, re-interventions). Mean midterm follow-up was 18.7 ± 12.3 [1.1-51.2] months. During follow-up, 16 patients died. Overall, a total of 397 patients (344 male; 67.6 ± 9.7 [32-88]) were included for follow-up (100%).

RESULTS

The RAA was successfully cannulated in 100% of patients. A cannula size of 16 Fr was used in 34.6%, 18 Fr in 63.9% and 20 Fr in 1.5% of all patients. There was no intraoperative bleeding complication. In two patients, intraoperative revision of the RAA was required, necessitating a venous patch repair. At follow-up, there were no differences between the systolic and diastolic blood pressure or the pressure gradients between the right and left arm. Transient numbness of the right hand was observed in two patients. Permanent numbness was not observed. No patient needed further intervention or surgical revision of the RAA.

CONCLUSIONS

The right axillary cannulation is feasible and safe in terms of vascular injury and brachial plexus injury with excellent in-hospital and follow-up outcome.

Comparing Transbrachial and Transradial as Alternatives to Transfemoral Access for Large-Bore Neuro Stenting: Insights From a Propensity-Matched Study

RATIONALE AND OBJECTIVES

This study aimed to evaluate the safety and effectiveness of transbrachial access (TBA) and transradial access (TRA) compared to transfemoral access (TFA) for large-bore neuro stenting (≥7 F).

METHODS

From January 2019 to January 2024, 4752 patients received large-bore neuro stenting in our center. The primary outcomes were procedural metrics. Safety outcomes were significant access site complications, including substantial hematoma, pseudoaneurysm, artery occlusion, and complications requiring treatment (medicine, intervention, or surgery). After propensity score matching with a ratio of 1:1:2 (TBA: TRA: TFA), adjusting for age, gender, aortic arch type, and neuro stenting as covariates, outcomes were compared between groups.

RESULTS

46 TBA, 46 TRA and 92 TFA patients were enrolled. The mean age was 67.8 ± 11.2 years, comprising 127 (69.0%) carotid artery stenting and 57 (31.0%) vertebral artery stenting. The rates of technical success (TBA: 100%, TRA: 95.7%, TFA: 100%) and significant access site complications (TBA: 4.3%, TRA: 6.5%, TFA: 1.1%) were comparable between the groups (P > 0.05). Compared to TFA, the TRA cohort exhibited significant delays in angiosuite arrival to puncture time (14 vs. 8 min, P = 0.039), puncture to angiography completion time (19 vs. 11 min, P = 0.027), and procedural duration (42 vs. 29 min, P = 0.031). There were no substantial differences in procedural time metrics between TBA (10, 14, and 31 min, respectively) and TFA.

CONCLUSION

TBA and TRA as the primary access for large-bore neuro stenting are safe and effective. Procedural delays in TRA may favor TBA as the first-line alternative access to TFA.

Postoperative bleeding in myocardial revascularization under cardiopulmonary bypass for patients treated with aspirin or dual antiplatelet therapy using reduced goal-directed anticoagulation

OBJECTIVES

Antiplatelet therapy increases the risk of bleeding and transfusion in patients undergoing extracorporeal circulation. Reduced goal-directed anticoagulation is a personalized approach to reduce the anticoagulation based on a lower targeted activated clotting time. We assessed whether reduced goal-directed anticoagulation using optimized extracorporeal circulation alleviates the risk of severe bleeding in patients treated by dual antiplatelet therapy (DAPT) compared to aspirin alone during coronary artery bypass grafting (CABG).

METHODS

A total of 2275 patients undergoing CABG from 2002 to 2022 were selected after propensity matching from a retrospective cohort of 3018 patients. Patients treated with a combination of aspirin and prasugrel or ticagrelor or clopidogrel were included in the DAPT group (n = 1111). Patients treated with aspirin alone (ASA) constituted the control group (n = 1164). Optimized extracorporeal circulation was conducted under reduced systemic anticoagulation with a target activated clotting time 250 s. Severe bleeding was assessed using 3 validated scores of bleeding: UDPB, E-CABG, and BARC-4.

RESULTS

While all scores showed low ranges of severe bleeding (<6%), they were significantly higher after DAPT compared to ASA (P values for UDPB, E-CABG, and BARC-4 at 0.016, 0.006, and 0.063, respectively). Higher maximal activated clotting time was associated with higher rate of transfusion (P < 0.001) and bleeding (P < 0.001) after multivariate adjustment. Mortality was 1.24% in DAPT vs 0.94% in ASA group (P = NS), whereas cardiac death, myocardial infarction, stroke, and transient ischaemic attack were low (<1%) and similar between groups.

CONCLUSIONS

Despite higher bleeding under DAPT compared to ASA alone, optimized extracorporeal circulation with reduced goal-directed anticoagulation alleviated severe bleeding which remained low in patients undergoing CABG.

Comparison of outcomes of Impella-assisted high-risk percutaneous coronary intervention in patients with and without prior coronary artery bypass graft

BACKGROUND

Limited data is available regarding in-hospital outcomes of patients undergoing high-risk percutaneous coronary intervention (HR-PCI) with Impella with and without a prior history of coronary artery bypass grafting (CABG).

METHODS

We performed a retrospective study from the Nationwide Inpatient Sample from year 2016 to 2020. We identified patients who underwent Impella and percutaneous coronary intervention on the same day and excluded those with cardiogenic shock. Subsequently, we stratified them into those with and without prior CABG.

RESULTS

During the study period, 18 925 patients underwent HR-PCI. Among these, 2043 (10.8%) patients had prior CABG. Patients without prior CABG had a higher percentage of acute coronary syndrome at presentation (62.7 vs 56.1%, P = 0.008). The proportion of females was significantly higher in those without prior CABG (32.4 vs 21.7%, P < 0.001). On multivariate analysis, there was no statistically significant difference in the in-hospital mortality (5.8% in CABG vs 8.5% in non-CABG, P = 0.52). Patients without prior CABG had higher rates of acute kidney injury, major bleeding, and blood transfusions. There were no significant differences in rates of cardiac arrest, ventricular arrhythmias, acute stroke, coronary dissections, and coronary perforations. Those without prior CABG had a longer duration of hospitalization (6.8 vs 9.3 days, P < 0.001) and higher hospital charges ($292 267 vs $322 206, P < 0.035).

CONCLUSION

Our study highlights that a history of previous CABG does not increase the risk of in-hospital mortality in patients undergoing Impella-assisted HR-PCI but is associated with reduced rates of complications.

Management of acute chest pain in the Emergency Department: benefits of coronary computed tomography angiography

Acute chest pain (ACP) is a frequent cause of Emergency Department (ED) admissions, with millions of cases reported globally each year. Timely and accurate diagnosis is crucial due to the wide range of underlying causes, such as acute coronary syndrome (ACS), pulmonary embolism (PE), aortic dissection, and others. Misdiagnosis can lead to missed life-saving interventions or, alternatively, unnecessary hospitalizations, escalating healthcare costs. While risk stratification tools like the HEART, GRACE, and TIMI scores are useful, additional imaging is often required to achieve diagnostic precision. Coronary computed tomography angiography (CCTA) has shown significant potential in enhancing diagnostic accuracy and improving patient outcomes. In this review, we explore the challenges physicians encounter when evaluating ACP in the ED, emphasizing the utility of CCTA as a key diagnostic tool. Additionally, we present a clinical case that illustrates how CT scan effectively aids in diagnosing patients with ambiguous symptoms, with CT imaging playing a pivotal role in identifying the underlying pathology.

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.

Sleep apnea prevalence and severity after coronary revascularization versus no intervention: a systematic review & meta-analysis

PURPOSE

Obstructive sleep apnea (OSA) is a common disease in patients with coronary artery disease (CAD). Approximately 40-80% of cardiovascular disease patients have obstructive sleep apnea. The manifestation of it can vary significantly in different types of CAD patients. This systematic review and meta-analysis investigate the prevalence and severity of OSA in patients with acute coronary syndrome (ACS).

METHODS

This systematic review was conducted according to PRISMA guidelines. The first inclusion criteria were that a reliable sleep study had to be done after treating the patients' acute coronary incident. All patients in the studies included were adults suffering from an ACS who underwent either coronary artery bypass grafting surgery (CABG), a percutaneous coronary intervention (PCI) or had no invasive coronary intervention done. A search was conducted within four valid databases 27.1.2023 and all suitable articles published after 1.1.2010 were included.

RESULTS

Eight studies fulfilled the full inclusion criteria. In five of them, a sleep study had been performed after PCI, in two after no coronary intervention, and in one study after CABG. Mean AHI in no-OSA group after PCI was 9.5 /h (95% CI 5.3-13.7) and in the no intervention group 6.4 /h (95% CI 3.5-9.4). In OSA patients, mean AHI after PCI was 34.9 /h (95% CI 25.9-43.8) vs. 24.1 /h without intervention (95% CI 15.6-32.6).

CONCLUSIONS

Sleep apnea is very common among ACS patients and should be screened for and addressed after the acute coronary intervention. Moreover, we found that OSA is more severe in patients in whom PCI for ACS was indicated as opposed to patients who underwent no coronary intervention.

Five-year clinical outcomes of STEMI patients treated with a pre-specified bioresorbable vascular scaffold implantation technique: Final results of the BVS STEMI STRATEGY-IT

BACKGROUND

Data on Absorb bioresorbable vascular scaffold (BVS) use in patients presenting with ST-segment elevation myocardial infarction (STEMI) are limited. Furthermore, Absorb studies including STEMI patients lacked a prespecified implantation technique to optimize BVS deployment. This study examines the 5-year outcomes of BVS in STEMI patients using an optimized implantation strategy and the impact of prolonged dual antiplatelet therapy (DAPT).

METHODS

The BVS STEMI STRATEGY-IT study is a prospective, non-randomized, single-arm multicenter trial (NCT02601781). It involved 505 STEMI patients undergoing primary percutaneous coronary intervention with a predefined BVS implantation protocol. Key endpoints were a 5-year device-oriented composite endpoint (DOCE) of cardiac death, target-vessel myocardial infarction (TV-MI), and ischemia-driven target lesion revascularization (ID-TLR). The study also compared outcomes based on DAPT duration (36 months vs. shorter).

RESULTS

502 (99.4 %) patients completed the 5-year follow-up. DOCE rate was 2.4 %. ID-TLR, TV-MI, and cardiac death rates were 1.6 %, 0.8 %, and 0.6 %, respectively. No DOCE occurred between three and five years. Scaffold thrombosis (ScT) was 1 %, all occurring within 24 months. Longer-term DAPT significantly reduced DOCE (1.3 % vs. 4.3 %; HR: 0.29; 95 % CI: 0.1-0.9; p = 0.03) driven by a lower rate of TV-MI (0 % vs. 2.2 %; p = 0.018) compared to shorter-term DAPT, as well as ScT (0 % vs 2.7 %, p = 0.007).

CONCLUSIONS

This study shows favorable 5-year outcomes for BVS in selected STEMI patients with an optimized implantation strategy. Prolonged DAPT further improved outcomes, emphasizing its role in reducing adverse events during scaffold resorption. Further research is needed to assess newer-generation bioresorbable devices.

The use of outcome data from quality registries to learn and improve; a Dutch nationwide quantitative analysis in five disease areas

BACKGROUND

Clinical quality registries (CQR) aid in measuring, collecting and monitoring outcome data but it is still unknown how these data are used by hospitals to improve the quality of care. This study assessed the current state of outcome-based quality improvement in the Netherlands in 2022 based on data from multiple disease areas and CQRs; cardiothoracic surgery (Netherlands Heart Registration [NHR]), cardiology (NHR), nephrology, (Nefrovision), intensive care (National Intensive Care Evaluation [NICE]), and orthopaedic surgery (Dutch Arthroplasty Register [LROI]).

METHODS & RESULTS

The Health Outcomes Management Evaluation (HOME) model was used to assess the current state of outcome-based quality improvement. A questionnaire with 36 questions was sent to healthcare departments of the six disease areas in participating hospitals within five quality registrations in the Netherlands. In total, 124 responses were received; 20 within cardiology, 12 within cardiothoracic surgery, 30 within nephrology, 35 within intensive care and 27 within orthopaedic surgery. Results showed outcome measures were actively used to improve the quality of care, several improvement initiatives were implemented, but outcomes were not always monitored regularly. Results differed between hospitals, but differences were limited between disease areas.

CONCLUSION

The current state of outcome-based quality improvement in all five disease areas is that outcome measures were consequently employed and used on a frequent basis aiming to achieve quality improvement in healthcare. Results can be improved by structurally embedding the entire improvement cycle into the organisation.

Recommendations for prediction models in clinical practice guidelines for cardiovascular diseases are over-optimistic: a global survey utilizing a systematic literature search

Background

This study aimed to synthesize the recommendations for prediction models in cardiovascular clinical practice guidelines (CPGs) and assess the methodological quality of the relevant primary modeling studies.

Methods

We performed a systematic literature search of all available cardiovascular CPGs published between 2018 and 2023 that presented specific recommendations (whether in support or non-support) for at least one multivariable clinical prediction model. For the guideline-recommended models, the assessment of the methodological quality of their primary modeling studies was conducted using the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

Results

In total, 46 qualified cardiovascular CPGs were included, with 69 prediction models and 80 specific recommendations. Of the 80 specific recommendations, 74 supported 57 models (53 were fully recommended and 4 were conditionally recommended) in cardiovascular practice with moderate to strong strength. Most of the guideline-recommended models were focused on predicting prognosis outcomes (53/57, 93%) in primary and tertiary prevention, focusing primarily on long-term risk stratification and prognosis management. A total of 10 conditions and 7 types of target population were involved in the 57 models, while heart failure (14/57, 25%) and a general population with or without cardiovascular risk factor(s) (12/57, 21%) received the most attention from the guidelines. The assessment of the methodological quality of 57 primary studies on the development of the guideline-recommended models revealed that only 40% of the modeling studies had a low risk of bias (ROB). The causes of high ROB were mainly in the analysis and participant domains.

Conclusions

Global cardiovascular CPGs presented an unduly positive appraisal of the existing prediction models in terms of ROB, leading to stronger recommendations than were warranted. Future cardiovascular practice may benefit from well-established clinical prediction models with better methodological quality and extensive external validation.

Three finger toxins of elapids: structure, function, clinical applications and its inhibitors

The WHO lists snakebite as a "neglected tropical disease". In tropical and subtropical areas, envenoming is an important public health issue. This review article describes the structure, function, chemical composition, natural inhibitors, and clinical applications of Elapids' Three Finger Toxins (3FTX) using scientific research data. The primary venomous substance belonging to Elapidae is 3FTX, that targets nAChR. Three parallel β-sheets combine to create 3FTX, which has four or five disulfide bonds. The three primary types of 3FTX are short-chain, long-chain, and nonconventional 3FTX. The functions of 3FTX depend on the specific toxin subtype and the target receptor or ion channel. The well-known effect of 3FTX is probably neurotoxicity because of the severe consequences of muscular paralysis and respiratory failure in snakebite victims. 3FTX have also been studied for their potential clinical applications. α-bungarotoxin has been used as a molecular probe to study the structure and function of nAChRs (Nicotinic Acetylcholine Receptors). Acid-sensing ion channel (ASIC) isoforms 1a and 1b are inhibited by Mambalgins, derived from Black mamba venom, which hinders their function and provide an analgesic effect. α- Cobra toxin is a neurotoxin purified from Chinese cobra (Naja atra) binds to nAChR at the neuronal junction and causes an analgesic effect for moderate to severe pain. Some of the plants and their compounds have been shown to inhibit the activity of 3FTX, and their mechanisms of action are discussed.

Conservative fluid resuscitation protocol does not reduce the incidence of reoperation for bleeding after emergency CABG

Reoperation for bleeding (ROB) after emergency coronary artery bypass grafting (eCABG) has been identified as an independent risk factor for mortality. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. This retrospective single-center study included 265 patients undergoing eCABG between 2011 and 2020. From 2018, postoperative hemodynamic management was performed with lower volume administration and higher vasoactive support. The primary outcome measure was the incidence of ROB within 48 h according to altered fluid resuscitation strategy. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. Incidence of ROB was independent from the volume resuscitation protocol (P = .3). The ROB group had a higher perioperative risk, which was observed in EuroSCORE II. Fluid intake (P = .021), fluid balance (P = .001), and norepinephrine administration (P = .004) were associated with ROB. Fluid output and blood loss were not associated with ROB (P = .22). Post-test probability was low among all variables. Although fluid management might have an impact on specific postoperative complications, different fluid resuscitation protocols did not alter the incidence of ROB after emergency CABG.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov registration number NCT04533698; date of registration: August 31, 2020 (retrospectively registered due to nature of the study); URL: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04533698.

Age- and sex-related differences in risk factors for perioperative intra-aortic balloon pump application in patients undergoing coronary artery bypass grafting

Background

An intra-aortic balloon pump (IABP) is a mechanical circulatory device frequently used in patients undergoing coronary artery bypass grafting (CABG). As a treatment for perioperative haemodynamic instability, IABP insertion often implicates an adverse outcome. This study aimed to investigate the age- and sex-related disparity in risk factors for perioperative IABP insertion in CABG patients.

Methods

A total of 2,460 CABG patients were included and divided into subgroups by age (elderly subgroup, ≥65 years; young subgroup, <65 years) and sex. Basic characteristics were compared between IABP and non-IABP patients in the overall patient group and the subgroups. Multivariate logistic analysis was used to investigate the significant risk factors for perioperative IABP application, and interaction effects among the potential risk factors were analysed. Combined receiver operating characteristic analysis was used to evaluate the prediction value of combined risk factors.

Results

The overall patient group had a mean age of 61.5 years. The application rate of perioperative IABP was 8.0%. A left ventricular ejection fraction (LVEF) <50% significantly correlated with perioperative IABP application in the overall patient group and the subgroups. Traditional factors such as myocardial infarction history, atrial fibrillation history, and intraoperative estimated blood loss were significant risk factors in certain subgroups. Small dense low-density lipoprotein levels were significantly associated with IABP insertion in the male subgroup and young subgroup. The area under the curve of combined risk factors was significantly higher than that of LVEF <50% alone in the overall patient group and subgroups.

Conclusion

Age- and sex-related differences were present in the risk factor distribution for perioperative IABP insertion in CABG patients.

Epicardial Adipose Tissue and Major Adverse Cardiovascular Events in Myocardial Infarction Patients with and without Diabetes

BACKGROUND

Epicardial adipose tissue (EAT) accumulation plays a key role in the progression myocardial infarction (MI) and diabetes. Diabetic patients have elevated risk of major adverse cardiac events (MACEs) compared to non-diabetic patients. We aimed to investigate the prognostic value of EAT volume in MI patients with and without diabetes.

METHODS

This study included 458 MI patients who underwent cardiac computed tomography (CT) imaging and received successful stent implantation. EAT volume was quantified with cardiac CT imaging. Sub-study stratification of patients by diabetes status was further analyzed. Cox proportional hazards regression models were applied to evaluate the association between EAT volume and MACEs.

RESULTS

Diabetes was identified in 135 of the 458 patients (29.5%). EAT volume was significantly higher in diabetes than non-diabetes. During a median follow-up of 1154 days, MACEs occurred more frequently in patients with versus without diabetes. EAT volume was independent predictor of MACEs in all MI patients after adjustment for risk factors, and showed good predictive value in the evaluation of MACEs. Moreover, EAT volume was also significantly associated with MACEs after adjustment for risk factors in diabetes and non-diabetes in the subgroup analysis.

CONCLUSION

MI patients with diabetes had higher EAT volume and experienced higher rate of MACEs compared to non-diabetes. EAT volume is an independent risk of prognosis of MI, regardless of the diabetes status.

Clinical Outcomes of Surgical Revascularization Strategies Guided by Quantitative Flow Ratio in Primary Noncoronary Cardiac Surgery

PURPOSE

Information regarding quantitative flow ratio (QFR) usage in coronary artery bypass grafting (CABG) is lacking. We compared the incidence of postoperative long-term adverse cardiovascular and cerebrovascular events after QFR-guided or coronary angiography-guided adult cardiac surgery with concurrent bypass surgery.

MATERIALS AND METHODS

This study included 432 patients who underwent cardiopulmonary bypass (CPB) at our institution with at least 1 angiographical coronary artery lesion (diameter stenosis: 30% to 90%) between January 2015 and January 2016. The QFR of each patient was calculated. Patients who only underwent intraoperative coronary revascularization following the principles of optimal revascularization strategy were assigned to group A. Patients with coronary lesions not meeting the above criteria were placed in group B.

RESULTS

The average number of distal anastomoses of patients with combined CABG in group B was similar to that in Group A (1.9±1.0 vs. 1.7±0.9; P =0.081). Group A had a shorter CPB duration (114.4±49.2 vs 135.8±55.2 minutes; P <0.001) and shorter aortic cross-clamping time (83.6±36.2 vs 101.1±40.6 minutes; P <0.001). The rates of perioperative mortality and major complications did not differ between groups. Long-term major adverse cardiovascular and cerebrovascular events (MACCEs) were less common in group A than in group B (14.7% vs 29.5%; P <0.001).

CONCLUSIONS

In primary noncoronary cardiac surgery, despite the similar average numbers of distal anastomoses, the group with target vessels treated using an optimal coronary revascularization strategy presented shorter CPB time and aortic cross-clamping time than the other group. Multivariate analyses also showed a lower incidence of long-term MACCEs.

Thoracic sarcopenia measured by Hounsfield unit average calculation predicts morbidity and mortality in coronary artery bypass grafting

OBJECTIVES

The aim of the study was to investigate the potential prognostic role of preoperative measurement of erector spinae myosteatosis with Hounsfield unit average calculation as a marker for sarcopenia and frailty in patients undergoing coronary bypass surgery.

METHODS

Preoperative computer tomography-derived measurements of 479 consecutive patients undergoing coronary bypass surgery between January 2017 and December 2019 were retrospectively performed. The erector spinae muscle at the level of the 12th vertebra was manually outlined bilaterally on the axial computer tomography slices and Hounsfield unit average calculation was performed. The lower quartile of muscle density values was defined as myosteatotic and thus sarcopenic. Sarcopenic (n = 121) versus non-sarcopenic patients (n = 358) were compared regarding postoperative morbidity and short- and long-term mortality. Results were adjusted for age, body mass index, atrial fibrillation and hypertension using inverse probability weighting.

RESULTS

Sarcopenia was associated with higher 30-day mortality (4.1% vs 0.8%; P = 0.012), mid-term mortality after 1 year (9.3% vs 3.1%; P = 0.047) and 2 years (10.8% vs 4.2%; P = 0.047). Long-term mortality (5 years) was 20.8% for sarcopenic and 13.0% for non-sarcopenic patients but was not found to be significantly different (P = 0.089). Sarcopenia was associated with higher rates of reintubation (7.5% vs 1.1%; P < 0.001), sternal wound infections (7.5% vs 2.8%; P = 0.039) and acute kidney injury requiring haemodialysis (2.5% vs 0.4%; P = 0.021).

CONCLUSIONS

In patients undergoing coronary bypass surgery, sarcopenia was associated with increased short-term mortality, mid-term mortality and morbidity. The measurement of erector spinae myosteatosis could be an easy and useful parameter in preoperative risk assessment.

How I do it: Endoscope-assisted in situ arterial reconstruction of the lower limb

Arterial reconstruction with the great saphenous vein is a frequently performed vascular surgery technique for revascularization of chronic limb threatening ischemia. Surgeon variations of the procedure are common and aim to balance patency, limb salvage, complications, hospital resources, and technical feasibility. We describe a minimally invasive revascularization option using endoscope assistance for in situ great saphenous vein-arterial bypass to treat infrainguinal occlusive disease. We highlight patient selection, operating room setup, instrument details, and procedure strategies that facilitate the use of this technique. The development and refinement of minimally invasive techniques for lower extremity arterial bypass are critical to reduce wound complications and improve limb salvage outcomes in patients.

Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial

BACKGROUND

Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain.

METHODS

This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions.

RESULTS

The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications.

CONCLUSION

The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB.

STUDY REGISTRATION

This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

Association of Positive TwaVR/STaVR ECG Changes with Adverse Outcomes in Heart Failure Patients with Reduced Ejection Fraction Undergoing CABG in Turkey: A Retrospective Study

BACKGROUND

Positive T-wave polarity in the augmented vector right lead (Tw-aVR) and ST-segment deviation in the augmented vector right lead (STaVR) have been identified as potential predictors of adverse outcomes in various cardiac conditions.

AIM

The aim of the study was to examine the effect of positive Tw-aVR and STaVR on in-hospital mortality after coronary artery bypass grafting (CABG) surgery in patients with heart failure with reduced ejection fraction (HFrEF).

METHODS

A five-year retrospective study was conducted on 250 HFrEF patients who underwent CABG at a tertiary care hospital between January 2018 and December 2022. The primary outcome was in-hospital mortality, and the main exposures were positive Tw-aVR and STaVR on preoperative electrocardiograms. Logistic regression models were used to assess the factors associated with in-hospital mortality.

RESULTS

Two hundred and fifty patients with a mean age of 67.4 ± 8.1 years were studied. Males constituted 68% of the participants. Among the participants, 60 (24%) had positive Tw-aVR, and 96 (38.4%) had STaVR. The overall in-hospital mortality rate was 7.6%, and patients with positive Tw-aVR and STaVR had significantly higher mortality rates than those without (odds ratio: 3.62 and 2.87, respectively, P < 0.01). These associations remained significant even after controlling for potential confounders such as age (adjusted odds ratio [AOR]: 1.11; 95% confidence interval [CI]: 1.03-1.20; P = 0.008), sex (AOR: 0.82; 95% CI: 0.31-2.18; P = 0.684), diabetes mellitus (AOR: 2.12; 95% CI: 0.88-5.12; P = 0.091), and chronic kidney disease (AOR: 1.79; 95% CI: 0.75-4.27; P = 0.194).

CONCLUSION

Positive Tw-aVR and STaVR were found to be associated with in-hospital mortality in HFrEF patients after CABG. These findings suggest that identifying patients with positive Tw-aVR and STaVR may help identify those at higher risk of adverse outcomes and facilitate closer monitoring and more aggressive interventions.

Sternum-sparing multivessel coronary surgery as a routine procedure: Midterm results of total coronary revascularization via left anterior thoracotomy

Objective

A sternum-sparing approach of minimally invasive total coronary revascularization via left anterior thoracotomy demonstrated promising early outcomes in unselected patients with coronary artery multivessel disease. Follow-up data are still missing.

Methods

From November 2019 to September 2023, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed as a routine procedure in 392 consecutive, nonemergency patients (345 men; 67.0 ± 9.9 years; range, 32-88 years). All patients had multivessel coronary artery disease (77.6% 3-vessel-disease, 22.4% 2-vessel-disease, and 32.9% left main stenosis). Patients at old age (older than a 80 years, 12.5%), with severe left ventricular dysfunction (ejection fraction <30%, 7.9%), diabetes mellitus (34.9%), massive obesity (body mass index > 35, 8.9%), and chronic lung disease (17.1%) were included. Mean European System for Cardiac Operative Risk Evaluation II score was 2.9 ± 2.8. Mean midterm follow-up (100%) was 15.2 ± 10.7 months (range, 0.1-39.5 months).

Results

Left internal thoracic artery (99.0%), radial artery (70.4%), and saphenous vein grafts (57.4%) were used, and 70.4% of patients received at least 2 arterial grafts. A total of 3.0 ± 0.8 anastomoses (range, 2-5 anastomoses) per patient were performed to revascularize the territories of left anterior descending (98.7%), circumflex (91.6%), and right coronary (70.9%) artery. Complete anatomical revascularization was achieved in 95.1%. At follow-up, all-cause-mortality, myocardial infarction, repeat revascularization, and stroke was 3.1%, 1.5%, 5.4%, and 0.7%, respectively. Overall major adverse cardiac and cerebrovascular events rate was 8.7%.

Conclusions

This is the first report of midterm follow-up after routine sternum-sparing total coronary revascularization via left anterior thoracotomy for multivessel coronary artery disease with a high rate of multiple arterial grafting and complete anatomical revascularization. Outcome was favorable and similar to that of contemporary conventional coronary artery bypass grafting.

Evaluation of the Factors Influencing Blood Transfusion during Minimally Invasive Direct Coronary Artery Bypass Surgery

INTRODUCTION

The objective of this study was to analyze the blood transfusion factors of minimally invasive direct coronary artery bypass (MIDCAB) surgery using artificial intelligence.

METHODS

A retrospective analysis was performed for patients undergoing MIDCAB operations and no heart-lung machine was used from January 2017 to September 2022 in our hospital. The influencing factors of blood transfusion were used to build the artificial intelligence model. Eighty percent of the database was used as the training set, and twenty percent database was used as the testing set. To predict whether to use red blood cells during operation, we compared 104 artificial intelligence models. We aimed to assess whether which factors influence allogeneic transfusion in MIDCAB operations.

RESULTS

Of the 104 machine learning algorithms, the XGBoost model delivered the best performance, with an AUC of 0.726 in the testing set and an accuracy of 0.854 in the testing set. The artificial intelligence model showed preoperative hemoglobin less than 120 g/L, prothrombin time greater than 13.75, body mass index less than 22.7 kg/m2, coronary heart disease with additional comorbidities, a history of percutaneous coronary intervention, weight lower than 67 kg were the six major risk factors of allogeneic transfusion.

CONCLUSION

The XGBoost model can predict transfusion or not transfusion in MIDCBA surgery with high accuracy.

INTRODUCTION

The objective of this study was to analyze the blood transfusion factors of minimally invasive direct coronary artery bypass (MIDCAB) surgery using artificial intelligence.

METHODS

A retrospective analysis was performed for patients undergoing MIDCAB operations and no heart-lung machine was used from January 2017 to September 2022 in our hospital. The influencing factors of blood transfusion were used to build the artificial intelligence model. Eighty percent of the database was used as the training set, and twenty percent database was used as the testing set. To predict whether to use red blood cells during operation, we compared 104 artificial intelligence models. We aimed to assess whether which factors influence allogeneic transfusion in MIDCAB operations.

RESULTS

Of the 104 machine learning algorithms, the XGBoost model delivered the best performance, with an AUC of 0.726 in the testing set and an accuracy of 0.854 in the testing set. The artificial intelligence model showed preoperative hemoglobin less than 120 g/L, prothrombin time greater than 13.75, body mass index less than 22.7 kg/m2, coronary heart disease with additional comorbidities, a history of percutaneous coronary intervention, weight lower than 67 kg were the six major risk factors of allogeneic transfusion.

CONCLUSION

The XGBoost model can predict transfusion or not transfusion in MIDCBA surgery with high accuracy.

Sex Differences in Fractional Flow Reserve Utilization

Background: The literature review shows that female patients are more frequently underdiagnosed or suffer from delayed diagnosis. Recognition of sex-related differences is crucial for implementing strategies to improve cardiovascular outcomes. We aimed to assess sex-related disparities in the frequency of fractional flow reserve (FFR)-guided procedures in patients who underwent angiography and/or percutaneous coronary intervention (PCI). Methods: We have derived the data from the national registry of percutaneous coronary interventions and retrospectively analyzed the data of more than 1.4 million angiography and/or PCI procedures [1,454,121 patients (62.54% men and 37.46% women)] between 2014 and 2022. The logistic regression analysis was conducted to explore whether female sex was associated with FFR utilization. Results: The FFR was performed in 61,305 (4.22%) patients and more frequently in men than women (4.15% vs. 3.45%, p < 0.001). FFR was more frequently assessed in females with acute coronary syndrome than males (27.75% vs. 26.08%, p < 0.001); however, women with chronic coronary syndrome had FFR performed less often than men (72.25% vs. 73.92%, p < 0.001). Females with FFR-guided procedures were older than men (69.07 (±8.87) vs. 65.45 (±9.38) p < 0.001); however. less often had a history of myocardial infarction (MI) (24.79% vs. 36.73%, p < 0.001), CABG (1.62% vs. 2.55%, p < 0.005) or PCI (36.6% vs. 24.79%, p < 0.001) compared to men. Crude comparison has shown that male sex was associated with a higher frequency of FFR assessment (OR = 1.2152-1.2361, p < 0.005). Conclusions: Despite a substantial rise in FFR utilization, adoption in women remains lower than in men. Female sex was found to be an independent negative predictor of FFR use.

Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review

OBJECTIVE

We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD).

METHODS

A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date.

RESULTS

A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m2 (24.5 to 30.1 kg/m2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days).

CONCLUSIONS

MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

Electroacupuncture for slow flow/no-reflow phenomenon in patients with acute myocardial infarction undergoing percutaneous coronary intervention: protocol for a pilot randomized controlled trial

Background

Slow flow/no-reflow (SF-NR) during percutaneous coronary intervention (PCI) is associated with poor prognosis of patients with acute myocardial infarction (AMI). Currently, effective treatment is not available for SF-NR. Electroacupuncture (EA) has shown significant efficacy as an adjuvant therapy for many cardiovascular diseases by improving microcirculation and reducing ischemia-reperfusion injury. However, its effects on SF-NR in the AMI patients during PCI are not clear. This pilot trial aims to determine the efficacy of intraoperative EA in alleviating SF-NR in AMI patients undergoing PCI.

Methods

This prospective, single-center, randomized controlled, pilot trial will recruit 60 AMI patients scheduled for PCI at the Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, China. The patients will be randomized in a 1:1 ratio into the EA or the control groups. Patients in the control group will undergo standard PCI. Patients in the EA group will undergo intraoperative electroacupuncture while undergoing standard PCI. Incidence of SF-NR is the primary outcome for this study. This study will also assess secondary outcomes including cardiac biomarkers, inflammatory biomarkers, pain and anxiety scores, electrocardiography parameters, traditional Chinese medicine (TCM) symptom score, and major adverse cardiovascular and cerebrovascular events (MACCE). All the included patients will undergo laboratory tests including routine blood tests, levels of electrolytes, as well as liver and renal function tests. Patients will be followed up for 1 month after the procedure.

Discussion

This pilot trial will provide evidence for the potential benefits of intraoperative EA in improving microvascular perfusion and preventing or alleviating SF-NR during PCI in patients with AMI. If proven effective, intraoperative EA will provide a new and effective strategy against SF-NR and provide evidence for subsequent multicenter trials.

Clinical Trial Registration

ClinicalTrials.gov, identifier (ChiCTR2300072265). Registered on 8 June 2023.

POBS-Card, a new score of severe bleeding after cardiac surgery: Construction and external validation

Objective

Bleeding after cardiac surgery leads to poor outcomes. The objective of the study was to build the PeriOperative Bleeding Score in Cardiac surgery (POBS-Card) to predict bleeding after cardiac surgery.

Methods

We conducted a retrospective cohort study in 2 academic hospitals (2016-2019). Inclusion criteria were adult patients after cardiac surgery under cardiopulmonary bypass. Exclusion criteria were heart transplantation, assistance, aortic dissection, and preoperative hemostasis diseases. Bleeding was defined by the universal definition for perioperative bleeding score ≥2. POBS-Card score was built using multivariate regression (derivation cohort, one center). The performance diagnosis was assessed using the area under the curve in a validation cohort (2 centers) and compared with other scores.

Results

In total, 1704 patients were included in the derivation cohort, 344 (20%) with bleeding. Preoperative factors were body mass index <25 kg/m2 (odds ratio [OR], 1.48 [1.14-1.93]), type of surgery (redo: OR, 1.76 [1.07-2.82]; combined: OR, 1.81 [1.19-2.74]; ascendant aorta: OR, 1.56 [1.02-2.38]), ongoing antiplatelet therapy (single: OR, 1.50 [1.09-2.05]; double: OR, 2.00 [1.15-3.37]), activated thromboplastin time ratio >1.2 (OR, 1.44 [1.03-1.99]), prothrombin ratio <60% (OR, 1.91 [1.21-2.97]), platelet count <150 g/L (OR, 1.74 [1.17-2.57]), and fibrinogen <3 g/L (OR, 1.33 [1.02-1.73]). In the validation cohort of 597 patients, the area under the curve was 0.645 [0.605-0.683] and was superior to other scores (WILL-BLEED, Papworth, TRUST, TRACK). A threshold >14 predicted bleeding with a sensitivity of 50% and a specificity of 73%.

Conclusions

POBS-Card score was superior to other scores in predicting severe bleeding after cardiac surgery. Performances remained modest, questioning the place of these scores in the perioperative strategy of bleeding-sparing.

Transient time flow measurement in arterial grafts

Coronary artery bypass grafting (CABG) is one of the foundations of treatment for coronary artery disease. While it has improved substantially since its inception more than 50 years ago, including a rising use of multiple arterial grafting, intraoperative quality assessment is yet to be disseminated as an integral part of the procedure. Herein we review the fundamentals of intraoperative quality assessment in CABG using transient time flow measurement (TTFM) with a focus on its use in arterial grafting.

Complete Coronary Revascularization and Outcomes in Patients Who Underwent Coronary Artery Bypass Grafting: Insights from The REGROUP Trial

There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted.

Perioperative Cardiovascular Risk Assessment and Management in Liver Transplant Recipients: A Review of the Literature Merging Guidelines and Interventions

Liver transplantation (LT) is the second most performed solid organ transplant. Coronary artery disease (CAD) is a critical consideration for LT candidacy, particularly in patients with known CAD or risk factors, including metabolic dysfunction associated with steatotic liver disease. The presence of severe CAD may exclude patients from LT; therefore, precise preoperative evaluation and interventions are necessary to achieve transplant candidacy. Cardiovascular complications represent the earliest nongraft-related cause of death post-transplantation. Timely intervention to reduce cardiovascular events depends on adequate CAD screening. Coronary disease screening in end-stage liver disease is challenging because standard noninvasive CAD screening tests have low sensitivity due to hyperdynamic state and vasodilatation. As a result, there is overuse of invasive coronary angiography to exclude severe CAD. Coronary artery calcium scoring using a computed tomography scan is a tool for the prediction of cardiovascular events, and can be used to achieve risk stratification in LT candidates. Recent literature shows that qualitative assessment on both noncontrast- and contrast-enhanced chest computed tomography can be used instead of calcium score to assess the presence of coronary calcium. With increasing prevalence, protocols to address CAD in LT candidates must be reconsidered. Percutaneous coronary intervention could allow a shorter duration of dual-antiplatelet therapy in simple lesions, with safer perioperative outcomes. Hybrid coronary revascularization is an option for high-risk LT candidates with multivessel disease nonamenable to percutaneous coronary intervention. The objective of this review is to evaluate existing methods for preoperative cardiovascular risk stratification, and to describe interventions before surgery to optimize patient outcomes and reduce cardiovascular event risk.

Mesenchymal stromal cells for improvement of cardiac function following acute myocardial infarction: a matter of timing

Acute myocardial infarction (AMI) is the leading cause of cardiovascular death and remains the most common cause of heart failure. Reopening of the occluded artery, i.e., reperfusion, is the only way to save the myocardium. However, the expected benefits of reducing infarct size are disappointing due to the reperfusion paradox, which also induces specific cell death. These ischemia-reperfusion (I/R) lesions can account for up to 50% of final infarct size, a major determinant for both mortality and the risk of heart failure (morbidity). In this review, we provide a detailed description of the cell death and inflammation mechanisms as features of I/R injury and cardioprotective strategies such as ischemic postconditioning as well as their underlying mechanisms. Due to their biological properties, the use of mesenchymal stromal/stem cells (MSCs) has been considered a potential therapeutic approach in AMI. Despite promising results and evidence of safety in preclinical studies using MSCs, the effects reported in clinical trials are not conclusive and even inconsistent. These discrepancies were attributed to many parameters such as donor age, in vitro culture, and storage time as well as injection time window after AMI, which alter MSC therapeutic properties. In the context of AMI, future directions will be to generate MSCs with enhanced properties to limit cell death in myocardial tissue and thereby reduce infarct size and improve the healing phase to increase postinfarct myocardial performance.

Value of different CTO scoring systems in predicting procedural success in coronary chronic total occlusion intervention in Egyptian patients

BACKGROUND

Chronic total occlusion (CTO) lesions in coronary arteries pose a significant challenge for coronary interventionists, often leading to referrals for coronary artery bypass graft surgery (CABG). Successful percutaneous coronary intervention (PCI) for CTOs requires accurate assessment of procedural potential. This study, comprising 100 Egyptian patients aged 37-81, compares the predictive efficacy of various CTO scoring systems in PCI success determination. Patients with CTO in at least one coronary artery, planned for elective PCI based on objective evidence of ischemia, were included. Experienced operators performed PCI, recording procedural variables, and assessing complications. Logistic regression analysis revealed an inverse linear relationship between success rates and score values across all systems.

RESULTS

Although, the predictive capacity of the scores was similar, with slight differences. The Euro CTO (CASTLE) score10 exhibited superior predictive efficacy, followed by the CL score9, while PROGRESS8 and J-CTO7 scores showed lower significance. ORA CTO11 score demonstrated intermediate predictive ability, and PROGRESS score8 had the least predictive value.

CONCLUSION

The CASTLE score10 proved most effective in predicting PCI success for CTO cases in Egyptian patients, with operators advised to choose scoring systems based on experience and case characteristics. Proper planning remains crucial for optimizing success rates in CTO PCI procedures, irrespective of the scoring system employed.

Meta-analysis of immediate complete vs staged complete revascularization in patients with acute coronary syndrome and multivessel disease

BACKGROUND

Randomized controlled trials (RCTs) have shown varying results between immediate and staged complete percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). We conducted a meta-analysis to reconcile the findings.

METHODS

Online databases were searched for RCTs comparing immediate vs staged complete PCI in patients presenting with ACS. The outcomes of interest were major adverse cardiovascular events (MACE), all cause death, myocardial infarction (MI), cardiovascular death, stent thrombosis, target vessel revascularization (TVR), cerebrovascular events, bleeding and acute kidney injury (AKI)/contrast induced nephropathy (CIN). Risk ratios (RR) with 95 % confidence intervals (CI) were calculated using the random-effects model.

RESULTS

Nine RCTs with a total of 3637 patients - 1821 in the immediate PCI group and 1816 in the staged PCI group, were included. The mean age was 64 years, 78 % of patients were men and the mean duration of follow up was 1 year. As compared with staged complete PCI, the immediate PCI group was associated with significant reduction of MI (RR 0.53, 95 % CI 0.36-0.77) and TVR (RR 0.69, 95 % CI 0.53-0.90). The risks of all-cause death, cardiovascular death, MACE, cerebrovascular events, stent thrombosis, bleeding and AKI/CIN were similar in the two groups.

CONCLUSIONS

In ACS patients selected for complete revascularization strategy, multivessel PCI during the index procedure may be associated with significant reduction in the risk of MI and TVR without harm when compared with a staged PCI strategy.

Effect of right internal mammary artery versus radial artery as a second graft vessel in coronary artery bypass grafting on postoperative wound infection in patients: A meta-analysis

Few studies have shown that radial artery (RA), which is used as a secondary arterial graft, offers superior results compared with right internal thoracic artery (RIMA) in coronary artery bypass grafting (CABG). In a meta-analysis of observational studies starting in 2023, we looked at the effect of re-operation on postoperative infection and haemorrhage in CABG with RA vs. RIMA. The electronic database up to October 2023 was examined in the course of the research. Analysis was carried out on the clinical trials of postoperative wound infections and haemorrhage re-surgery. Among 912 trials associated with CABG, we selected 8 trials to be included in the final data analysis. The main results were secondary wound infection and re-operation after surgery. The odds ratios (OR) and confidence intervals (CIs) were computed on the basis of a randomized or fixed-effect model of wound infection and re-operation. Seven trials showed a significant reduction in the risk of wound infection in RA treated as a secondary artery transplant compared with RIMA (OR, 1.60; 95% CI, 1.03, 2.47 p = 0.04); Four trials showed that RIMA was not significantly different from RA in the rate of re-operation for postoperative bleeding (OR, 1.31; 95% CI, 0.60, 2.88 p = 0.50). In CABG, RA is used as a secondary arterial conduit graft to lower the risk of wound infection in CABG patients.

Outcomes after surgical revascularization in diabetic patients

OBJECTIVES

Patients with diabetes mellitus (DM) undergoing coronary artery bypass grafting (CABG) have been repeatedly demonstrated to have worse clinical outcomes compared to patients without DM. The objective of this study was to evaluate the impact of DM on 1-year clinical outcomes after isolated CABG.

METHODS

The European DuraGraft registry included 1130 patients (44.6%) with and 1402 (55.4%) patients without DM undergoing isolated CABG. Intra-operatively, all free venous and arterial grafts were treated with an endothelial damage inhibitor. Primary end point in this analysis was the incidence of a major adverse cardiac event (MACE), a composite of all-cause death, repeat revascularization or myocardial infarction at 1 year post-CABG. To balance between differences in baseline characteristics (n = 1072 patients in each group), propensity score matching was used. Multivariable Cox proportional hazards regression was performed to identify independent predictors of MACE.

RESULTS

Diabetic patients had a higher cardiovascular risk profile and EuroSCORE II with overall more comorbidities. Patients were comparable in regard to surgical techniques and completeness of revascularization. At 1 year, diabetics had a higher MACE rate {7.9% vs 5.5%, hazard ratio (HR) 1.43 [95% confidence interval (CI) 1.05-1.95], P = 0.02}, driven by increased rates of death [5.6% vs 3.5%, HR 1.61 (95% CI 1.10-2.36), P = 0.01] and myocardial infarction [2.8% vs 1.4%, HR 1.99 (95% CI 1.12-3.53) P = 0.02]. Following propensity matching, no statistically significant difference was found for MACE [7.1% vs 5.7%, HR 1.23 (95% CI 0.87-1.74) P = 0.23] or its components. Age, critical operative state, extracardiac arteriopathy, ejection fraction ≤50% and left main disease but not DM were identified as independent predictors for MACE.

CONCLUSIONS

In this study, 1-year outcomes in diabetics undergoing isolated CABG were comparable to patients without DM.

Long-Term Outcomes After Hybrid Coronary Revascularization Versus Coronary Artery Bypass Grafting: Meta-Analysis of Kaplan-Meier-Derived Data

Hybrid coronary revascularization (HCR) is an alternative option to conventional coronary artery bypass grafting (CABG), but the long-term outcomes of HCR versus CABG remain unclear. We aimed to analyze the long-term outcomes after HCR and CABG for patients with multivessel coronary artery disease using meta-analysis. A systemic literature search of PubMed and EMBASE was performed from inception to March 2023. Studies reporting Kaplan-Meier curves with follow-up ≥1 year were included. The primary outcome was all-cause mortality, and the secondary outcomes were major adverse cardiac and cerebrovascular events (MACCEs) and repeat revascularization. In total, 13 studies (1 randomized controlled trial and 12 propensity-score matched observational studies) were analyzed. The mean follow-up period was 5.1 ± 3.1 years. HCR was associated with similar overall mortality (hazard ratio [HR] 1.09, 95% confidence interval [CI] 0.87 to 1.36), significantly higher incidence of MACCEs (HR 1.49, 95% CI 1.07 to 2.06), and repeat revascularization (HR 2.01, 95% CI 1.53 to 2.64) compared with CABG. In phase-specific analysis, the mortality rate was similar, and the incidence of repeat revascularization was higher in HCR regardless of phases. The incidence of MACCEs was higher in HCR during the mid-term phase (1 to 5 years), but it was similar during the long-term phase (long-term: ≥5 years). In conclusion, despite the higher incidence of MACCEs and repeat revascularization compared with CABG, HCR offered a similar long-term survival. Even longer-term follow-up and randomized controlled trials with a large population are warranted to investigate the role of HCR for multivessel coronary artery disease.

Intrastent Restenosis: A Comprehensive Review

The primary objective of this paper is to delineate and elucidate the contemporary advancements, developments, and prevailing trajectories concerning intrastent restenosis (ISR). We aim to provide a thorough overview of the most recent developments in this area, covering various aspects such as pathophysiological insights, therapeutic approaches, and new strategies for tackling the complex challenges of ISR in modern clinical settings. The authors have undertaken a study to address a relatively new medical challenge, recognizing its significant impact on the morbidity and mortality of individuals with cardiovascular diseases. This effort is driven by the need to fully understand, analyze, and possibly improve the outcomes of this emerging medical issue within the cardiovascular disease field. We acknowledge its considerable clinical implications and the necessity for innovative methods to mitigate its effects on patient outcomes. Therefore, our emphasis was directed towards elucidating the principal facets of the condition's prevalence, expounding upon the foundational mechanisms underscoring conspicuous restenosis, and delineating the risk factors relevant in shaping the contemporary landscape of diagnostic and therapeutic modalities. This thorough examination aims to provide a comprehensive understanding of the various dimensions of the condition, including epidemiological data, pathophysiological complexities, and clinical considerations critical for evaluating and enhancing current diagnostic and treatment approaches.

The heart team: the multidisciplinary approach to coronary artery disease

The recommendation to employ a heart team to guide revascularization has persisted for over a decade. Despite evidence for improved adherence to guidelines, widespread adoption of the heart team approach has been limited. This review delves into the history of the guidelines endorsing the use of a heart team and the supporting data. Additionally, it outlines some attributes of a successful heart team, and how the heart team has been run at several large academic centers. Finally, it reviews some of the barriers to a heart team and future considerations.