Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting

Outcomes of coronary artery bypass grafting with coronary endarterectomy: A systematic review and meta-analysis of recent studies

Objective: The aim of this systematic review and meta-analysis was to evaluate the short-term and long-term outcomes of coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) versus isolated CABG.Methods: Studies evaluating outcomes of CABG with CE (CE-CABG) were searched from 1 January 2000 to 30 September 2022, on PubMed, Embase, and Cochrane databases. The primary outcome was 30 -days mortality. Secondary outcomes were postoperative myocardial infraction, low output syndrome, cardiac arrhythmia, renal dysfunction, and 5 years survival.Results: A total of 12 observational studies including 114,319 patients assessing CE-CABG (n = 35,174) versus isolated CABG (n = 79,145) were included. Compared to isolated CABG alone, CE-CABG was significantly associated with increased incidences of 30-days mortality (RR, 1.87; 95% CI, 1.73-2.07; p < 0.01), postoperative myocardial infraction (RR, 1.61; 95% CI, 1.26-2.05; p < 0.01), low output syndrome (RR, 1.54; 95% CI, 1.17-2.02; p < 0.01), and renal dysfunction (RR, 1.56; 95% CI, 1.44-1.69; p < 0.01). However, there was no difference in either rate of cardiac arrhythmia (RR, 1.06; 95% CI, 0.97-1.15; p = 0.20) or 5 years survival (RR, 1.05; 95% CI, 0.95-1.16; p = 0.34) between the CE-CABG group and the control group. Subgroup analysis on CE technique showed that CE-CABG was also associated with 30 days mortality in patients undergoing closed CE (RR, 1.49; 95% CI, 1.09-2.03), whereas this association between CE and 30 days mortality was not observed in patients undergoing open CE (RR, 1.76; 95% CI, 0.58-5.32).Conclusions: Despite poor short-term outcomes, CE-CABG appeared to offer satisfactory long-term survival in patients with diffuse coronary artery disease.

Coronary endarterectomy combined with coronary artery bypass grafting might decrease graft patency: A cohort study

BACKGROUND

Little is known about the graft patency after coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG). This study aimed to investigate the graft patency after CABG + CE.

METHODS

Eligible patients hospitalized at our center during September 2008 and July 2022 with complete follow-up coronary angiographic data available were retrospectively enrolled. The primary end point was the follow-up graft patency of CE targets. Logistic regression was performed to explore the potential predictors of the CE-targeted graft failure.

RESULTS

A total of 160 patients (age: 59.4 ± 9.3 years, male: 75.6%) were enrolled, and 560 grafts were anastomosed. CE was performed on 166 sites, including LAD (36.1%), right coronary artery (RCA, 48.2%), left circumflex artery (9.6%), and diagonal branches (6.0%). Postoperative myocardial infarction was observed in 7 (4.4%) of the patients. During a median follow-up of 12.1 months, the CE-targeted graft patency was 69.9%. The CE-targeted graft patency rate was much higher among the LAD-CE patients than the non-LAD-CE patients (80.0% vs. 64.2%, P = 0.032) but lower than non-endarterectomized LAD (80.0% vs. 92.9%, P = 0.013). No difference was observed regarding the graft patency between off-pump and on-pump surgery (P = 0.585). In the logistic regression, RCA-CE was associated with an increased risk of graft failure even after multiple adjustments (odds ratio: 2.35, 95% confidence interval: 1.05-5.28, P = 0.028).

CONCLUSIONS

CABG + CE might be associated with decreased graft patency, especially in those who received RCA-CE, irrespective of surgical technique or antiplatelet/anticoagulation regimen. A multi-center prospective, possibly randomized study with a larger sample size is warranted.

Early tirofiban versus heparin for bridging dual antiplatelet therapy in patients undergoing coronary endarterectomy combined with coronary artery bypass grafting: a multicenter randomized controlled trial protocol (the THACE-CABG trial)

BACKGROUND

For complete revascularization, patients with diffuse coronary artery disease should have a coronary endarterectomy and a coronary artery bypass graft (CE-CABG). Sadly, CE can lead to a lack of endothelium, which raises the risk of thrombotic events. Even though daily dual antiplatelet therapies (DAPT) have been shown to reduce thrombotic events, the risk of perioperative thrombotic events is high during the high-risk period after CE-CABG, and there is no consistent protocol to bridge DAPT. This trial aims to compare safety and efficacy between tirofiban and heparin as DAPT bridging strategies after CE-CABG.

METHODS

In phase I, 266 patients undergoing CE-CABG will be randomly assigned to tirofiban and heparin treatment groups to compare the two treatments in terms of the primary safety endpoint, chest tube drainage in the first 24 h. If the phase I trial shows tirofiban non-inferiority, phase II will commence, in which an additional 464 patients will be randomly assigned. All 730 patients will be studied to compare major cardiovascular and cerebrovascular events (MACCEs) between the groups in the first 30 days after surgery.

DISCUSSION

Given the possible benefits of tirofiban administration after CE-CABG, this trial has the potential to advance the field of adult coronary heart surgery.

TRIAL REGISTRATION

chictr.org.cn, ChiCTR2200055697. Registered 6 January 2022. https://www.chictr.org.cn/com/25/showproj.aspx?proj=149451 . Current version: 20,220,620.

Risk Prediction After Coronary Artery Bypass Grafting Combined With Coronary Endarterectomy

Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) is used for complete revascularization of diffusely diseased coronary arteries. Nevertheless, studies reported an increased risk after this procedure. Therefore, risk prediction in these patients is essential. Patients who underwent CABG + CE during September 2008 and July 2022 at our center were retrospectively recruited. A total of 32 characteristics were analyzed. The least absolute shrinkage and selection operator regression were used for the feature selection, and multivariable Cox regression was applied to develop a nomogram for risk prediction. The primary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE), a composite of all-cause death, nonfatal myocardial infarction, repeat revascularization, and stroke. A total of 570 patients with 601 CE targets, including left anterior descending (41.4%), right coronary artery (43.9%), left circumflex artery (6.8%), and diagonal branches/intermedius ramidus (8.0%), were enrolled. The mean age was 61.0 ± 8.9 years, and 77.7% were men. A total of 4 features were identified as the predictors of MACCE, including age ≥65 years (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.38 to 3.25, p <0.001), left main disease (HR 2.56, 95% CI 1.46 to 4.49, p = 0.001), mitral regurgitation (≥mild, HR 1.91, 95% CI 1.01 to 3.65, p = 0.049), and left anterior descending endarterectomy (HR 1.69, 95% CI 1.09 to 2.62, p = 0.018), and a nomogram for the 1- and 3-year MACCE prediction was developed. The model showed relatively good discrimination (C-index 0.68), calibration, and clinical usefulness. In conclusion, the nomogram provides estimation of the 1- and 3-year MACCE risk after CABG + CE.