Comparison of hybrid coronary revascularization versus coronary artery bypass grafting in patients with multivessel coronary artery disease: a meta-analysis

A Review of Cardiac Preoperative Screening Guidelines for Liver Transplantation

Orthotopic liver transplant (OLT) medicine is a constantly evolving field, especially with the demographics of individuals with advanced liver disease drastically changing. OLT candidates are now older, and there is an increase of nonalcoholic steatohepatitis cirrhosis due to the epidemic of obesity, which has also resulted in an increase in cardiac comorbidities in this population. The pathophysiology of liver cirrhosis creates many complexities during the pre- and postoperative management of OLT. We discuss the role of screening for common co-existent cardiovascular comorbidities, including coronary artery disease, congestive heart failure, arrhythmias, and portopulmonary hypertension, as well as challenges in the standardization of pre-liver transplant cardiovascular care.

Perioperative Multi-Kingdom Gut Microbiota Alters in Coronary Artery Bypass Grafting

Background: Coronary artery bypass grafting (CABG) is one of the main treatments for coronary heart disease (CHD). Gut microbiota, including bacteria, fungi, archaea, and virus, has been reported to be associated with CHD. However, the changes in the multi-kingdom gut microbiota after CABG are not yet clear. This study aimed to explore the changes in multi-kingdom gut microbiota during the early postoperative period of CABG. Methods: We collected fecal samples from 40 patients before and 1 week after CABG surgery. Metagenomic sequencing was used to detect the microbial spectrum and gene functions in the patients' fecal samples. Results: Post-CABG patients exhibited significant changes in the composition of multi-kingdom gut microbiota and gene functions. Among bacteria, beneficial species such as Bifidobacterium, Bacteroides, and Blautia were significantly reduced after CABG, while the harmful species Enterococcus was significantly increased. In fungi, Schizosaccharomyces pombe was significantly decreased in the postoperative group, while Saccharomyces cerevisiae and Aspergillus chevalieri were significantly increased postoperatively. Spearman correlation analysis indicated that Schizosaccharomyces pombe had positive interactions with beneficial bacteria such as Lachnospiraceae, Ruminococcus, and Blautia. Among archaea, the preoperatively enriched Methanomethylovorans-SGB40959 was significantly reduced postoperatively, and Spearman correlation analysis showed a significant positive interaction with probiotics Ruminococcus and Dorea. In viruses, the phage Enterococcus virus EFP01, which infects Enterococcus, was significantly increased postoperatively and showed a significant positive interaction with Enterococcus. Additionally, postoperative dysregulation of gene functions such as the Phosphoenolpyruvate-dependent Sugar Phosphotransferase System (PTS), Transposition, DNA-mediated, and Transposase Activity was observed, and Spearman correlation analysis indicated significant correlations between the dysregulated gene functions and the microbial communities. Conclusions: This study comprehensively revealed the changes in multi-kingdom species post-CABG. The reduction of beneficial microorganisms and the increase of harmful microorganisms after surgery are of significant clinical importance for understanding the overall health status of post-CABG patients and for optimizing postoperative treatment plans. Future research needs to further explore how to improve the prognosis of post-CABG patients by modulating the gut microbiota.

Electrocoagulation-free strategy in minimally invasive direct coronary artery bypass with hybrid revascularisation - a case report

BACKGROUND

Hybrid coronary revascularisation benefits patients with multivessel disease, as it amalgamates the minimally invasive direct coronary artery bypass (MIDCAB) procedure and percutaneous coronary intervention (PCI). We present a 63-year-old female with triple-vessel coronary artery disease including marked ostial stenosis of the left main coronary artery, as well as moderate stenosis of the right coronary artery. The risk of death following heart surgery (EuroSCORE II) is 4.27%. The patient exhibited multiple morbidities including chronic obstructive pulmonary disease, renal impairment, extracardiac arteriopathy, and multiple prior gastrointestinal surgeries, as well as a recent episode of paroxysmal atrial fibrillation. A MIDCAB procedure without electrocoagulation was stipulated by the ENT specialist due to the patient's cochlear implant.

CONCLUSION

A successful MIDCAB procedure omitting electrocoagulation was performed for the first time for multivessel coronary disease in a multimorbid patient as part of a hybrid approach.

Ten-year outcomes of hybrid coronary revascularization at a single center

Background

Hybrid coronary revascularization (HCR) is a well-established technique for treating multi-vessel coronary disease. There remains a paucity of discussion assessing the efficacy of HCR with respect to the timing of the surgical component relative to that of the percutaneous coronary intervention (PCI).

Methods

A retrospective review was undertaken of our prospectively collected database from January 2009 to December 2019. Of 395 HCR patients analyzed, we examined the outcomes of 109 pairs of propensity-matched patients who either underwent robotic-assisted minimally-invasive direct coronary artery bypass (MIDCAB) first, or who had PCI prior to surgery.

Results

Thirty-day mortality was 0.25% (1 death) for the entire cohort. Mid-term survival for the total 'MIDCAB-first' group was 94.1% (17 deaths), not significantly different to that for the 'PCI-first' cohort (8 deaths, 92.7%), and this was also statistically comparable after propensity matching. Perioperative morbidity was not different between patient groups. Freedom from major adverse cardiac and cerebrovascular events (MACCE) and the incidence of repeat revascularization was similar between the two groups at up to 11-year follow-up. Elevated serum creatinine independently predicted increased MACCE for all patients, irrespective of the sequence of HCR revascularization employed.

Conclusions

In appropriately selected patients with multi-vessel coronary disease, HCR is associated with excellent short and longer-term results, irrespective of whether the MIDCAB or PCI procedure is performed first.

The Current State of Hybrid Coronary Revascularization

Hybrid coronary revascularization (HCR) combines a minimally invasive surgical approach with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary artery disease. Despite decades of use, widespread acceptance has been limited. In this review, we conduct a comparative assessment of HCR in relation to traditional coronary artery bypass graft surgery and multivessel PCI. Although large-scale randomized data are still lacking, numerous studies have demonstrated that HCR may offer benefits regarding resource utilization and short-term morbidity while delivering comparable mid- and long-term survival compared with traditional bypass surgery. Compared with PCI, HCR may offer similar periprocedural morbidity while mitigating the need for repeat revascularization by providing a surgical arterial bypass graft to the left anterior descending artery.

Controversy. On pump or off pump: what will I do when I grow up? A narrative systematic review

The transition from the second to the third millennium happened to be a turning point in the history of myocardial revascularization on a beating heart, which moved from technical development to critical evaluation. This article describes how the initial acceptance and spread of off-pump coronary artery bypass grafting (OPCABG) was followed by the general perception that the technique could not fulfill the expectations placed in it and provides some insight on what should we do with the know-how of OPCABG in the present and the future of coronary surgical revascularization.

Coronary Artery Bypass Surgery: Evidence-Based Practice

Coronary artery bypass graft (CABG) surgery remains a pivotal cornerstone, offering established symptomatic alleviation and prognostic advantages for patients grappling with complex multivessel and left main coronary artery diseases. Despite the lucid guidance laid out by contemporary guidelines regarding the choice between CABG and percutaneous coronary intervention (PCI), a notable hesitation persists among certain patients, characterized by psychological reservations, knowledge gaps, or individual beliefs that sway their inclination toward surgical intervention. This comprehensive review critically synthesizes the prevailing guidelines, modern practices, and outcomes pertaining to CABG surgery, delving into an array of techniques and advancements poised to enhance both short-term and enduring surgical outcomes. The exploration encompasses advances in on-pump and off-pump procedures, conduit selection strategies encompassing the bilateral utilization of internal mammary artery and radial artery conduits, meticulous graft evaluation methodologies, and the panorama of minimally invasive approaches, including those assisted by robotic technology. Furthermore, the review navigates the terrain of hybrid coronary revascularization, shedding light on the pivotal roles of shared decision-making and the heart team in shaping treatment pathways. As a comprehensive compendium, this review not only navigates the intricate landscape of CABG surgery but also aligns it with contemporary practices, envisioning its trajectory within the evolving currents of healthcare dynamics.

Multivessel Coronary Disease and Severe Atherosclerotic Aorta: Real-World Experience

Background and Objectives: Surgical revascularisation of patients with atherosclerosis of the ascending aorta remains a challenge. Different surgical strategies have been described in coronary surgical patients to offer alternative revascularisation strategies other than the conventional surgical revascularisation in patients unsuitable for it. The aim of this study is to compare the real-world outcomes between two groups of patients who underwent off-pump surgery (left internal mammary artery graft to the left anterior descending artery) or a hybrid with a percutaneous revascularisation procedure at a later stage. Materials and Methods: This is a single-centre retrospective observational study. Between the years 2010 and 2021, 91/6863 patients (1.33%) were diagnosed with severe atherosclerosis of the ascending aorta. All the patients were treated with off-pump revascularisation (91 patients), and the cardiologist would decide at a later stage whether the rest of the vessels would be treated with percutaneous revascularisation (25 patients). Results: There was no statistical difference in the various preoperative characteristics, except for coronary artery left main disease (30.30% vs. 64%; p = 0.0043). The two groups had no statistical differences in the perioperative characteristics and postoperative complications. The 1-, 5-, and 10-year mortality rates in the two groups were 6.1% vs. 0%, 59% vs. 80%, and 93.9% vs. 100%, respectively (off-pump vs. hybrid with percutaneous revascularisation procedure, p = 0.1958). Conclusions: Both strategies have high long-term comparable mortality. The off-pump surgery and the HCR procedure at a later stage may be solutions for these high-risk patients, but the target treatment should be complete HCR revascularisation during the index hospitalization.

Revascularization Modalities in Acute Coronary Syndrome: A Review of the Current State of Evidence

Acute coronary syndrome (ACS) stands as a leading global cause of mortality, underscoring the importance of effective prevention, early diagnosis, and timely intervention. While medications offer benefits to many patients, revascularization procedures such as coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and emerging hybrid approaches remain pivotal for ACS management. This review delves into the 2018 ESC/EACTS guidelines alongside an analysis of existing literature to shed light on the spectrum of revascularization methods. While both CABG and PCI demonstrate promising outcomes, the optimal choice between the two hinges on a comprehensive assessment of individual patient factors, anatomical complexity guided by advanced imaging, comorbidities, and age. The determination of whether to pursue culprit or total revascularization, as well as immediate or staged revascularization, is contingent upon various factors, including age, disease complexity, and clinical outcomes. This evidence-based decision-making process is orchestrated by a multidisciplinary heart team grounded in ongoing clinical evaluation. The primary objective of this review is to provide valuable insights into revascularization strategies and scrutinize the congruence of current guidelines with recent advancements in the field.

Minimally Invasive Direct Coronary Artery Bypass: An Evolving Paradigm Over the Past 25 Years

OBJECTIVE

We have routinely utilized minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending (LAD) coronary artery. We examined how this procedure has evolved.

METHODS

A retrospective review was undertaken of 2,283 consecutive patients who underwent MIDCAB between 1997 and 2021. Patients were divided into 3 groups: group A from 1997 to 2002 (n = 751, 32.9%), group B from 2003 to 2009 (n = 452, 19.8%), and group C from 2009 to 2021 (n = 1,080, 47.3%). Risk profiles and short-term outcomes were analyzed for the entire cohort and for 293 propensity-matched patients drawn from each group.

RESULTS

The left internal mammary artery was harvested open in group A but with robotic assistance in group C. Thirty-day mortality was higher in group A versus group C (12 deaths, 1.6% vs 5 deaths, 0.5%, P = 0.044); this difference was negated after propensity matching. Group A had more comorbidities than group C, including peripheral vascular disease (17.7% vs 10.0%, P < 0.001), congestive heart failure (39.6% vs 18.0%, P < 0.001), and a history of stroke (17.9% vs 10.0%, P < 0.001), although diabetes mellitus was more common in group C (51.4% vs 31.0%, P < 0.001). Stroke was greater in group A (1.2% vs 0.0% vs 0.2%, respectively, P = 0.004), as was the need for prolonged ventilation (3.6% vs 0.2% vs 0.9%, respectively, P < 0.001), before and after propensity matching.

CONCLUSIONS

MIDCAB patients had less comorbidities than in the past. Robot-assisted MIDCAB was associated with lower stroke risk.