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Karapanagiotidis GT, Anastasakis E, Nana C, Gukop PS, Zakkar M, Tossios P, Grosomanidis V, Sarridou D, Krimiotis D, Sarsam MAI. Transaortic septal myectomy at the time of aortic valve replacement for severe aortic stenosis: a case series of 55 cases. Indian J Thorac Cardiovasc Surg 2024; 40:292-299. [PMID: 38681705 PMCID: PMC11045907 DOI: 10.1007/s12055-023-01661-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 05/01/2024] Open
Abstract
Introduction Symptomatic aortic valve stenosis (AS) is associated with asymmetric basal septal hypertrophy (ABSH) in 10% of cases. In this cohort, it has been suggested that rectification of the left ventricular outflow tract obstruction (LVOTO) by concomitant septal myectomy (CSM) can improve the results of aortic valve replacement (AVR). Objective This study aims to present the technique of AVR with CSM for severe AS with ABSH and to determine the associated early and late post-operative outcomes. Methods Fifty-five patients were prospectively recruited to undergo AVR with CSM between 2011 and 2021 at two centres. The primary outcomes were mortality within 30 days, incidence of post-operative ventricular septal defects (VSD) and prosthetic valve sizing. The secondary outcomes were in-hospital complications, permanent pacemaker implantation (PPI), survival at 15 months and changes on transthoracic echocardiogram. Results Post-operative mortality was 1.8% and this figure was unchanged at 15-month follow-up. No patients developed a post-operative VSD. Intra-operatively, it was found that in 94.6% cases the direct valve sizing increased by one, when compared to the measurement made before CSM. The indexed effective orifice area (iEOA) was > 85 cm2/m2 in 96.4% and no patients had an iEOA ≤ 0.75 cm2/m2. Four patients (7.3%) required PPI due to complete atrioventricular block. Conclusion AVR with CSM is a simple technique that can be utilised in severe AS with ABSH. There does not appear to be an increase in mortality or incidence of iatrogenic VSDs. Importantly, CSM allows for the implantation of a larger aortic valve compared to measurements made before CSM.
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Affiliation(s)
| | - Evangelos Anastasakis
- Department of Cardiothoracic Surgery, St George’s Hospital, London, UK
- St George’s University of London, London, UK
- Ashford and St Peter’s NHS Foundation Trust, Chertsey, UK
- St George’s Hospital, University of London, London, SW17 0QT UK
| | - Chrysoula Nana
- Department of Cardiothoracic Surgery, St George’s Hospital, London, UK
| | | | - Mustafa Zakkar
- Department of Cardiothoracic Surgery, St George’s Hospital, London, UK
- University Hospital of Leicester NHS Trust, Leicester, UK
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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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3
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Abbasciano RG, Layton GR, Torre S, Abbaker N, Copperwheat A, Lucarelli C, Bhandari S, Nijjer S, Mikhail G, Casula R, Zakkar M, Viviano A. Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review. Front Cardiovasc Med 2024; 11:1348341. [PMID: 38516003 PMCID: PMC10955066 DOI: 10.3389/fcvm.2024.1348341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/20/2024] [Indexed: 03/23/2024] Open
Abstract
Objective Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear. Methods A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice. Results Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment. Conclusions At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy. Systematic Review Registration ClinicalTrials.gov, identifier (CRD42023414604).
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Affiliation(s)
- R. G. Abbasciano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. R. Layton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Torre
- Cardiac Surgery Unit, Giaccone Hospital, Palermo, Italy
| | - N. Abbaker
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - A. Copperwheat
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - C. Lucarelli
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - S. Bhandari
- Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - S. Nijjer
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - G. Mikhail
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - R. Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - M. Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- Department of Cardiac Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - A. Viviano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London, United Kingdom
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Fudulu DP, Argyriou A, Kota R, Chan J, Vohra H, Caputo M, Zakkar M, Angelini GD. Effect of on-pump vs. off-pump coronary artery bypass grafting in patients with non-dialysis-dependent severe renal impairment: propensity-matched analysis from the UK registry dataset. Front Cardiovasc Med 2024; 11:1341123. [PMID: 38414924 PMCID: PMC10897021 DOI: 10.3389/fcvm.2024.1341123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/09/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction On-pump coronary artery bypass (ONCABG) grafting in patients with a pre-existing poor renal reserve is known to carry significant morbidity and mortality. There is limited controversial evidence on the benefit of off-pump coronary artery bypass (OPCABG) grafting in these high-risk groups of patients. We compared early clinical outcomes in propensity-matched cohorts of patients with non-dialysis-dependent pre-operative severe renal impairment undergoing OPCABG vs. ONCABG, captured in a large national registry dataset. Methods All data for patients with a pre-operative creatinine clearance of less than 50 mL/min who underwent elective or urgent isolated OPCABG or ONCABG from 1996 to 2019 were extracted from the UK National Adult Cardiac Surgery Audit (NACSA) database. Propensity score matching was performed using 1:1 nearest neighbor matching without replacement using several baseline characteristics. We investigated the effect of ONCABG vs. OPCABG in the matched cohort using cluster-robust standard error regression. Results We identified 8,628 patients with severe renal impairment undergoing isolated CABG, of whom 1,142 (13.23%) underwent OPCABG during the study period. We compared 1,141 propensity-matched pairs of patients undergoing OPCABG vs. ONCABG. The median age of the matched population was 78 years in both groups, with no significant imbalance post-matching in the rest of the variables. There was no difference between OPCABG and ONCABG in in-hospital mortality rates, post-operative dialysis, and stroke rates. However, the return to theatre for bleeding or tamponade was higher in ONCABG vs. OPCABG (P > 0.02); however, OPCABG reduced the total length of stay in the hospital by 1 day (P = 0.008). After double adjustment in the matched population using cluster-robust standard regression, ONCABG did not increase mortality compared to OPCABG (OR, 1.05, P = 0.78), postoperative stroke (OR, 1.7, P = 0.12), and dialysis (OR, 0.7, P = 0.09); however, ONCABG was associated with an increased risk of bleeding (OR, 1.53, P = 0.03). Discussion In this propensity analysis of a large national registry dataset, we found no difference in early mortality and stroke in patients with pre-operative severe renal impairment undergoing OPCABG or ONCABG surgery; however, ONCABG was associated with an increased risk of return to theatre for bleeding and an increased length of hospital stay.
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Affiliation(s)
- Daniel P. Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Amerikos Argyriou
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Rahul Kota
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jeremy Chan
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Hunaid Vohra
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Massimo Caputo
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Mustafa Zakkar
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Gianni D. Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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McQueen LW, Ladak SS, Layton GR, Wadey K, George SJ, Angelini GD, Murphy GJ, Zakkar M. Osteopontin Activation and Microcalcification in Venous Grafts Can Be Modulated by Dexamethasone. Cells 2023; 12:2627. [PMID: 37998362 PMCID: PMC10670684 DOI: 10.3390/cells12222627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Osteopontin has been implicated in vascular calcification formation and vein graft intimal hyperplasia, and its expression can be triggered by pro-inflammatory activation of cells. The role of osteopontin and the temporal formation of microcalcification in vein grafts is poorly understood with a lack of understanding of the interaction between haemodynamic changes and the activation of osteopontin. METHODS We used a porcine model of vein interposition grafts, and human long saphenous veins exposed to ex vivo perfusion, to study the activation of osteopontin using polymerase chain reaction, immunostaining, and 18F-sodium fluoride autoradiography. RESULTS The porcine model showed that osteopontin is active in grafts within 1 week following surgery and demonstrated the presence of microcalcification. A brief pretreatment of long saphenous veins with dexamethasone can suppress osteopontin activation. Prolonged culture of veins after exposure to acute arterial haemodynamics resulted in the formation of microcalcification but this was suppressed by pretreatment with dexamethasone. 18F-sodium fluoride uptake was significantly increased as early as 1 week in both models, and the pretreatment of long saphenous veins with dexamethasone was able to abolish its uptake. CONCLUSIONS Osteopontin is activated in vein grafts and is associated with microcalcification formation. A brief pretreatment of veins ex vivo with dexamethasone can suppress its activation and associated microcalcification.
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Affiliation(s)
- Liam W. McQueen
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
| | - Shameem S. Ladak
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
| | - Georgia R. Layton
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
| | - Kerry Wadey
- Translational Health Sciences, Bristol Medical School, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - Sarah J. George
- Translational Health Sciences, Bristol Medical School, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - Gianni D. Angelini
- Translational Health Sciences, Bristol Medical School, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - Gavin J. Murphy
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
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6
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Fudulu DP, Layton GR, Nguyen B, Sinha S, Dimagli A, Guida G, Abbasciano R, Viviano A, Angelini GD, Zakkar M. Trends and outcomes of concomitant aortic valve replacement and coronary artery bypass grafting in the UK and a survey of practices. Eur J Cardiothorac Surg 2023; 64:ezad259. [PMID: 37462523 PMCID: PMC10580967 DOI: 10.1093/ejcts/ezad259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 07/03/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVES Concomitant revascularization of coronary artery disease at the same time as treatment for aortic valvopathy favourably impacts survival. However, combined surgery may be associated with increased adverse outcomes compared to aortic valve replacement (AVR) or coronary artery bypass grafting in isolation. METHODS We retrospectively analyzed all patients who underwent AVR with bypass grafting between February 1996 and March 2019 using data from the National Adult Cardiac Surgery Audit. We used a generalized mixed-effects model to assess the effect of the number and type of bypass grafts associated with surgical AVR on in-hospital mortality, postoperative stroke, and the need for renal dialysis. Furthermore, we conducted an international cross-sectional survey of cardiac surgeons to explore their views about concomitant AVR with coronary bypass grafting interventions. RESULTS Fifty-one thousand two hundred and seventy-two patients were included in the study. Patients receiving 2 or more bypass grafts demonstrated more significant preoperative comorbidity and disease severity. Patients undergoing 2 and >2 grafts in addition to AVR had increased mortality as compared to patients undergoing AVR and only 1 graft [odds ratio (OR) 1.17, 95% confidence interval (CI) [1.05-1.30], P = 0.005 and OR 1.15, 95% CI [1.02-1.30], P = 0.024 respectively]. A single arterial conduit was associated with a reduction in mortality (OR 0.75, 95% CI [0.68-0.82], P < 0.001) and postoperative dialysis (OR 0.87, 95% CI [0.78-0.96], P = 0.006), but this association was lost with >1 arterial conduit. One hundred and three surgeons responded to our survey, with only a small majority believing that the number of bypass grafts can influence short- or long-term postoperative outcomes in these patients, and an almost equal split in responders supporting the use of staged or hybrid interventions for patients with concomitant pathology. CONCLUSIONS The number of grafts performed during combined AVR and coronary artery bypass grafting is associated with increased morbidity and mortality. The use of an arterial graft was also associated with reduced mortality. Future studies are needed to assess the effect of incomplete revascularization and measure long-term outcomes. Based on our data, current published evidence, and the collective expert opinion we gathered, we endorse future work to investigate the short and long-term efficacy and safety of hybrid intervention for patients with concomitant advanced coronary and aortic valve disease.
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Affiliation(s)
- Daniel P Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Georgia R Layton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | - Bao Nguyen
- Department of Cardiac Surgery, Derriford Hospital, Plymouth, UK
| | - Shubhra Sinha
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Arnaldo Dimagli
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Gustavo Guida
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Riccardo Abbasciano
- Department of Cardiac Surgery, Imperial College, Hammersmith Hospital, London, UK
| | - Alessandro Viviano
- Department of Cardiac Surgery, Imperial College, Hammersmith Hospital, London, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
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7
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Layton GR, Ladak SS, Abbasciano R, McQueen LW, George SJ, Murphy GJ, Zakkar M. The Role of Preservation Solutions upon Saphenous Vein Endothelial Integrity and Function: Systematic Review and UK Practice Survey. Cells 2023; 12:815. [PMID: 36899951 PMCID: PMC10001248 DOI: 10.3390/cells12050815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/19/2023] [Accepted: 02/22/2023] [Indexed: 03/08/2023] Open
Abstract
The long saphenous vein is the most used conduit in cardiac surgery, but its long-term patency is limited by vein graft disease (VGD). Endothelial dysfunction is a key driver of VGD; its aetiology is multi-factorial. However emerging evidence identifies vein conduit harvest technique and preservation fluids as causal in their onset and propagation. This study aims to comprehensively review published data on the relationship between preservation solutions, endothelial cell integrity and function, and VGD in human saphenous veins harvested for CABG. The review was registered with PROSPERO (CRD42022358828). Electronic searches of Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases were undertaken from inception until August 2022. Papers were evaluated in line with registered inclusion and exclusion criteria. Searches identified 13 prospective, controlled studies for inclusion in the analysis. All studies used saline as a control solution. Intervention solutions included heparinised whole blood and saline, DuraGraft, TiProtec, EuroCollins, University of Wisconsin (UoW), buffered, cardioplegic and Pyruvate solutions. Most studies demonstrated that normal saline appears to have negative effects on venous endothelium and the most effective preservation solutions identified in this review were TiProtec and DuraGraft. The most used preservation solutions in the UK are heparinised saline or autologous whole blood. There is substantial heterogeneity both in practice and reporting of trials evaluating vein graft preservation solutions, and the quality of existing evidence is low. There is an unmet need for high quality trials evaluating the potential for these interventions to improve long-term patency in venous bypass grafts.
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Affiliation(s)
- Georgia R. Layton
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Shameem S. Ladak
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK
| | | | - Liam W. McQueen
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Sarah J. George
- Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol BS2 1UDD, UK
| | - Gavin J. Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK
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8
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Ladak S, McQueen L, Joeldavid L, Murphy G, Zakkar M. Acute arterial haemodynamics activation of endothelial to mesenchymal transition in long saphenous veins. Impact on vein graft disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.3084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
The long saphenous vein (LSV) is frequently used in cardiac surgery; however, its use is complicated by late stenosis or occlusion due to the development of intimal hyperplasia (IH). TGF-β has been implicated in the process of IH however the impact of acute haemodynamic changes on the activation of TGF-β endothelial-to mesenchymal transition (EndMT) has not been assessed and it's the focus of this study.
Purpose
To assess the role of acute haemodynamics changes in veins implanted into arterial circulation on EndMT.
Methods
Surplus LSV were exposed to acute arterial haemodynamics using a perfusion bioreactor. Changes in EndMT markers at the RNA and protein level evaluated by quantitative real time PCR, RNAScope and immunofluorescence.
Results
The acute exposure of veins to arterial haemodynamics ex-vivo induced significant increase in inflammatory marker IL-8 expression and transcription factor TWIST1 in LSV (both p≤0.01, Figure 1A) endothelium. Furthermore, immunostaining demonstrated the activation of pSMAD (p≤0.01, Figure 1B) acutely in endothelium after 45 minutes of exposure to arterial haemodynamics. This was followed by significant increase of SMC related markers (Vimentin and α-SMA; Figure 1C, both p≤0.001) and the suppression of endothelial cell related marker CD31 after 4 hours of LSV exposure to acute arterial haemodynamics. RNAScope and IHC results showed localisation of TWIST1 RNA and protein in CD31+ (p≤0.001) and VECAD+ (p≤0.001) cells respectively following exposure to acute arterial haemodynamics (Figure 1D). Furthermore, TGF-β pathway phosphorylation array identified the activation of Smad1 (p≤0.05) but not TAK1 in LSV endothelial cells indicating that acute arterial haemodynamics activates the TGF-β–SMAD pathway specifically (Figure 1E).
Conclusion
The exposure of LSV to acute arterial haemodynamics is associated with the activation of TGF-β–SMAD pathway leading to EndMT changes in the endothelium of vein grafts ex-vivo. This contributes to our understanding of the changes that occur in veins after implantation into arterial circulation and that the acute changes in the endothelium and suggests that strategies to modulate TGF-β–SMAD can be utilised to modulate IH in vein grafts.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Van Geest Foundation Heart and Cardiovascular Diseases Research Fund
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Affiliation(s)
- S Ladak
- University of Leicester, Department of Cardiovascular Sciences, Glenfield hospital , Leicester , United Kingdom
| | - L McQueen
- University of Leicester, Department of Cardiovascular Sciences, Glenfield hospital , Leicester , United Kingdom
| | - L Joeldavid
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - G Murphy
- University of Leicester, Department of Cardiovascular Sciences, Glenfield hospital , Leicester , United Kingdom
| | - M Zakkar
- University of Leicester, Department of Cardiovascular Sciences, Glenfield hospital , Leicester , United Kingdom
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9
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Ladak SS, McQueen LW, Layton GR, Aujla H, Adebayo A, Zakkar M. The Role of Endothelial Cells in the Onset, Development and Modulation of Vein Graft Disease. Cells 2022; 11:3066. [PMID: 36231026 PMCID: PMC9561968 DOI: 10.3390/cells11193066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 01/23/2023] Open
Abstract
Endothelial cells comprise the intimal layer of the vasculature, playing a crucial role in facilitating and regulating aspects such nutrient transport, vascular homeostasis, and inflammatory response. Given the importance of these cells in maintaining a healthy haemodynamic environment, dysfunction of the endothelium is central to a host of vascular diseases and is a key predictor of cardiovascular risk. Of note, endothelial dysfunction is believed to be a key driver for vein graft disease-a pathology in which vein grafts utilised in coronary artery bypass graft surgery develop intimal hyperplasia and accelerated atherosclerosis, resulting in poor long-term patency rates. Activation and denudation of the endothelium following surgical trauma and implantation of the graft encourage a host of immune, inflammatory, and cellular differentiation responses that risk driving the graft to failure. This review aims to provide an overview of the current working knowledge regarding the role of endothelial cells in the onset, development, and modulation of vein graft disease, as well as addressing current surgical and medical management approaches which aim to beneficially modulate endothelial function and improve patient outcomes.
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Affiliation(s)
| | | | | | | | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
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10
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Ward AO, Sala-Newby GB, Ladak S, Angelini GD, Caputo M, Suleiman MS, Evans PC, George SJ, Zakkar M. Nrf2-Keap-1 imbalance under acute shear stress induces inflammatory response in venous endothelial cells. Perfusion 2022; 37:582-589. [PMID: 33899586 DOI: 10.1177/02676591211012571] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vascular endothelial cell stimulation is associated with the activation of different signalling pathways and transcription factors. Acute shear stress is known to induce different pro-inflammatory mediators such as IL-8. Nrf2 is activated by prolonged high shear stress promoting an antiinflammatory and athero-protective environment. However, little is known about the impact of acute shear stress on Nrf2 and Keap1 function and its role in IL-8 regulation. We aimed to examine Nrf2-Keap1 complex activation in-vitro and its role in regulating IL-8 transcripts under acute arterial shear stress (12 dyn/cm2) in venous endothelial cells (ECs). We note that acute high shear stress caused a significant upregulation of Nrf2 target genes, HO-1 and GCLM and an increased IL-8 upregulation at 90 and 120 minutes. Mechanistically, acute high shear did not affect Nrf2 nuclear translocation but resulted in reduced nuclear Keap1, suggesting that the reduction in nuclear Keap1 may result in increased free nuclear nrf2 to induce transcription. Consistently, the suppression of Keap1 using shRNA (shKeap1) resulted in significant upregulation of IL-8 transcripts in response to acute shear stress. Interestingly; the over expression of Nrf2 using Nrf2-Ad-WT or Sulforaphane was also associated with significant upregulation of IL-8 compared to controls. This study highlights the role of Keap1 in Nrf2 activation under shear stress and indicates that activation of Nrf2 may be deleterious in ECs in the context of acute haemodynamic injury.
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Affiliation(s)
- Alexander O Ward
- Bristol Medical School, Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Shameem Ladak
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester, UK
| | - Gianni D Angelini
- Bristol Medical School, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Medical School, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - M-Saadeh Suleiman
- Bristol Medical School, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Paul C Evans
- Department of Infection, Immunity and Cardiovascular Disease, The Medical School, Sheffield, UK
| | - Sarah J George
- Bristol Medical School, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester, UK
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11
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Fashina O, Abbasciano RG, McQueen LW, Ladak S, George SJ, Suleiman S, Punjabi PP, Angelini GD, Zakkar M. Large animal model of vein grafts intimal hyperplasia: A systematic review. Perfusion 2022:2676591221091200. [PMID: 35624557 DOI: 10.1177/02676591221091200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Coronary artery bypass grafting remains the treatment of choice for a large cohort of patients with significant coronary disease. Despite the increased use of arterial grafts, the long saphenous vein remains the most commonly used conduit. Long-term graft patency continues to be the Achilles heel of saphenous vein grafts. This is due to the development of intimal hyperplasia, a chronic inflammatory disease that results in the narrowing and occlusion of a significant number of vein grafts. Research models for intimal hyperplasia are essential for a better understanding of pathophysiological processes of this condition. Large animal models resemble human anatomical structures and have been used as a surrogate to study disease development and prevention over the years. In this paper, we systematically review all published studies that utilized large animal models of vein graft disease with a focus on the type of model and any therapeutic intervention, specifically the use of external stents/mesh.
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Affiliation(s)
- Oluwatomini Fashina
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Riccardo G Abbasciano
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Liam W McQueen
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Shameem Ladak
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Sarah J George
- Bristol Heart Institute and Translational Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Sadeeh Suleiman
- Bristol Heart Institute and Translational Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Prakash P Punjabi
- Department of Cardiovascular Sciences, Imperial College, Hammersmith Hospital, London, UK
| | - Gianni D Angelini
- Bristol Heart Institute and Translational Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK
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12
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Abbasciano RG, Mariscalco G, Barwell J, Owens G, Zakkar M, Joel-David L, Pathak S, Adebayo A, Shannon N, Haines RL, Aujla H, Eagle-Hemming B, Kumar T, Lai F, Wozniak M, Murphy G. Evaluating the Feasibility of Screening Relatives of Patients Affected by Nonsyndromic Thoracic Aortic Diseases: The REST Study. J Am Heart Assoc 2022; 11:e023741. [PMID: 35383466 PMCID: PMC9238461 DOI: 10.1161/jaha.121.023741] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Diseases of the thoracic aorta are characterized by a familial etiology in up to 30% of the cases. Nonsyndromic thoracic aorta diseases (NS‐TADs) lack overt clinical signs and systemic features, which hinder early detection and prompt surgical intervention. We hypothesize that tailored genetic testing and imaging of first‐degree and second‐degree relatives of patients affected by NS‐TADs may enable early diagnosis and allow appropriate surveillance or intervention. Methods and Results We conducted a feasibility study involving probands affected by familial or sporadic NS‐TADs who had undergone surgery, which also offered screening to their relatives. Each participant underwent a combined imaging (echocardiogram and magnetic resonance imaging) and genetic (whole exome sequencing) evaluation, together with physical examination and psychological assessment. The study population included 16 probands (8 sporadic, 8 familial) and 54 relatives (41 first‐degree and 13 second‐degree relatives) with median age 48 years (range: 18–85 years). No syndromic physical features were observed. Imaging revealed mild‐to‐moderate aortic dilation in 24% of relatives. A genetic variant of uncertain significance was identified in 3 families. Imaging, further phenotyping, or a form of secondary prevention was indicated in 68% of the relatives in the familial group and 54% in the sporadic group. No participants fulfilled criteria for aortic surgery. No differences between baseline and 3‐month follow‐up scores for depression, anxiety, and self‐reported quality of life were observed. Conclusions In NS‐TADs, imaging tests, genetic counseling, and family screening yielded positive results in up to 1 out of 4 screened relatives, including those in the sporadic NS‐TAD group. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03861741.
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Affiliation(s)
| | - Giovanni Mariscalco
- Department of Cardiac Surgery University Hospitals of Leicester NHS Trust Leicester UK
| | - Julian Barwell
- Department of Genetics and Genome Biology University of Leicester UK
| | - Gareth Owens
- Aortic Dissection Awareness UK & Ireland York UK
| | - Mustafa Zakkar
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Lathishia Joel-David
- Department of Cardiac Surgery University Hospitals of Leicester NHS Trust Leicester UK
| | - Suraj Pathak
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Adewale Adebayo
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Nora Shannon
- Department of Clinical Genetics Nottingham University Hospitals Nottingham UK
| | | | - Hardeep Aujla
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Bryony Eagle-Hemming
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit University of Leicester Leicester UK
| | - Florence Lai
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Marcin Wozniak
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
| | - Gavin Murphy
- Leicester NIHR Biomedical Research Centre & Department of Cardiovascular Sciences University of Leicester UK
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13
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McQueen LW, Ladak SS, Zakkar M. Acute shear stress and vein graft disease. Int J Biochem Cell Biol 2022; 144:106173. [PMID: 35151879 DOI: 10.1016/j.biocel.2022.106173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/08/2021] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Abstract
The long saphenous vein is commonly used in cardiac surgery to bypass occluded coronary arteries. Its use is complicated by late stenosis and occlusion due to the development of intimal hyperplasia. It is accepted that intimal hyperplasia is a multifactorial inflammatory process that starts immediately after surgery. The role of acute changes in haemodynamic conditions when the vein is implanted into arterial circulation, especially shear stress, is not fully appreciated. This review provides an overview of intimal hyperplasia and the effect of acute shear stress changes on the activation of pro-inflammatory mediators.
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Affiliation(s)
- Liam W McQueen
- Department of Cardiovascular Sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Shameem S Ladak
- Department of Cardiovascular Sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester, UK.
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14
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McQueen LW, Ladak SS, Abbasciano R, George SJ, Suleiman MS, Angelini GD, Murphy GJ, Zakkar M. Next-Generation and Single-Cell Sequencing Approaches to Study Atherosclerosis and Vascular Inflammation Pathophysiology: A Systematic Review. Front Cardiovasc Med 2022; 9:849675. [PMID: 35419441 PMCID: PMC8996078 DOI: 10.3389/fcvm.2022.849675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background and Aims Atherosclerosis is a chronic inflammatory disease that remains the leading cause of morbidity and mortality worldwide. Despite decades of research into the development and progression of this disease, current management and treatment approaches remain unsatisfactory and further studies are required to understand the exact pathophysiology. This review aims to provide a comprehensive assessment of currently published data utilizing single-cell and next-generation sequencing techniques to identify key cellular and molecular contributions to atherosclerosis and vascular inflammation. Methods Electronic searches of Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases were undertaken from inception until February 2022. A narrative synthesis of all included studies was performed for all included studies. Quality assessment and risk of bias analysis was evaluated using the ARRIVE and SYRCLE checklist tools. Results Thirty-four studies were eligible for narrative synthesis, with 16 articles utilizing single-cell exclusively, 10 utilizing next-generation sequencing and 8 using a combination of these approaches. Studies investigated numerous targets, ranging from exploratory tissue and plaque analysis, cell phenotype investigation and physiological/hemodynamic contributions to disease progression at both the single-cell and whole genome level. A significant area of focus was placed on smooth muscle cell, macrophage, and stem/progenitor contributions to disease, with little focus placed on contributions of other cell types including lymphocytes and endothelial cells. A significant level of heterogeneity exists in the outcomes from single-cell sequencing of similar samples, leading to inter-sample and inter-study variation. Conclusions Single-cell and next-generation sequencing methodologies offer novel means of elucidating atherosclerosis with significantly higher resolution than previous methodologies. These approaches also show significant potential for translatability into other vascular disease states, by facilitating cell-specific gene expression profiles between disease states. Implementation of these technologies may offer novel approaches to understanding the disease pathophysiology and improving disease prevention, management, and treatment.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021229960, identifier: CRD42021229960.
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Affiliation(s)
- Liam W McQueen
- Department of Cardiovascular Sciences, Clinical Science Wing, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
| | - Shameem S Ladak
- Department of Cardiovascular Sciences, Clinical Science Wing, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
| | - Riccardo Abbasciano
- Department of Cardiovascular Sciences, Clinical Science Wing, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
| | - Sarah J George
- Bristol Heart Institute and Translational Biomedical Research Centre, Bristol Medical School, Bristol Royal Infirmary, University of Bristol, Bristol, United Kingdom
| | - M-Saadeh Suleiman
- Bristol Heart Institute and Translational Biomedical Research Centre, Bristol Medical School, Bristol Royal Infirmary, University of Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- Bristol Heart Institute and Translational Biomedical Research Centre, Bristol Medical School, Bristol Royal Infirmary, University of Bristol, Bristol, United Kingdom
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, Clinical Science Wing, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Science Wing, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
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15
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Zakkar M, Bruno VD, Zacek P, Di Centa I, Acar C, Khelil N, Debauchez M, Lansac E. Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach. Eur J Cardiothorac Surg 2021; 57:308-316. [PMID: 31292613 DOI: 10.1093/ejcts/ezz193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/02/2019] [Accepted: 05/05/2019] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty). METHODS Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair. RESULTS The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007). CONCLUSIONS Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.
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Affiliation(s)
- Mustafa Zakkar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France.,Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, UK
| | - Vito D Bruno
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University Hospital in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | | | - Christophe Acar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Nizar Khelil
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Mathieu Debauchez
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
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16
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Guida GA, Guida GA, Bruno VD, Zakkar M, De Garate E, Pecchinenda MT, Homes A, Borzellino C, Mendoza P, Pecora G, Bonillo I, Benedetto U, Calafiore AM, Angelini GD, Guida MC. Left thoracotomy approach for off-pump coronary artery bypass grafting surgery: 15 years of experience in 2500 consecutive patients. Eur J Cardiothorac Surg 2021; 57:271-276. [PMID: 31209460 DOI: 10.1093/ejcts/ezz180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 04/02/2019] [Accepted: 05/03/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Our goal was to describe the experience at 2 centres with off-pump coronary artery bypass grafting using a left thoracotomy. METHODS From January 2002 to December 2017, a total of 2528 consecutive patients (578 women, mean age 62.3 ± 9.1 years) were operated on using this technique. Data were collected prospectively and analysed retrospectively. RESULTS There were no conversions to median sternotomy and 6 patients (0.2%) were converted to on-pump CABG. The mean number of grafts per patient was 2.8 ± 0. 9. The 30-day mortality rate was 1.0% (25 patients). Most patients were extubated in the operating theatre (97.3%), and 47 patients (1.9%) needed re-exploration for bleeding. Seven patients (0.3%) experienced a cerebrovascular event; 4 (0.3%) had a postoperative myocardial infarction; and 84 (3.4%) had new-onset atrial fibrillation. A total of 1510 patients (61.1%) were discharged from the hospital in the first 48 h after surgery. Long-term survival rates were 98.8%, 93.6% and 69.1% at 1, 5 and 10 years, respectively (central image). During the follow-up period, 60 patients (2.9%) were re-examined for recurrence of angina with a new coronary angiogram; of those, 24 (1.2%) required percutaneous coronary intervention and 11 (0.5%) had redo surgery. CONCLUSIONS A left thoracotomy is a safe alternative to a median sternotomy for coronary artery bypass grafting on the beating heart, with low early complications and good mid- and long-term results.
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Affiliation(s)
- Gustavo Antonio Guida
- Department of Cardiac Surgery, Fundacardio Foundation, Valencia, Venezuela.,Bristol Heart Institute, Bristol University, Bristol, UK
| | | | | | - Mustafa Zakkar
- Bristol Heart Institute, Bristol University, Bristol, UK
| | | | | | - Alfredo Homes
- Cardiac Surgery Service, Clinica Acosta Aortiz, Barquisimeto, Venezuela
| | | | - Pablo Mendoza
- Department of Cardiac Surgery, Fundacardio Foundation, Valencia, Venezuela
| | - Giuseppina Pecora
- Department of Cardiac Surgery, Fundacardio Foundation, Valencia, Venezuela
| | - Ivan Bonillo
- Department of Cardiac Surgery, Fundacardio Foundation, Valencia, Venezuela
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17
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Marsico R, Zakkar M, Bruno VD, Mansour S, Bryan AJ, Angelini GD. The impact of patient-prosthesis mismatch on early and long-term survival after aortic replacement with the Edwards Perimount valve: A propensity score-matched analysis. J Card Surg 2021; 36:2269-2276. [PMID: 33821500 DOI: 10.1111/jocs.15534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND To investigate the impact of severe patient-prosthesis mismatch (PPM) related to the Edwards Lifesciences Perimount (EP) bioprosthesis in the aortic position on early in-hospital outcomes and long-term survival. METHODS A total of 5964 consecutive patients underwent aortic valve replacement at the Bristol Heart Institute between 1998 and 2014, 2667 representing the cohort of this study received EP. PPM was defined severe as EOAi < 0.65 cm2 /m2 . To minimize bias, propensity score matching was conducted and two groups A and B (without and with severe PPM) of 320 patients with similar preoperative characteristics were matched. We assessed early in-hospital outcomes including CVA, re-exploration for bleeding, low cardiac output, wound infection, acute renal injury, length of hospital stay, and long-term survival for both groups in unmatched and matched populations. RESULTS In the unmatched analysis, 18.3% of patients had severe PPM. Severe PPM was not associated with increased in-hospital mortality (4.5% vs. 2.9%, respectively, p = .09) or any other early adverse outcomes except increased length of hospital stay (10.57 ± 8.2 vs. 11.7 ± 9.4, respectively, p = .01). Long-term survival differed significantly between groups at 2 and 8 years (91.8% vs. 91.4% and 60.5% vs. 55.7%, respectively, p = .02). Matched analysis showed no differences between the groups in early health outcomes and overall survival at 2 and 8 years was also similar (89.7% vs. 91% and 57.3% vs. 58%, group A vs. B, respectively p = .9). CONCLUSION Presence of PPM does not seem to affect early in-hospital outcomes or late survival when using EP in patients undergoing aortic valve replacement.
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Affiliation(s)
- Roberto Marsico
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Vito D Bruno
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Sherif Mansour
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Alan J Bryan
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
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18
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Di Tommaso E, Rapetto F, Guida GA, Zakkar M, Bruno VD. Benefits of mitral valve repair over replacement in the elderly: a systematic review and meta-analysis. J Card Surg 2021; 36:2524-2530. [PMID: 33783032 DOI: 10.1111/jocs.15506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/09/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Mitral valve (MV) repair has demonstrated excellent short- and long-term outcomes, however, its merit in the elderly population is still debated. We conducted a meta-analysis of studies that have compared the MV repair to replacement in the elderly population. METHODS A systematic literature search was conducted for any study published on MV surgery on elderly patients (≥75 years old). A pooled risk-ratio meta-analysis was done to evaluate short-term mortality, postoperative complications, surgical timings, and long-term survival rates. RESULTS A total of nine retrospective observational studies were included in the quantitative meta-analysis. Pooled meta-analysis showed a reduced risk of short-term mortality for the MV repair group (risk ratio [RR] = 0.41 [0.24-0.71], p-value = .005). Postoperative neurological complications were in favor of repair, although not significantly (RR = 0.49 [0.21-1.11], p-value = .07). Operative timings (cardiopulmonary bypass and crossclamp time) were not different between the groups although no data were available on the complexity of the repairs. Long-term survival rates were in favor of the repairs (pooled treatment effect of -0.47 [-0.64; -0.29], p = .005). CONCLUSIONS MV surgery is a safe and effective procedure for the elderly. MV repair demonstrated better short-term outcomes compared to replacement. Long-term survival rates are significantly better after repair.
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Affiliation(s)
- Ettorino Di Tommaso
- Bristol Medical School, Translational Health Science, University of Bristol, Bristol, UK
| | - Filippo Rapetto
- Bristol Heart Institute, University Hospital Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Gustavo A Guida
- Bristol Heart Institute, University Hospital Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield General Hospital, University of Leicester, Leicester, UK
| | - Vito D Bruno
- Bristol Medical School, Translational Health Science, University of Bristol, Bristol, UK
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19
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Bruno VD, Zakkar M. Instantaneous wave- free ratio for decision making in cardiac surgery, an important step in the right direction. Int J Cardiol 2020; 326:71-72. [PMID: 33137326 DOI: 10.1016/j.ijcard.2020.10.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Vito D Bruno
- Bristol Medical School, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Research Floor Level 7, Queens' Building, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK.
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20
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Karapanagiotidis GT, Gukop PS, Zakkar M, Tossios P, Leventis F, Ntontos G, Sarsam MAI. Combination of internal (epicardial) and external (transthoracic) defibrillation during heart surgery. Indian J Thorac Cardiovasc Surg 2020; 36:163-165. [PMID: 33061118 DOI: 10.1007/s12055-019-00882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/17/2019] [Accepted: 09/22/2019] [Indexed: 10/25/2022] Open
Abstract
Objectives This report describes a modified defibrillation technique during cardiac surgery using a combined internal (epicardial) and external (transthoracic) defibrillation system. Methods We routinely used 30 J (J) shock between the epicardial pad placed directly onto the right atrium and the left anterolateral transthoracic pad placed in the left anterolateral chest wall directly to the skin in the area of the cardiac apex under the nipple. Results Thirty-two patients whom developed ventricular fibrillation (VF) during surgery were managed in theatre using this method. A single 30 J shock was successfully given in 29 patients while the remaining three required an additional shock with the same amount (30 J). Conclusions We believe that this technique is safe and complications free. It is easy to perform especially in patients with difficult access such as redo operations.
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Affiliation(s)
- Georgios Theodoros Karapanagiotidis
- Cardiothoracic Surgery Department, St George's Hospital, Blackshaw Road SW, Tooting, London, 17 0QT UK.,Cardiothoracic Surgery Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Philemon Sylvester Gukop
- Cardiothoracic Surgery Department, St George's Hospital, Blackshaw Road SW, Tooting, London, 17 0QT UK
| | - Mustafa Zakkar
- Cardiothoracic Surgery Department, St George's Hospital, Blackshaw Road SW, Tooting, London, 17 0QT UK
| | - Paschalis Tossios
- Cardiothoracic Surgery Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Fotios Leventis
- Cardiothoracic Surgery Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgios Ntontos
- Cardiothoracic Surgery Department, AHEPA University Hospital, Thessaloniki, Greece
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21
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Ward AO, Angelini GD, Caputo M, Evans PC, Johnson JL, Suleiman MS, Tulloh RM, George SJ, Zakkar M. NF-κB inhibition prevents acute shear stress-induced inflammation in the saphenous vein graft endothelium. Sci Rep 2020; 10:15133. [PMID: 32934266 PMCID: PMC7492228 DOI: 10.1038/s41598-020-71781-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 08/14/2020] [Indexed: 12/17/2022] Open
Abstract
The long saphenous vein (LSV) is commonly used as a conduit in coronary artery bypass grafting. However, long term patency remains limited by the development of vascular inflammation, intimal hyperplasia and accelerated atherosclerosis. The impact of acute exposure of venous endothelial cells (ECs) to acute arterial wall shear stress (WSS) in the arterial circulation, and the subsequent activation of inflammatory pathways, remain poorly defined. Here, we tested the hypothesis that acute exposure of venous ECs to high shear stress is associated with inflammatory responses that are regulated by NF-κB both in-vitro and ex-vivo. Analysis of the LSV endothelium revealed that activation of NF-κB occurred within 30 min after exposure to arterial rates of shear stress. Activation of NF-κB was associated with increased levels of CCL2 production and enhanced binding of monocytes in LSVECs exposed to 6 h acute arterial WSS. Consistent with this, ex vivo exposure of LSVs to acute arterial WSS promoted monocyte interactions with the vessel lumen. Inhibition of the NF-κB pathway prevented acute arterial WSS-induced CCL2 production and reduced monocyte adhesion, both in vitro and in human LSV ex vivo, demonstrating that this pathway is necessary for the induction of the acute arterial WSS-induced pro-inflammatory response. We have identified NF-κB as a critical regulator of acute endothelial inflammation in saphenous vein in response to acute arterial WSS. Localised endothelial-specific inhibition of the NF-κB pathway may be beneficial to prevent vein graft inflammation and consequent failure.
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Affiliation(s)
- Alexander O Ward
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Gianni D Angelini
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Massimo Caputo
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Paul C Evans
- Department of Infection, Immunity and Cardiovascular Diseases, University of Sheffield, Sheffield, S10 2TN, UK
| | - Jason L Johnson
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - M Saadeh Suleiman
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Robert M Tulloh
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Sarah J George
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - Mustafa Zakkar
- Bristol Medical School, University of Bristol, Research Floor Level 7, Queens' Building, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW, UK.
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22
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Bruno VD, Zakkar M. Commentary: Don't get lost in the loop. JTCVS Tech 2020; 3:122-123. [PMID: 34317838 PMCID: PMC8302933 DOI: 10.1016/j.xjtc.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Vito Domenico Bruno
- Bristol Medical School - Translational Health Science, University of Bristol, Bristol, United Kingdom
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, United Kingdom
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23
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Guida G, Ward AO, Bruno VD, George SJ, Caputo M, Angelini GD, Zakkar M. Saphenous vein graft disease, pathophysiology, prevention, and treatment. A review of the literature. J Card Surg 2020; 35:1314-1321. [PMID: 32353909 DOI: 10.1111/jocs.14542] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The saphenous vein remains the most frequently used conduit for coronary artery bypass grafting, despite reported unsatisfactory long-term patency rates. Understanding the pathophysiology of vein graft failure and attempting to improve its longevity has been a significant area of research for more than three decades. This article aims to review the current understanding of the pathophysiology and potential new intervention strategies. METHODS A search of three databases: MEDLINE, Web of Science, and Cochrane Library, was undertaken for the terms "pathophysiology," "prevention," and "treatment" plus the term "vein graft failure." RESULTS Saphenous graft failure is commonly the consequence of four different pathophysiological mechanisms, early acute thrombosis, vascular inflammation, intimal hyperplasia, and late accelerated atherosclerosis. Different methods have been proposed to inhibit or attenuate these pathological processes including modified surgical technique, topical pretreatment, external graft support, and postoperative pharmacological interventions. Once graft failure occurs, the available treatments are either surgical reintervention, angioplasty, or conservative medical management reserved for patients not eligible for either procedure. CONCLUSION Despite the extensive amount of research performed, the pathophysiology of saphenous vein graft is still not completely understood. Surgical and pharmacological interventions have improved early patency and different strategies for prevention seem to offer some hope in improving long-term patency.
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Affiliation(s)
- Gustavo Guida
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Alex O Ward
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Vito D Bruno
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Sarah J George
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK.,Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, England
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24
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Bruno VD, Zakkar M, Guida G, Rapetto F, Rathore A, Ascione R. Combined Degenerative Mitral Valve and Coronary Surgery: Early Outcomes and 10-Year Survival. Ann Thorac Surg 2020; 110:1527-1533. [PMID: 32277884 DOI: 10.1016/j.athoracsur.2020.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 01/01/2020] [Accepted: 03/02/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study investigated the impact of combined degenerative mitral valve (DMV) and coronary artery bypass grafting (CABG+DMV) surgery vs DMV surgery only on in-hospital health outcome and 10-year survival. METHODS We identified 745 patients with DMV disease. Of these, 186 (24.9%) were affected also by coronary disease and underwent combined DMV+CABG. They were compared with the remaining 559 patients receiving DMV-only surgery in in-hospital and 1-, 5-, and 10-year survival. We evaluated a short-term composite outcome of hospital mortality, acute kidney injury, cerebrovascular events, and low cardiac output requiring postoperative use of intraaortic balloon pump. In addition, we assessed mitral valve repair rates over time and their correlation with long-term survival. To minimize bias, we conducted a propensity score-matching analysis. RESULTS DMV+CABG surgery was associated with a similar incidence of the composite end point compared with DMV-only surgery in the unmatched analysis (6.5% vs 5.4%, P = .71) and matched analysis (7.5% vs 8.2%, P = .82). The 10-year survival was 70.5% vs 68.6% (P = .07) for the unmatched analysis and 64.6% vs 62.5% (P = .9) for the matched analysis, DMV+CABG vs DMV-only, respectively. Mitral valve repair had a beneficial effect on short-term outcomes and long-term mortality rates, regardless the presence of concomitant coronary surgery. CONCLUSIONS Combined DMV+CABG surgery is a very effective surgical treatment with high mitral valve repair rate. Early in-hospital outcome and long-term survival are comparable with DMV-only surgery. In these combined procedures, mitral valve repair is associated with better long-term survival.
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Affiliation(s)
- Vito D Bruno
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Mustafa Zakkar
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Gustavo Guida
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Filippo Rapetto
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Asif Rathore
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Raimondo Ascione
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom.
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25
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Stoica SC, Dorobantu DM, Vardeu A, Biglino G, Ford KL, Bruno DV, Zakkar M, Mumford A, Angelini GD, Caputo M, Emanueli C. MicroRNAs as potential biomarkers in congenital heart surgery. J Thorac Cardiovasc Surg 2020; 159:1532-1540.e7. [PMID: 31043318 DOI: 10.1016/j.jtcvs.2019.03.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 03/10/2019] [Accepted: 03/26/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Pediatric congenital heart surgery (CHS) involves intracardiac, valvular, and vascular repairs. Accurate tools to aid short-term outcome prediction in pediatric CHS are lacking. Clinical scores, such as the vasoactive-inotrope score and ventilation index, are used to define outcome in clinical studies. MicroRNA-1-3p (miR-1) is expressed by both cardiomyocytes and vascular cells and is regulated by hypoxia. In adult patients, miR-1 increases in the circulation after open-heart cardiac surgery, suggesting its potential as a clinical biomarker. Thus, we investigated whether perioperative circulating miR-1 measurements can help predict post-CHS short-term outcomes in pediatric patients. METHODS Plasma miR-1 was retrospectively measured in a cohort of 199 consecutive pediatric CHS patients (median age 1.2 years). Samples were taken before surgery and at the end of the operation. Plasma miR-1 concentration was measured by reverse transcription-quantitative polymerase chain reaction and expressed as miR-1 copies/μL and as relative expression to spiked-in exogenous cel-miR-39. RESULTS Baseline plasma miR-1 did not vary across different diagnoses, increased during surgery (204-fold median relative increase, P < .001), and was associated with aortic crossclamp duration postoperatively (P < .001). Importantly, miR-1 levels at the end of the operation positively correlated with intensive care stay (P < .001), early severe cardiovascular events (P = .01), and with high vasoactive-inotrope score (P = .001) and ventilation index (P < .001), suggesting that miR-1 could accelerate the identification of patients with cardiopulmonary bypass-related ischemic complications, requiring more intensive support. CONCLUSIONS Our study suggests miR-1 as a novel potential circulating biomarker to predict early postoperative outcome and inform clinical management in pediatric heart surgery.
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Affiliation(s)
- Serban C Stoica
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Dan M Dorobantu
- Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom; "Professor C.C. Iliescu" Emergency Institute for Cardiovascular Diseases, Cardiology Department, Bucharest, Romania
| | - Antonella Vardeu
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Giovanni Biglino
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Kerrie L Ford
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Domenico V Bruno
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Mustafa Zakkar
- Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Andrew Mumford
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom; Rush Medical Center, Chicago, Ill
| | - Costanza Emanueli
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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26
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Zakkar M, Bruno VD. Commentary: Cardioplegia in complex root surgery for adults: Many solutions, but does it really matter? J Thorac Cardiovasc Surg 2020; 162:526-527. [PMID: 32127204 DOI: 10.1016/j.jtcvs.2020.01.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 01/29/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Vito Domenico Bruno
- Translational Health Science, Bristol Medical School, University of Bristol, Bristol, United Kingdom.
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27
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Bruno VD, Zakkar M. Commentary: Concomitant atrial fibrillation ablation: The forgotten procedure. J Thorac Cardiovasc Surg 2020; 161:1825-1826. [PMID: 31932060 DOI: 10.1016/j.jtcvs.2019.10.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Vito Domenico Bruno
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, United Kingdom
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28
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Abstract
Reconstruction of the intervalvular fibrosa is normally associated with endocarditis and the surgical principles are well established. Here, we describe how these principles are further extended and applied for the elective enlargement of the aorto-mitral continuity. Our aim was to achieve double valve upsizing in noninfective conditions. The first patient had rheumatic fever and a first double valve replacement as an adult. Her two tissue valves were later upsized at the time of replacement with mechanical prostheses. The concept was then used to perform a substantial annular enlargement in another adult patient whose original double valve replacement was done in childhood, when she received aortic and mitral prostheses measuring 17 and 23 mm, respectively. After upsizing with the technique described, her new valves were 25 and 29 mm in diameter.
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Affiliation(s)
- Daniel Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | | | - Serban Stoica
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
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29
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Carlotta B, Zakkar M, Zacek P, Palladino M, Lansac E. Bicuspid aortic valve repair with hemi‐remodeling technique and external ring annuloplasty. J Card Surg 2019; 35:146-150. [DOI: 10.1111/jocs.14334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Brega Carlotta
- Department of Cardiac Surgery Institute Mutualiste Montsouris Paris France
| | - Mustafa Zakkar
- Department of Cardiac Surgery, School of Clinical Sciences, Bristol Heart Institute University of Bristol Bristol UK
| | - Pavel Zacek
- Department of Cardiac Surgery, Faculty of Medicine and Faculty Hospital Charles University in Prague Hradec Kralove Czech Republic
| | - Michele Palladino
- Department of Cardiac Surgery Institute Mutualiste Montsouris Paris France
| | - Emmanuel Lansac
- Department of Cardiac Surgery Institute Mutualiste Montsouris Paris France
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30
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Benedetto U, Caputo M, Zakkar M, Davies A, Gibbison B, Bryan A, Angelini GD. The effect of obesity on survival in patients undergoing coronary artery bypass graft surgery who receive a radial artery. Eur J Cardiothorac Surg 2019; 51:376-381. [PMID: 28186261 DOI: 10.1093/ejcts/ezw323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 12/15/2022] Open
Affiliation(s)
- Umberto Benedetto
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Alan Davies
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Ben Gibbison
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Alan Bryan
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
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31
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Abstract
The bicuspid aortic valve (BAV) is the most common congenital cardiovascular anomaly and may present with differing phenotypes including almost constant annular dilation. We have developed a standardized approach to BAV repair with a systematic adjunct of aortic annuloplasty according to the three phenotypes of the proximal aorta, which include a dilated aortic root, dilated ascending aorta and normal root and ascending aorta. In our cohort of 191 patients, freedom from AV-related re-intervention was 98% for remodeling with annuloplasty (n=100) and 100% for tubular aortic replacement with annuloplasty (n=31) at 8 years. In an isolated aortic insufficiency (AI) group, freedom from AV-related re-intervention varied from 72.4% with a single subvalvular annuloplasty ring (n=31) compared to 100% at 6 years when a double sub- and supra-valvular (STJ) annuloplasty ring was performed (n=29). Restoration of the annulus: sinotubular junction (STJ) ratio is a key factor to ensure longevity of the bicuspid valve repair and freedom from re-intervention.
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Affiliation(s)
- Mustafa Zakkar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France.,Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Pouya Youssefi
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Christophe Acar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Nizar Khelil
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Mathieu Debauchez
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
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32
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Zakkar M, Youssefi P, Di Centa I, Khelil N, Debauchez M, Lansac E. Isolated aortic valve repair-how to do it and long-term results: external ring annuloplasty. Ann Cardiothorac Surg 2019; 8:418-421. [PMID: 31240190 DOI: 10.21037/acs.2019.04.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mustafa Zakkar
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France.,Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Pouya Youssefi
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | | | - Nizar Khelil
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Mathieu Debauchez
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
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33
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Bruno VD, Zakkar M. Commentary: Aortic valve sparing procedure: Is this the future of aortic root surgery? J Thorac Cardiovasc Surg 2019; 158:1512-1513. [PMID: 31005296 DOI: 10.1016/j.jtcvs.2019.02.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/26/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Vito Domenico Bruno
- Translational Health Science Department, Bristol Medical School, University of Bristol, Bristol, United Kingdom.
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; Clinical Sciences Wing, Glenfield General Hospital, Leicester, United Kingdom
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34
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Zakkar M, Benedetto U, Angelini GD, Murphy G, Shah R, Jahangiri M, Page R. Cardiothoracic surgery training in the United Kingdom. J Thorac Cardiovasc Surg 2018; 157:1948-1955. [PMID: 30661815 DOI: 10.1016/j.jtcvs.2018.11.076] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 11/02/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Mustafa Zakkar
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom.
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom
| | - Gianni D Angelini
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom
| | - Gavin Murphy
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, United Kingdom
| | - Rajesh Shah
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Marjan Jahangiri
- Department of Cardiothoracic Surgery, St George's Hospital, University of London, London, United Kingdom
| | - Richard Page
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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35
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Bruno VD, Zakkar M. Psoas muscle index: a novel instrument in planning the treatment of severe aortic stenosis in frail patients. J Thorac Dis 2018; 10:S4156-S4158. [PMID: 30631580 DOI: 10.21037/jtd.2018.10.80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Vito D Bruno
- Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol, UK
| | - Mustafa Zakkar
- Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol, UK.,Department of Cardiothoracic surgery, St George's Hospital NHS Trust, London, UK
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36
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Guida GA, Ward A, Bruno VD, Sarah George P, Krishnadas R, Gianni P, Angelini D, Zakkar M. P13 INCREASED EXPRESSION AND TRANSLOCATION OF KRUPPEL-LIKE FACTOR 4 AND SMOOTH MUSCLE ALPHA ACTIN AFTER BEING SUBMITTED TO ACUTE SHEAR STRESS IN AN EX-VIVO MODEL. Cardiovasc Res 2018. [DOI: 10.1093/cvr/cvy216.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gustavo A Guida
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Alex Ward
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Vito D Bruno
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Prof Sarah George
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Rakesh Krishnadas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Prof Gianni
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - D Angelini
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
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37
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Bianco R, Di Gregoli K, Caputo M, Zakkar M, George SJ, Johnson JL. P2 VALIDATION OF A NOVEL HUMAN EX-VIVO MODEL OF ANEURYSM TO SUPPLANT MOUSE MODELS. Cardiovasc Res 2018. [DOI: 10.1093/cvr/cvy216.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- R Bianco
- Laboratory of Cardiovascular Pathology, Bristol Medical School, University of Bristol, Bristol, UK
| | - K Di Gregoli
- Laboratory of Cardiovascular Pathology, Bristol Medical School, University of Bristol, Bristol, UK
| | - M Caputo
- Laboratory of Cardiovascular Pathology, Bristol Medical School, University of Bristol, Bristol, UK
| | - M Zakkar
- Laboratory of Cardiovascular Pathology, Bristol Medical School, University of Bristol, Bristol, UK
| | - S J George
- Laboratory of Cardiovascular Pathology, Bristol Medical School, University of Bristol, Bristol, UK
| | - J L Johnson
- Laboratory of Cardiovascular Pathology, Bristol Medical School, University of Bristol, Bristol, UK
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Abstract
The role of concomitant aortic and pectus repair in Marfan patients remains controversial. We present our surgical technique for concomitant aortic repair of aortic root pathology and pectus correction. The concomitant surgery can be safely achieved in Marfan patients, thus, avoiding the need for a risky second stage operation.
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Affiliation(s)
- Mustafa Zakkar
- Department of Cardiac Surgery, L‘Institut Mutualiste Montsouris, Paris, France
- Department of Cardiothoracic Surgery, Bristol Heart Institute, Bristol, UK
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L‘Institut Mutualiste Montsouris, Paris, France
| | - Alain Wurtz
- Department of Thoracic Surgery, L‘Institut Mutualiste Montsouris, Paris, France
| | - Emmanuel Brian
- Department of Thoracic Surgery, L‘Institut Mutualiste Montsouris, Paris, France
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39
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Bianco R, Di Gregoli K, Caputo M, Zakkar M, George S, Johnson J. Development and characterisation of a human ex-vivo model of aneurysm. Atherosclerosis 2018. [DOI: 10.1016/j.atherosclerosis.2018.06.425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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40
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Brown B, Jayaraman P, Zakkar M, Pula G, Gaston K, George S. Casein kinase-2 (CK2) inhibition by TBCA attenuates VSMC and fibroblast proliferation without adverse effects on endothelial cell behaviour or inflammation. Atherosclerosis 2018. [DOI: 10.1016/j.atherosclerosis.2018.06.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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41
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Bruno VD, Zakkar M, Rapetto F, Rathore A, Marsico R, Chivasso P, Ascione R. Early health outcome and 10-year survival in patients undergoing redo coronary surgery with or without cardiopulmonary bypass: a propensity score-matched analysis. Eur J Cardiothorac Surg 2018; 52:945-951. [PMID: 28505298 PMCID: PMC5848803 DOI: 10.1093/ejcts/ezx137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/17/2017] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To investigate the in-hospital health outcome and 10-year survival in patients undergoing redo coronary surgery with (redo-CABG) or without (redo-OPCAB) cardiopulmonary bypass. METHODS A total of 349 redo coronary surgery patients were identified from our registry. Of these, 143 redo-OPCAB patients (40.97%) were compared with 206 redo-CABG patients. To minimize the bias, we also conducted propensity score matching. In Matched Analysis A, 111 redo-OPCAB patients with any type of primary cardiac operation were compared with 111 redo-CABG cases. In Matched Analysis B, 84 redo-OPCAB patients with isolated coronary surgery as their primary operation were compared with 84 redo-CABG patients. We assessed for all 3 analyses a composite of in-hospital mortality, acute kidney injury, stroke and severe low cardiac output requiring intra-aortic balloon pump. In addition, we assessed 1-, 5-, and 10-year survival. RESULTS In the unmatched analysis, redo-CABG was associated with higher usage of intra-aortic balloon pump (10 vs 3%, P = 0.01) and composite compared with redo-OPCAB (25 vs 16%, P = 0.06) and similar 10-year survival (67.2 vs 68.5%, log-rank test: P = 0.78). Matched Analysis A showed similar rates of composite (15 vs 21%, P = 0.25) and 10-year survival (65.1 vs 60.8%, log-rank test: P = 0.5). Matched Analysis B showed reduction of the composite (19 vs 8%, P = 0.04), less in-hospital mortality (5 vs 0%, P = 0.13), 4.5 times less need for intra-aortic balloon pump (2 vs 11%, P = 0.02) favouring redo-OPCAB and a similar 10-year survival (71.6 vs 71.7%, log-rank test: P = 0.61). CONCLUSIONS Redo-OPCAB surgery is feasible, safe and effective with improved in-hospital outcome and similar 10-year survival compared to redo-CABG.
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Affiliation(s)
- Vito D Bruno
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Filippo Rapetto
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Asif Rathore
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Roberto Marsico
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Pierpaolo Chivasso
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Raimondo Ascione
- School of Clinical Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
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42
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Zakkar M, Angelini GD. Totally endoscopic coronary artery bypass grafting, the new frontier. Int J Cardiol 2018; 261:47-48. [PMID: 29657056 DOI: 10.1016/j.ijcard.2018.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
Affiliation(s)
- M Zakkar
- Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, BS2 8HW Bristol, UK
| | - G D Angelini
- Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, BS2 8HW Bristol, UK.
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43
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Bianco R, Di Gregoli K, Caputo M, Zakkar M, George SJ, Johnson JL. 28Development and characterisation of a human ex-vivo model of aneurysm. Cardiovasc Res 2018. [DOI: 10.1093/cvr/cvy060.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- R Bianco
- University of Bristol, School of Clinical Sciences., Bristol, United Kingdom
| | - K Di Gregoli
- University of Bristol, School of Clinical Sciences., Bristol, United Kingdom
| | - M Caputo
- University of Bristol, School of Clinical Sciences., Bristol, United Kingdom
| | - M Zakkar
- University of Bristol, School of Clinical Sciences., Bristol, United Kingdom
| | - S J George
- University of Bristol, School of Clinical Sciences., Bristol, United Kingdom
| | - J L Johnson
- University of Bristol, School of Clinical Sciences., Bristol, United Kingdom
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44
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Zakkar M, Bruno VD, Visan AC, Curtis S, Angelini G, Lansac E, Stoica S. Surgery for Young Adults With Aortic Valve Disease not Amenable to Repair. Front Surg 2018; 5:18. [PMID: 29564333 PMCID: PMC5850822 DOI: 10.3389/fsurg.2018.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/12/2018] [Indexed: 11/27/2022] Open
Abstract
Aortic valve replacement is the gold standard for the management of patients with severe aortic stenosis or mixed pathology that is not amenable to repair according to currently available guidelines. Such a simplified approach may be suitable for many patients, but it is far from ideal for young adults considering emerging evidence demonstrating that conventional valve replacement in this cohort of patients is associated with inferior long-term survival when compared to the general population. Moreover; the utilisation of mechanical and bioprosthetic valves can significantly impact on quality and is linked to increased rates of morbidities. Other available options such as stentless valve, homografts, valve reconstruction and Ross operation can be an appealing alternative to conventional valve replacement. Young patients should be fully informed about all the options available - shared decision making is now part of modern informed consent. This can be achieved when referring physicians have a better understanding of the short and long term outcomes associated with every intervention, in terms of survival and quality of life. This review presents up to date evidence for available surgical options for young adults with aortic stenosis and mixed disease not amenable to repair.
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Affiliation(s)
- Mustafa Zakkar
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom.,Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Vito Domanico Bruno
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Alexandru Ciprian Visan
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Stephanie Curtis
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Gianni Angelini
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Serban Stoica
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
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45
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Brega C, Zakkar M, Lansac E. Aortic valve cord mimicking fibroelastoma. Eur J Cardiothorac Surg 2017. [PMID: 28637231 DOI: 10.1093/ejcts/ezx204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Mustafa Zakkar
- Institute Mutualiste Montsouris, Paris, France.,Department of Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
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46
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Affiliation(s)
- Emma Redfern
- Consultant in Accident and Emergency, Department of Accident and Emergency, Bristol Royal Infirmary, Bristol BS2 8HW
| | - Mark Callaway
- Consultant Radiologist, Department of Radiology, Bristol Royal Infirmary, Bristol
| | - Mustafa Zakkar
- Academic Clinical Lecturer in Cardiac Surgery, Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol
| | - Alan J Bryan
- Consultant Cardiac Surgeon, Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol
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47
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Guida GA, Chivasso P, Fudulu D, Rapetto F, Sedmakov C, Marsico R, Zakkar M, Bryan AJ, Angelini GD. Off-pump coronary artery bypass grafting in high-risk patients: a review. J Thorac Dis 2016; 8:S795-S798. [PMID: 27942397 DOI: 10.21037/jtd.2016.10.107] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The role of off-pump coronary artery bypass (OPCAB) grafting in high risk patients remains controversial. While there have been studies showing the potential benefits of it, there is still a lot to be learned from the application of this technique in this sub-group of patients. The results of the different trials and papers that we reviewed seem to indicate a benefit in the OPCAB group. Despite of the fact that trials were significantly different in methodology, especially when choosing the risk score stratification tool or the cut-off to define high risk the literature seems to suggest a benefit from the use of OPCAB surgery. Here, we present a review which focussed on early and late outcome in high risk patients undergoing on- and off-pump coronary revascularization.
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Affiliation(s)
| | | | - Daniel Fudulu
- Bristol Heart Institute, Bristol University, Bristol, UK
| | | | | | | | - Mustafa Zakkar
- Bristol Heart Institute, Bristol University, Bristol, UK
| | - Alan J Bryan
- Bristol Heart Institute, Bristol University, Bristol, UK
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48
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Chivasso P, Guida GA, Fudulu D, Bruno VD, Marsico R, Sedmakov H, Zakkar M, Rapetto F, Bryan AJ, Angelini GD. Impact of off-pump coronary artery bypass grafting on survival: current best available evidence. J Thorac Dis 2016; 8:S808-S817. [PMID: 27942399 DOI: 10.21037/jtd.2016.10.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The superiority of either off-pump (OPCAB) or on-pump (ONCAB) coronary artery bypass grafting (CABG) remains unclear despite a large body of literature evidence comparing the two approaches. The potential advantages of avoiding cardiopulmonary bypass (CPB), minimizing aortic manipulation and maintaining pulsatile flow may be associated with reduced inflammatory responses and embolic events. Numerous studies compared OPCAB with ONCAB and the cumulative data have been presented in meta-analyses of both randomized and observational studies. Although there is an abundance of data with respect to the operative morbidity and mortality and the short-term outcomes associated with these two strategies, not much is known about how they impact long-term survival and recurrence of myocardial ischaemic events. Recent studies and meta-analyses have focused on long-term survival and major secondary outcomes in OPCAB vs. ONCAB within the general population. Significant limitations in methodology, however, have raised concerns about the strength of several randomized trials with restrictive inclusion criteria that reduced the populations to those at low risk only, thus creating result bias. Here, we present a review of the best available evidence with a focus on long-term outcomes.
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Affiliation(s)
- Pierpaolo Chivasso
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Gustavo A Guida
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Daniel Fudulu
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Vito D Bruno
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Roberto Marsico
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Hristo Sedmakov
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Mustafa Zakkar
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Filippo Rapetto
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Alan J Bryan
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, Bristol University, Upper Maudlin Street, BS2 8HW, Bristol, UK
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49
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Affiliation(s)
- M Zakkar
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - A J Bryan
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| | - G D Angelini
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
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50
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Benedetto U, Caputo M, Zakkar M, Bryan A, Angelini GD. Are three arteries better than two? Impact of using the radial artery in addition to bilateral internal thoracic artery grafting on long-term survival. J Thorac Cardiovasc Surg 2016; 152:862-869.e2. [DOI: 10.1016/j.jtcvs.2016.04.054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/11/2016] [Accepted: 04/19/2016] [Indexed: 11/26/2022]
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