Periprocedural Myocardial Infarction and Injury

Periprocedural myocardial infarction (PMI) and injury, pertinent to both cardiac and non-cardiac procedures, have gained increasing recognition in clinical practice. Over time, diverse definitions for diagnosing PMI have been developed and validated among patient populations undergoing coronary revascularization. However, this variety in definitions presents considerable challenges in clinical settings and complicates both the design and interpretation of clinical trials. The necessity to accurately diagnose PMI has spurred significant interest in establishing universally accepted and prognostically meaningful thresholds for cardiac biomarkers elevation and supportive ancillary criteria. In fact, elevations in cardiac biomarkers in line with the 4th Universal Definition of Myocardial Infarction, have been extensively confirmed to be associated with increased mortality and cardiovascular events. In the context of non-coronary cardiac procedures, such as Transcatheter Aortic Valve Implantation, there is a growing acknowledgment of both the high incidence rates and the adverse impact of PMI on patient outcomes. Similarly, emerging research underscores the significance of PMI and injury in non-cardiac surgery, highlighting the urgent need for effective prevention and risk management strategies in this domain.

Investigate the relationship between obstructive sleep apnea and cardiac arrhythmia after CABG surgery

BACKGROUND AND OBJECTIVE

Heart rhythm disorder is one of the most common problems after coronary artery bypass graft surgery. Various factors, such as the history of sleep apnoea before the operation, may aggravate the occurrence of this disorder. The present study was conducted to determine the relationship between sleep apnoea before surgery and heart rhythm disorder after surgery in patients undergoing coronary Artery Bypass Grafting in 2019.

METHODS

This analytical cross-sectional study was conducted on 192 patients who were selected by sequential sampling. The research tool included demographic information, a checklist of heart rhythm disorders, and the Berlin sleep apnoea questionnaire. Descriptive statistics and the Chi-square test, Fisher's exact test, Mann-Whitney's U-test, and logistic regression were used to analyze the data.

RESULTS

A total of 71.35% of the samples were male, and the mean age of the participants was 57.8 ± 7.5 years. Also, 46.0% of the samples had sleep pane and 21.35% had rhythm disorder. The most frequent heart rhythm disorder in patients with obstructive sleep apnoea was atrial fibrillation. There was a significant relationship between the occurrence of rhythm disorder and a history of smoking (P = 0.021), and the regression model showed that a history of smoking is the only variable related to the occurrence of rhythm disorder after coronary Artery Bypass Grafting (P = 0.005, CI 95%: 6.566-1.386, OR = 3.017).

CONCLUSIONS

The results showed that there is no statistically significant relationship between sleep apnea and rhythm disorder after coronary artery bypass surgery.

Post-Infarction Ventricular Septal Defect: A quarter century experience

Objectives

Post-infarction ventricular septal defect (VSD) is one of the known complications after acute myocardial infarction. This study investigated the clinical results after surgical repair of VSD.

Methods

This retrospective study included all patients undergoing surgical repair of VSD from 1996 to 2020 in Oman.

Results

Out of a total of 75 patients, 62.5% were men, with a mean age of 59 years. The mean follow-up was 17.2 (7.5) years. Of the 75 patients, 34 (45.3%) patients died within 30 days. Total survival was 41.3% at 5 years, while the 10-year survival rate was 33.3%. Outcomes and predictors for 30 days mortality were the number of concomitant coronary involvement and anastomoses performed, residual postoperative shunt and postoperative dialysis.

Conclusion

Even with surgical repair, early mortality of post-infarction septal defect is still considerably high. Early repair and the anatomically posterior rupture are predictors of early mortality. In patients surviving the immediate postoperative period, long-term survival is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.

Five-Year Follow-Up After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis and Concomitant Coronary Artery Disease: A Single-Center Experience

INTRODUCTION

There is no consensus on the impact of coronary artery disease in patients undergoing transcatheter aortic valve implantation. Therefore, the objective of this study was, in a single-center setting, to evaluate the five-year outcome of transcatheter aortic valve implantation patients with or without coronary artery disease.

METHODS

All transcatheter aortic valve implantation patients between 2009 and 2019 were included and grouped according to the presence or absence of coronary artery disease. The primary endpoint, five-year all-cause mortality, was evaluated using Cox regression adjusted for age, sex, procedure years, and comorbidities. Comorbidities interacting with coronary artery disease were evaluated with interaction tests. In-hospital complications was the secondary endpoint.

RESULTS

In total, 176 patients had aortic stenosis and concomitant coronary artery disease, while 170 patients had aortic stenosis only. Mean follow-up was 2.2±1.6 years. There was no difference in the adjusted five-year all-cause mortality between transcatheter aortic valve implantation patients with and without coronary artery disease (hazard ratio 1.00, 95% confidence interval 0.59-1.70, P=0.99). In coronary artery disease patients, impaired renal function, peripheral arterial disease, or ejection fraction < 50% showed a significant interaction effect with higher five-year all-cause mortality. No significant differences in complications between the groups were found.

CONCLUSION

Five-year mortality did not differ between transcatheter aortic valve implantation patients with or without coronary artery disease. However, in patients with coronary artery disease and impaired renal function, peripheral arterial disease, or ejection fraction < 50%, we found significantly higher five-year all-cause mortality.

Effects of glargine on hyperglycemia in patients with diabetes mellitus type II undergoing off-pump coronary artery bypass graft: A randomized, controlled, double-blind clinical trial

Introduction: In this trial, effects of glargine on hyperglycemia in patients with diabetes mellitus type II who were undergoing off-pump coronary artery bypass graft (CAGB), were examined. Methods: Seventy diabetic patients who were candidate for off-pump CABG were randomly divided into the following two groups (1) Control group who were treated with normal saline+regular insulin and (2) Glargine group who received glargine+regular insulin. Normal saline and glargine were administered subcutaneously 2 hours before surgery, and regular insulin was injected before, during and after the surgery in the intensive care unit (ICU) in both groups. Finally, levels of blood sugar before, 2 hours after starting the surgery and at the end of the surgery, were recorded. Blood sugar levels during ICU stay were also measured every 4 hours for 36 hours. Results: There were no significant differences in blood sugar levels between the groups at the three time points (i.e. before, 2 hours after starting the surgery and at the end of the surgery). In addition, during 36 hours of ICU stay, blood sugar levels did not show significant variations between the groups; however, 20 hours after ICU admission, blood sugar level was significantly higher in the glargine group (P=0.04). Conclusion: The results indicated that both glargine and regular insulin effectively control the blood glucose in diabetic patients undergoing CABG. However, the blood sugar fluctuation was less in the glargine group than control group.

Intraoperative Awareness in Patients Undergoing Cardiac Surgery in an Academic Center in the North of Iran

Background

Coronary artery bypass grafting (CABG) has distinctive characteristics that may increase the risk of awareness during general anesthesia (AGA).

Objectives

This study was conducted to assess the incidence of AGA in cardiac surgery in an academic hospital in Guilan, Iran.

Methods

This descriptive cross-sectional study was performed in Dr. Heshmat Hospital in Rasht, Iran. Eligible patients candidates for CABG were enrolled in the survey in 2022. After surgery, when the patient was cooperative enough, a questionnaire including demographic data and specialized questions related to different stages of anesthesia was completed via face-to-face interviews. The data were analyzed using IBM SPSS Statistics 21 with chi-square, Fisher's exact, and t-test.

Results

The data from 322 patients were analyzed, of whom 14 (4.3%) experienced AGA. Among them, the "feeling of fear and anxiety" reported by 9 (39.1%) cases was the most common awareness state. "Dreaming during surgery and anesthesia" and "feeling unable to move during anesthesia,", each reported by 6 (26.1%) cases, were the other common types of awareness state. None of the demographic data had a significant association with the occurrence of AGA.

Conclusions

The incidence of AGA during CABG was almost acceptable according to the credible evidence.

Non Invasive Detection of Coronary Sinus Flow Changes Over Time After CABG

Background

Coronary New blood in the vascular bed after Coronary Artery Bypass Grafting (CABG) may represent a turning point between ischemia and normal tissue nutrition. Its quantification can help to better understand coronary artery hemodynamics after revascularization.

Objective

Quantification of coronary sinus blood flow changes over time after Coronary Artery Bypass Grafting (CABG) using Transthoracic Echocardiography (TTE).

Methods

Prospective basic research, with repeated measurements on hospital sample of 61 patients whom CABG was conducted. We performed TTE recordings to measure CS flow before and two times after CABG (1 and 6 postoperative day). We measure CS diameter, Velocity Time Integral (VTI) and systemic hemodynamic data. Data needed for LV mass calculation were recorded once. During statistical analysis we define: α = 0,01, β = 0,01 (power = 1-β β= 0,99), Sample size = 60, Effect size= 0,68. We used ANOVA for Repeated Measures as main statistical test in SPSS.

Results

Preoperatively we found low overall CS flow of 181 ±72 ml/min (0,68 ±0,30 ml/gram-LV/min). After surgery there was constant increase of CS flow from 276 ±79 ml/min (1,13 ±0,35 ml/gram-LV/min) first postoperative day, to 355 (±99) ml/min (1,30 ±0,46 ml/gram-LV/min) sixth postoperative day.

Discussion

Amount of new blood was statistically significant after CABG with P<0,001. Same result was found after classifying patients per number of graft received, with the highest amount of new blood after four bypasses. Amount of new blood was not different if patient gets two or three bypasses.

Conclusion

There was significantly new amount of blood in coronary bed after CABG, with constant increase over first 6 days.

Off-pump coronary artery bypass with heparin in a patient with a history of heparin-induced thrombocytopenia: a case report

Background

Cardiovascular surgery for patients with a history of heparin-induced thrombocytopenia (HIT) with thrombosis requires careful perioperative anticoagulation therapy. When cardiovascular surgery is required for patients having ‘remote’ HIT, such as those who had a history of HIT and platelet factor-4/heparin antibodies turned out to be negative, it is recommended that re-exposure to heparin should be limited only to the intraoperative phase. However, few case reports have described detailed strategies for perioperative anticoagulation regimens.

Case presentation

We present the case of a 76-year-old woman, presenting with unstable angina pectoris and requiring coronary artery bypass grafting. She had a history of cardiac resuscitation and percutaneous coronary intervention for unstable angina pectoris with ventricular tachycardia 7 years prior, which caused HIT with thrombosis resulting in amputation of four fingers. On admission, platelet factor-4/heparin antibodies, biomarkers for HIT were not detected; the platelet count was 18.0 × 10⁴/µl. Off-pump coronary artery bypass grafting was performed using heparin; argatroban infusion was continued until 9 h prior to the operation and restarted 3 h postoperatively, bridged with regular warfarin from 4 days to 3 months postoperatively. Platelet factor-4 /heparin antibodies were detected on postoperative day 8 without any clinical symptoms and became negative by day 91.

Conclusion

We consider this anticoagulation strategy is effective especially in countries, where bivalirudin is not available. Re-exposure to heparin in cardiovascular surgery for patients with a history of ‘remote HIT’ is reasonable, and appropriate anticoagulation is important for an uneventful postoperative course.

Outcome of Chair Aerobics & Pranayama on Anxiety and Exercise Tolerance in Coronary Artery Bypass Grafting Patients: Study Protocol of a Randomized Clinical Trial

Objectives:

The current Indian scenario follows the western cardiac rehabilitation protocol; hence the primary aim of the study is to develop a cardiac rehabilitation phase 1 protocol for the Indian scenario. The protocol will be used in the study as standard rehabilitation protocol for the intervention groups. The literature suggests the use of Pranayama and chair aerobics to improve the anxiety in CABG patients. This study also aims to provide the answer for the effect of Pranayama and chair aerobics on anxiety and exercise tolerance in CABG patients. And also try to find out which among the two intervention is superior among one another.

Methods:

The cardiac rehabilitation protocol will be validated by experts in the field and applied in the patients and the results will be analysed. Then the protocol will be used as the standard rehabilitation protocol in both the groups. 100 patients will be randomised and allocated into 2 groups. Group 1 will receive Nadi Sodhana Chair aerobics for 15 minutes along with phase I cardiac rehabilitation. The group 2 will receive Chair aerobics for 15 minutes along with phase I cardiac rehabilitation. The outcome measures will be taken before the surgery and on the post-operative day 7. The primary outcome measures are Hospital anxiety and depression scale (HADS) and Heart rate and the secondary outcome measure is 6-minute walk test. The intention to treat analysis will be done after the data collection.

Results:

The data will be analysed using unpaired t test, p value <0.05 will be considered significant.

Conclusion:

The result will give a new insight into the field of cardiac surgery, where the effect of pranayama and chair aerobics on anxiety and functional outcome will be proved.

CTRI registration:

This trial is prospectively registered in CTRI, the registration number of the trial is CTRI/2021/09/037008.

Highlights:

What is already known about this subject? The effect of Pranayama and chair aerobics on various components like pain, peak expiratory flow after CABG is proven in different studies. The phase 1 cardiac rehabilitation is practiced and adopted from western protocol.

What does this study add? The study will give a new insight into the field of cardiac rehabilitation. Definite phase I cardiac rehabilitation protocol for Indian population is not exist in the literature. The Indian set up is using the western protocol, which is not suitable for the Indian population hence could not achieve the expected outcome on discharge. We believe that this study will provide a definite phase I cardiac rehabilitation protocol for the Indian population. This can be followed in the community. Also, this study aims to explore the unexplored area of anxiety after CABG. Where the effect of the Pranayama and chair aerobics will be identified. And also give idea about which treatment technique is superior, and feasible for the patients.

How might this impact on clinical practice? The study will provide a new phase I cardiac rehabilitation protocol for the Indian population. The protocol can be practiced in the Indian scenario. This will help to improve the exercise tolerance of the patients after the surgery. The study will recommend the feasible and effective technique for relieving the anxiety and improving the exercise tolerance in CABG patients. This can be implemented as a best practice in reducing anxiety after CABG.

Evaluation of the Effect of Modafinil on Respiratory and Cerebral Outcomes after Coronary Artery Bypass Graft Surgery

BACKGROUND

Pulmonary complications following cardiopulmonary bypass (CPB) pump during coronary artery bypass grafting (CABG) are relatively common and the incidence of cognitive dysfunction is reported as ranging in rate from 30% to 80% in the early postoperative period. The purpose of this study was to assess the effect of modafinil administration on the prevention of pulmonary and cerebral complications and shortening the hospital stay after CABG surgery.

METHODS

This randomized double-blind intervention-controlled clinical trial was performed on 74 patients (37 in the intervention group and 37 in the control group) undertaking CABG surgery. The intervention group was orally treated with doses of 200 mg of modafinil on the day of surgery, and on the morning of the day after surgery, the second dose of modafinil 200 mg was given to patients. The control group underwent a placebo with the same intervals.

RESULTS

Administration of modafinil in intervention group significantly decreased the time to reach consciousness (P = 0.001), ventilator time in intensive care unit (ICU) (P < 0.001), length of stay in ICU (P = 0.009), duration of hospitalization (P = 0.008), and arterial blood carbon dioxide pressure (PaCO2) (P = 0.047). In the intervention group, no patients with delirium, agitation, respiratory depression, non-invasive respiratory ventilation, and endotracheal re-intubation were observed.

CONCLUSION

Modafinil tablet as a respiratory and brain stimulant through the central nervous system (CNS) can improve the quality of breathing and arterial blood gases (ABGs) and also can increase the level of consciousness and shorten the recovery time.

Nomogram Predicts Improvement of Ischemic Mitral Regurgitation after Coronary Artery Bypass Grafting

BACKGROUND

Developing a nomogram to predict improvement in moderate ischemic mitral regurgitation (IMR) after coronary artery bypass grafting (CABG) is in need.

METHODS

Between 2010 and 2018, data were retrospectively collected from 112 patients with prior myocardial infarction and moderate IMR undergoing CABG. Patients were divided into two groups based on IMR degree 1 year after CABG as follows: Improved Group with no or mild IMR (n=54) and Failure Group with moderate or severe IMR (n=58). To determine the predictors of postoperative IMR improvement, preoperative clinical and echocardiographic data were compared, and a nomogram was formulated based on all independent predictors. Discriminative ability, calibration, and clinical usefulness of the prediction model were assessed.

RESULTS

Independent predictors of IMR improvement after CABG constructing the nomogram included duration between infarction and operation, poster-inferior to left ventricular volume ratio, maximum difference of the time to reach minimum systolic volume of 16 segments, P3 leaflet tethering angle, and annular Non-planar angle. The nomogram exhibited well-fitted calibration curves and excellent discriminative ability. The area under receiver operating characteristic curve was 0.974. Patients with a score > 236 demonstrated a high probability of IMR improvement (sensitivity, 90.7%; specificity, 93.1%). Patients in the Improved Group demonstrated greater actuarial survival rates than those in the Failure Group.

CONCLUSIONS

The nomogram combining 5 preoperative clinical and echocardiographic predictors provides an accurate preoperative estimation of moderate IMR improvement after surgery, with excellent discriminative ability. Based on this nomogram, patients with a higher score predict higher probabilities of IMR improvement.

Cardiovascular Physiotherapy on Respiratory Sinus Arrhythmia of Patients Undergoing Coronary Artery Bypass Grafting

Introduction: Patients in the postoperative period of coronary artery bypass grafting (CABG) present respiratory and autonomic dysfunctions. In this sense, cardiovascular physiotherapy has been offered as an indispensable differential for the improvement of the prognosis of this population. Heart rate variability is a simple, noninvasive method to analyze autonomic modulation, as well as the accentuation maneuver of respiratory sinus arrhythmia, which demonstrates the parasympathetic autonomic control over the heart. Five patients undergoing cardiac surgery performed a protocol of cardiovascular physiotherapy in the postoperative period and had their data referring to the preoperative period, the 1st and 4th postoperative days analyzed.

Comparison of survival rate and complications of percutaneous coronary intervention, coronary artery bypass graft, and medical treatment in patients with left main and/or three vessel diseases

BACKGROUND

The probable complications of 3 different cardiovascular diseases treatment options including percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and medical therapy (MT), especially in individuals suffering from left main (LM) and/or three vessel diseases (3VDs), have received less attention. Thus, the aim of this study was to compare the complications of the aforementioned therapeutic strategies in patients admitted with LM coronary artery disease (CAD) and/or having 3VDs.

METHODS

From March 2018 to March 2019, a total number of 251 eligible individuals (87, 86, and 78 subjects treated with PCI, CABG, and MT, respectively) were recruited in this cohort study. After the initiation of treatment, all individuals were followed for 6 months. Occurrence of any complications including chest pain (CP), re-hospitalization due to cardiac problems, heart failure (HF), death, myocardial infarction (MI), and stroke as well as major adverse cardiac events (MACE) were assessed.

RESULTS

Significantly lower percentages of CP, readmission, and HF were observed in the CABG group compared to the PCI and MT groups (24.4% vs. 47.1% and 53.9%, P < 0.001; 3.5% vs. 13.8% and 5.1%, P = 0.020; 1.2% vs. 2.3% and 9%; P = 0.040, respectively). Further analysis revealed an increased likelihood of hospitalization in the PCI group (OR: 3.82, 95% CI: 1.01-14.41, P = 0.040), and a lower risk of CP and HF occurrence in the CABG group subjects compared to the MT group (OR: 0.28, 95% CI: 0.13-0.62, P = 0.002 and OR: 0.05, 95% CI: 0.004-0.71, P = 0.030, respectively). This pattern was also observed in the PCI group in terms of HF (OR: 0.12, 95% CI: 0.02-0.83, P = 0.030).

CONCLUSION

Patients suffering from LM and/or 3VDs would most likely benefit from CABG followed by PCI, rather than MT. Further large-scale studies are required to confirm these results.

Characteristics, morbidity and mortality factors associated with Intra-Aortic Balloon Pump in Coronary Artery Bypass Graft Surgery patients

Objective:

The aim of our study is to analyze the characteristics, morbidity and mortality of patients requiring an Intra-Aortic Balloon Pump (IABP) in Coronary Artery Bypass Grafting (CABG).

Methods:

An analysis was done on the prospectively collected data of 1216 patients who had CABG in our center between July, 2017 and May, 2019 at our hospital. We categorized patients in to an IABP and non-IABP group on the basis of IABP use. We then compared the pre-operative, per-operative and post-operative characteristics of the two groups. We further stratified the patients according to pre-op ejection fraction (EF).

Results:

Out of 1216 patients, 135(11.10%) patients required an IABP. 70(51.9%) patients of IABP group and 699(64.7%) patients of non-IABP group had hypertension (p-value 0.0036). 23.0% had previous myocardial infarction (MI) in the IABP group and 13.8% had prior myocardial infarction (MI) in non-IABP group (p-value 0.0463). Among the patients requiring an IABP, 21(15.5%) of patients had normal EF (>50%) (P-value<0.0001), 72 (53.3%) had EF 35-50%, and 41(30.3%) patients had EF<35% (p-value <0.0001). Mortality of IABP group (19.3%) was greater than non-IABP group (2.4%) (P-value 0.00001).

Conclusions:

Use of IABP increased as the EF decreased. Rate of post-operative stroke, prolonged ICU stay, prolonged ventilation, re-opening due to bleeding and mortality was seen to be significantly higher in the IABP group.

A rare case of patent ductus arteriosus diagnosed during coronary artery bypass grafting operation in a 73-year-old man

BACKGROUND

Although patent ductus arteriosus (PDA) is more prevalent among infants and children, it might be seen among adults as well. It is not usually seen among adults, since it is often diagnosed and treated in childhood.

CASE REPORT

In the present case, a 73-year-old man referred to the hospital with symptoms including dyspnea, cold sweating, and chest pain with a burning nature which was lasting for 30 minutes. Angiography revealed coronary artery obstruction, so he became a coronary artery bypass grafting (CABG) candidate. Except for dilatation of the left atrium, no specific findings were reported in the patient's echocardiography report. When the pump was turned off by the surgeon, the patient's heart filled up and he was not able to get off the pump. Simultaneously, the patient started to have bloody respiratory secretions. With all that in mind, the surgeon suspected that he might suffer from a PDA, then he found an 8-mm PDA and closed it. Then, the patient was taken off the cardiorespiratory pump.

CONCLUSION

Although PDA is more common among children and infants, it can be found among adults according to previous cases and our case as well. Since patients with PDA refer to physicians for other clinical issues, it is recommended to apply more precision in diagnostic methods such as taking a good history, echocardiography, and electrocardiogram (ECG). Moreover, it is recommended that if a patient has conditions similar to our patient, the surgeon must be sure of a possible PDA.

Comparison of cardiovascular risk factors among coronary artery bypass graft patients in 2010 and 2016: A single-center study in Guilan province, Iran

BACKGROUND

There has been a change in the risk factor profile of patients with coronary artery disease (CAD) in the western world. We sought to compare the risk factor profile of patients undergoing coronary artery bypass graft (CABG) surgery in northern part of Iran in 2010 and 2016.

METHODS

In a cross-sectional study, medical records of 296 CABG patients in 2010 and 500 patients in 2016 were collected from a referral university hospital in Guilan province, Iran. We compared the risk factor profile using chi-square test or independent t-test as needed in the two time points, 2010 and 2016.

RESULTS

The age of CABG patients significantly decreased from 62.49 ± 8.05 to 58.09 ± 9.20 over time. The frequency of hypertension (HTN) (66.2% vs. 59.1%, P = 0.045), diabetes mellitus (DM) (51.8% vs. 43.6%, P = 0.025), smoking (35.6% vs. 28.0%, P = 0.028), and patients with multimorbidity (31.8% vs. 26.7%, P = 0.001) increased in the second period compared to the first period of study. Whereas, the prevalence of hypercholesterolemia and positive family history of coronary heart disease (CHD) remained stable over time (49.6% vs. 49.0%, P = 0.870; 10.5% vs. 11.1%, P = 0.810, respectively).

CONCLUSION

We observed a dramatic increase in DM, HTN, and cigarette smoking as well as the multimorbidity prevalence in 2016 compared to 2010. Even with considering all study limitations, primary and secondary prevention program to decrease cardiovascular disease is required.

Differential Signature of Obesity in the Relationship with Acute Kidney Injury and Mortality after Coronary Artery Bypass Grafting

BACKGROUND

Obesity is related to several comorbidities and mortality, but its relationship with acute kidney injury (AKI) and long-term mortality remain undetermined in patients undergoing coronary artery bypass grafting.

METHODS

Data from 3,018 patients (age ≥ 18 years) who underwent coronary artery bypass graft surgery from two tertiary referral centers were retrospectively reviewed between 2004 and 2015. Obesity was defined using the body mass index, according to the World Health Organization's recommendation. The odds and hazard ratios in post-surgical, AKI, and all-cause mortality were calculated after adjustment for multiple covariates. Patients were followed for 90 ± 40.9 months (maximum: 13 years).

RESULTS

Among the cohort, 37.4%, 2.4%, 21.1%, 35.1%, and 4.0% of patients were classified as normal weight, underweight, overweight-at-risk, obese I, and obese II, respectively. Post-surgical AKI developed in 799 patients (26.5%). Patients in the obese groups (overweight-at-risk to obese II) had a higher risk of AKI than did those in the normal-weight group. During the follow-up period, 787 patients (26.1%) died. Underweight patients had a higher risk of mortality than did normal-weight patients, whereas overweight-at-risk, obese I, and obese II patients showed better survival rates.

CONCLUSION

After coronary artery bypass graft surgery, obese patients encountered a high risk of AKI, and underweight patients exhibited a low chance of survival. Awareness of both obese and underweight statuses should be raised in these patients.

Coronary Artery Bypass Grafting with Arterial Grafts in Patients with Kawasaki Disease Affecting the Coronary Artery: a Korean Single-Center Study

BACKGROUND

This study aimed to review the long-term clinical outcomes and graft patency of coronary artery bypass grafting (CABG) using arterial grafts in patients with Kawasaki disease (KD) affecting the coronary artery.

METHODS

Twenty patients with KD who underwent CABG from January 2002 to June 2014 were enrolled. There were 4 male (20%) and 16 female (80%) patients with ages at operation ranging from 2 to 42 years (median, 17.5 years). Our routine operative strategy was off-pump CABG with arterial grafts. The mean follow-up duration was 59.5 ± 48.5 months (range, 1-159 months). Coronary angiogram or computed tomography angiogram was used to evaluate graft patency in 16 patients (80%).

RESULTS

All patients survived CABG without late mortality. Left internal thoracic arteries were used in 19 patients, while right internal thoracic arteries were used in 10 patients. Right gastroepiploic arteries were used in 3 patients, and a saphenous vein graft (SVG) was used in 1 patient. Among the 20 patients, 2 patients underwent coronary reintervention with balloon angioplasty because of graft failure. Two patients underwent coronary reintervention because of new obstructive lesions that were not significant at the time of the initial operation. Patency rates at 5 and 10 years were 94% and 87%, respectively. The rate of freedom from coronary reintervention at 10 years was 82%.

CONCLUSION

Off-pump CABG with mainly arterial graft revascularization may be considered a good surgical option for coronary lesions caused by KD.

Total Arterial Off-Pump Coronary Artery Bypass Grafting: A 10-Year Experience

Background:

Arterial grafts had better mid-term and long-term patency than saphenous vein grafts in coronary artery bypass grafting (CABG). We summarized our experience with total arterial off-pump coronary artery bypass grafting (OPCAB) and assessed the early clinical results, surgical complications, and follow-up.

Methods:

From January 2007 to May 2017, 508 coronary artery disease patients undergoing total arterial OPCAB were enrolled. Clinical features, approaches, outcomes of surgical treatments, and follow-up data of these patients were studied retrospectively. A total of 122 patients underwent single left internal mammary artery (IMA)-left anterior descending artery grafts, whereas the other 386 patients underwent multiple vessel grafts.

Results:

The average distal anastomosis was 2.34 ± 0.97 (range: 1–4). All the patients were discharged from hospital except one died. A total of 457 (90.32%) patients were followed up. In the 4-, 7-, and 10-year follow-up groups, the rate of death from any cause was 1.19%, 6.47%, and 10.67%; rate of cardiac death was 0.60%, 2.88%, and 3.33%; rate of repeat revascularization was 0.00%, 3.60%, and 8.67%; rate of ischemic symptoms was 1.79%, 7.91%, and 11.33%; and incidence of stroke was 2.38%, 4.32%, and 6.67%, respectively. Poor medication adherence was observed in 9.38% of the follow-up population.

Conclusions:

Total arterial OPCAB with bilateral IMA, radial artery, and right gastroepiploic artery grafting yielded satisfactory early and midterm outcomes in this patient group, without a significant increase in early mortality or morbidity. Moreover, the long-term outcomes are also positive.

Quality Measurement and Improvement Study of Surgical Coronary Revascularization: Medication Adherence (MISSION-2)

Background

Secondary preventive therapies play a key role in the prevention of adverse outcomes after coronary artery bypass grafting (CABG). However, medication adherence after CABG is often poor, and conventional interventions for improving adherence have limited success. With increasing penetration of smartphones, health-related smartphone applications might provide an opportunity to improve adherence. Carefully designed trials are needed to provide reliable evidence for the use of these applications in patients after CABG.

Methods

The Measurement and Improvement Studies of Surgical Coronary Revascularization: Medication Adherence (MISSION-2) study is a multicenter randomized controlled trial, aiming to randomize 1000 CABG patients to the intervention or control groups in a 1:1 ratio. We developed the multifaceted, patient-centered, smartphone-based Heart Health Application to encourage medication adherence in the intervention group through a health self-management program initiated during hospital admission for CABG. The application integrated daily scheduled reminders to take the discharge medications, cardiac educational materials, a dynamic dashboard to review cardiovascular risk factors and secondary prevention targets, and weekly questionnaires with interactive feedback. The primary outcome was secondary preventive medication adherence measured by the Chinese version of the 8-item Morisky Medication Adherence Scale at 6 months after randomization. Secondary outcomes included all-cause death, cardiovascular rehospitalization, and a composite of death, myocardial infarction, stroke, and repeat revascularization.

Discussion

Findings will not only provide evidence regarding the feasibility and effectiveness of the described intervention for improving adherence to CABG secondary preventive therapies but also explore a model for outpatient health self-management that could be translated to various chronic diseases and widely disseminated across resource-limited settings.

Trial Registration

https://clinicaltrials.gov (NCT02432469).

Comparative study of short-term cardiovascular autonomic control in cardiac surgery patients who underwent coronary artery bypass grafting or correction of valvular heart disease

Introduction: Our aim was to perform a comparative study of short-term cardiovascular autonomic control in cardiac surgery patients who underwent coronary artery bypass grafting (CABG) or surgical correction of valvular heart disease (SCVHD ). Methods: The synchronous 15 minutes records of heart rate variability (HRV) and finger's photoplethysmographic waveform variability (PPGV) were performed in 42 cardiac surgery patients (12 women) aged 61.8 ± 8.6 years (mean ± standard deviation), who underwent CABG, and 36 patients (16 women) aged 54.2 ± 14.9 years, who underwent SCVHD , before surgery and in 5-7 days after surgery. Conventional time and frequency domain measures of HRV and index S of synchronization between the slow oscillations in PPGV and HRV were analyzed. We also calculated personal dynamics of these indices after surgery. Results: We found no differences (Р > 0.05) in all studied autonomic indices (preoperative and post-surgery) between studied patients' groups, except for the preoperative heart rate, which was higher in patients who underwent SCVHD (P = 0.013). We have shown a pronounced preoperative and post-surgery variability (magnitude of inter-quartile ranges) of all autonomic indices in studied patients. In the cluster analysis based on cardiovascular autonomic indices (preoperative and post-surgery), we divided all patients into two clusters (38 and 40 subjects) which did not differ in all clinical characteristics (except for the preoperative hematocrit, P = 0.038), index S, and all post-surgery HRV indices. First cluster (38 patients) had higher preoperative values of the HR, TP, HF, and HF%, and lower preoperative values of the LF% and LF/HF. Conclusion: The variability of cardiovascular autonomic indices in on-pump cardiac surgery patients (two characteristic clusters were identified based on preoperative indices) was not associated with their clinical characteristics and features of surgical procedure (including cardioplegia).

Pharmacotherapy Evaluation and Utilization in Coronary Artery Bypass Grafting Patients in Kosovo during the Period 2016-2017

BACKGROUND:

Coronary Artery Bypass Grafting (CABG) is realised in patients with critical or advanced disease of coronary arteries. There are different pharmacotherapeutic approaches which are used as management, treatment and preventive therapy in cardiovascular disease or related comorbidities. Performing a successful surgery, pharmacotherapy, and increase of bypass patency rate remains a serious challenge.

AIM:

This study aims to analyse the patient characteristics undergoing CABG and evaluation of their drug utilisation rate and daily dosages in the perioperative period.

MATERIAL AND METHODS:

Data were collected from 102 patients in the period 2016-2017 and detailed therapeutic prescription and dosages, patient characteristics were analysed before the operation, after the operation and visit after operation in the Clinic of Cardiac surgery-University Clinical Center of Kosovo.

RESULTS:

Our findings had shown that patients provided to have normal biochemical parameters in the clinic before the operation, and were related to cardiovascular diseases and comorbidities and risk factors with mainly elective intervention. The, however, higher utilisation of cardiovascular drugs such as beta blockers, diuretics, anticoagulants, statins and lower calcium blockers, ACEi, ARBs, hydrochlorothiazide, amiodarone were founded. ARBs, beta blockers, statins, nitrates and nadroparin utilisation decreased after operation and visit after the operation, whereas amiodarone only in the visit after the operation. Diuretics are increased after the operation which decreases in the visit after the operation. Regarding the daily dosage, only metoprolol was increased in the visit after operation (P < 0.001) and visit after operation (P < 0.05) whereas losartan and furosemide were increased (P < 0.01) and (P < 0.05) respectively.

CONCLUSION:

The study showed that beta blockers, statins, aspirin, nitrates (before the operation), furosemide and spironolactone are the most utilised drugs. However, we found low utilisation rate for ACEi, ARBs, clopidogrel, nadroparin, warfarin, xanthines, amiodarone, calcium blockers. Daily dosages were different compared to before CABG only in metoprolol, losartan, and furosemide.

The impact of maintaining serum potassium ≥3.6 mEq/L vs ≥4.5 mEq/L on the incidence of new-onset atrial fibrillation in the first 120 hours after isolated elective coronary artery bypass grafting - study protocol for a randomised feasibility trial for the proposed Tight K randomized non-inferiority trial

Background

Atrial fibrillation (AF) occurs in approximately one in three patients after cardiac surgery, and is associated with increased short-term and long-term mortality, intensive care unit (ICU) and hospital stay, and increased cost of care. In an attempt to reduce AF incidence in these patients, serum potassium (K+) levels are commonly maintained at the high end of normal (4.5–5.5 mEq/L). However, such potassium supplementation is without proven benefit, and is not without negative consequences. It carries clinical risk, negatively impacts patient experience and is both time-consuming and costly. This protocol describes a randomised controlled pilot trial to assess the feasibility of a proposed randomised non-inferiority trial to investigate the impact of maintaining serum potassium ≥ 3.6 mEq/L vs ≥ 4.5 mEq/L on the incidence of new-onset atrial fibrillation in the first 120 hours after isolated elective coronary artery bypass grafting.

Methods

Design: this is a randomized feasibility trial as a pilot for a randomized non-inferiority trial. Participants: are 160 patients undergoing isolated coronary artery bypass grafting at two centres. Allocation: patients will be randomized (1:1) to protocols aiming to maintain serum potassium at either ≥ 3.6 mEq/L (“relaxed control”) or ≥ 4.5 mEq/L (“tight control”). Primary analytic aim: was to assess the feasibility and acceptability of planning and delivering the intervention and trial methods to inform a full-scale non-inferiority trial. Outcome: the primary indicative efficacy outcome measures being field-tested are feasibility of participant recruitment and randomization, maintaining a protocol violation rate < 10%, and retaining 90% patient follow up 28 days after surgery. The primary clinical outcome measure of the future full “Tight K Study” will be incidence of AF after cardiac surgery.

Discussion

The Tight K Pilot will assess the feasibility of conducting the full trial, which is intended to confirm or refute the efficacy of current potassium management in preventing AF after cardiac surgery.

Trial registration

ClinicalTrials.gov, NCT03195647. Registered on 23 May 2017. Last updated 19June 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2349-x) contains supplementary material, which is available to authorized users.

The effect of intraoperative lung protective ventilation vs conventional ventilation, on postoperative pulmonary complications after cardiopulmonary bypass

Introduction: This study aimed to evaluate the effects of high positive-end expiratory pressure (PEEP) and low tidal volume (TV) and recruitment maneuver, on postoperative pulmonary complications (PPCs) after coronary artery bypass grafting (CABG) surgery.

Methods: This study is a randomized double blind clinical trial on 64 patients who were undergoing CABG surgery, and were randomly divided into two groups of conventional ventilation (C-Vent) with TV of 9 mL/kg and PEEP=0 cm H2O, and lung protective ventilation (P-Vent), with 6 mL/kg TV and PEEP=10 cm H2O with recruitment maneuver every 30 minutes. Measures of PPCs and modified clinical pulmonary infection score (mCPIS), were assessed for the first 24 hours of postoperative time in order to evaluate the pulmonary complications.

Results: P-Vent with 31 patients and C-Vent with 30 patients, participated in the stage of data analysis. Demographic, and preoperative laboratory results showed no significant difference between two groups. During surgery, cardiovascular complications were higher in P-Vent group (P = 0.61) but pulmonary complications were higher in C-Vent group (P = 0.26). Extubation time was not significantly different between two groups, and also components of arterial blood gases (ABG) of 24 hours after surgery showed no significant difference between the two groups. Pathologic changes in the chest X-ray (CXR) of 24 hours after surgery, were lower in P-Vent group, but the difference was not significant (P = 0.22). The PPC criteria was less positive in P-Vent (2 patients) vs 9 patients in C-Vent group (P = 0.02) and mCPIS score was significantly lower in P-Vent group (1.2 ± 1.4) than C-Vent group (2 ± 1.6) (P = 0.048).

Conclusion: Lung protective strategy during and after cardiac surgery, reduces the postoperative mCPIS in patients undergoing open heart surgery for CABG.

Perioperative stroke as a predictor of mortality and morbidity in patients undergoing CABG

Perioperative stroke is a devastating neurological complication of Coronary Artery Bypass Grafting surgery (CABG). It results in significantly increased rates of mortality and morbidity and presents a significant financial burden to our healthcare system. It has not, however, been studied in a large population based sample. We aim to investigate the role of perioperative stroke as an independent risk factor for in-hospital mortality and morbidity following CABG, and to review trends in the early outcomes of CABG from the years 1999 to 2011. We hypothesize that perioperative stroke is an independent risk factor for in-hospital mortality and morbidity following CABG. We analyzed data from the 1999-2011 Nationwide Inpatient Sample, identifying patients who underwent CABG using ICD-9 and CCS codes. We excluded patients below the age of 18 and above the age of 100, and patients undergoing concomitant heart and/or vascular procedures. Analysis on our sample of 668,627 patients yielded an overall rate of perioperative stroke, mortality, and morbidity of 1.87%, 2.13%, and 49.07%, respectively. Along with age, risk category, gender, and other postoperative outcomes, perioperative stroke was found to be a strong predictor of mortality and morbidity, leading to more than a 5-fold risk of death and morbidity. From our study, we conclude that perioperative stroke remains a serious adverse outcome of CABG and is an independent predictor of mortality and morbidity. While rates of stroke and mortality are decreasing, morbidity continues to trend upwards. This study emphasizes the importance of prevention and early intervention in patients at risk for perioperative stroke.

Adaptive Support Ventilation Reduces the Incidence of Atelectasis in Patients Undergoing Coronary Artery Bypass Grafting: A Randomized Clinical Trial

Background

Pulmonary complications are common following cardiac surgery and can lead to increased morbidity, mortality, and healthcare costs. Atelectasis is the most common respiratory complication following cardiac surgery. One of the most important methods for reducing pulmonary complications is supportive care with protective ventilation strategies. In this study, we aimed to assess the effect of adaptive support ventilation (ASV) on atelectasis in patients undergoing cardiac surgery.

Methods

In this single-blind randomized clinical trial, 115 patients, undergoing coronary artery bypass grafting, were randomly allocated into 2 groups: 57 patients in the intervention and 58 patients in the control group. Patients in the intervention group were weaned with ASV, while patients in the control group were managed using synchronized intermittent mandatory ventilation (SIMV) and pressure support. The incidence of atelectasis, duration of mechanical ventilation, manual ventilator setting, arterial blood gas measurements, and length of hospital stay were compared between the groups.

Results

The incidence of atelectasis, number of changes in the manual ventilator setting, number of alarms, and length of hospital stay reduced in the intervention group. However, duration of mechanical ventilation and number of ABG measurements were not significantly different between the groups.

Conclusions

The ASV mode could reduce the incidence of atelectasis and length of hospital stay. However, it did not reduce the duration of mechanical ventilation. It seems that ASV is not a superior mode for faster extubation.

Effect Of Internal Mammary Artery Harvesting With And Without Pleurotomy On Respiratory Complications In Patients Undergoing Coronary Artery Bypass Grafting

BACKGROUND

Respiratory problems are one of the major issues faced by cardiovascular surgeons, which increase morbidity and mortality among patients undergoing coronary artery bypass grafting (CABG). It is possible to harvest the left internal mammary artery (LIMA) without opening the left pleura; however this cannot be reliably achieved in all cases due to intimate anatomical relationship. This study was designed to evaluate the effect of internal mammary artery harvesting with and without pleurotomy on respiratory complications in patients undergoing coronary artery bypass grafting.

METHODS

In this observational study 90 patients who underwent coronary artery bypass surgery were included by review of records. Patients were stratified into two groups according to surgical procedures, i.e., Internal Mammary artery harvesting with pleurotomy; (WP Group) (n=45) and with extra pleural harvesting technique; (EP Group) (n=45). Inclusion criteria were elective coronary artery bypass grafting, age over 18 years, willingness to be randomly assigned, provision of informed consent. Exclusion criteria were chronic obstructive pulmonary disease (COPD) or skeletal abnormalities that caused pulmonary restriction. Only the first 30 days postoperative outcome was studied. Data was analysed using SPSS version 21.

RESULTS

The demographic characteristics in terms of age and gender were comparable in study groups. The preoperative clinical presentation and medical history were also found similar. The hospital stay was significantly longer in WP Group than EP Group patients (7.2 vs 6.1 days, p<0.005). Moreover, post-operative morbidity was more prevalent in WP group 10 (22.2%) than EP Group 3 (66%) (p<0.03). In WP Group more respiratory complications were observed; 2 (4.4%) patients had dry cough and atelectasis, 1 (2.2%) patient experienced pleural effusion, 3 (6.6%) had bronchospasm while 1 (2.2%) patient each had sternal dehiscence and bleeding, however, these did not differ significantly among study groups.

CONCLUSIONS

Respiratory complications were more frequent in patients undergoing Internal Mammary artery harvesting with pleurotomy compared to those managed extra pleural harvesting.

Combined Open-Heart Coronary Artery Bypass Surgery and Subtotal Thyroidectomy in a 54-year-old patient: A Case Report

Background

Combined open-heart surgery and thyroidectomy is a rare procedure. However, some difficulties will occur for cardiac surgery when thyromegaly extends into the retrosternal space.

Case Details

A 54-year-old woman suffering from dyspnea, chest pain and decreased left ventricular function (EF=40%) was diagnosed with coronary artery disease (3 vessel disease) and became candidate for coronary artery bypass grafting (CABG). Also, she had multinodular goiter with normal thyroid function test. After midsternotomy, a huge goiter was seen in the upper mediastinum. Because the mass had covered the ascending aorta and involved the posterior aspect of the innominate vein making access to aorta impossible, thyroidectomy was performed at first followed by CABG. Post-operation course was satisfactory. Fourteen months later, the patient was euthyroid and in NYHA class 1.

Conclusion

The evidence of the case showed that combined CABG and thyroidectomy can be performed safely.

The combination of breast necrosis and chylothorax following the OPCAB

Due to long term patency, the internal mammary artery is considered as a conduit of choice for revascularization of the left anterior descending coronary artery. The internal mammary artery and its accessory branches in addition to perfusing the chest wall structures also contributes to supplying, part of the female breast arteries. In addition, due to the accompaniment of thoracic duct branches with the left internal mammary artery, harvesting may be associated with injury to these branches and contribute to chylothorax. We report a rare case of chylothorax and the breast necrosis following the coronary artery bypass grafting. The chylothorax was started in the second postoperative day and ceased gradually in the 12th day of operation. The breast necrosis appeared in the 3th weeks of operation with pain, and tenderness and black skin color change. The patient underwent total mastectomy in the 4th weeks of operation.

Effect of ischemic postconditioning on myocardial protection in patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass

INTRODUCTION

Reperfusion injury is a well-known phenomenon following restoration of the coronary circulation after coronary artery bypass grafting (CABG) that impairs myocardial function. In order to control the severity of this injury, we aimed to investigate the effect of a new conditioning strategy namely ischemic postconditioning (IPOC) along with controlled aortic root reperfusion (CARR) on myocardial protection in CABG surgery with cardiopulmonary bypass.

METHODS

In a doubled blind clinical trial study, 51 patients undergoing first-time elective CABG were randomly divided in three groups: CARR, IPOC, and combination of IPOC and CARR. At the end of procedure and just before aortic cross-clamp removal, reperfusion was started as following: In CARR-receiving groups, the reperfusion was started with low perfusion pressures for 10 minutes, and in IPOC-receiving groups, three cycles of 1 minute episodes of ischemia separated by 1 minute episodes of reperfusion was applied as postconditioning protocol. Left ventricular ejection fraction (EF) (by echocardiography), inotrope requirement index, and myocardial arrhythmias were measured up to 72 hours after operation.

RESULTS

Echocardiography revealed that the recovery of EF after operation in IPOC group was significantly higher than those of two other groups (P < 0.05). Inotropic support requirement was significantly lower in IPOC groups. In addition, the incidence of atrial and ventricular arrhythmias after opening of aortic clamp and in intensive care unit (ICU) as well as recovery time of cardiac rhythm upon reperfusion were lowered by administration of IPOC, as compared with CARR group.

CONCLUSION

The study suggests that IPOC may provide clinical benefits against reperfusion injury in patients undergoing CABG surgery and maintain the post ischemic left ventricular performance.

Saphenous vein graft aneurysm: A case report

BACKGROUND

Saphenous vein graft aneurysms (SVGAs) are rare seen issues after coronary artery bypass graft (CABG) operation which may lead to major complications including compression of adjacent structure, myocardial ischemia, rupture, and even death.

CASE REPORT

We report a patient with recurrent SVGA and its treatment by percutaneous intervention with a covered stent, the diagnostic and treatment procedure were based on contrast enhanced computed tomography and myocardial perfusion scintigraphy (MPS).

CONCLUSION

Multimodality imaging is required to demonstrate the true size and complications of the SVGA, the relationship among the adjacent structure, and to assess ischemia and size of myocardial territory supplied by the aneurysmal graft to decide treatment strategy.

Early outcome of Coronary Artery Bypass Graft Surgery in patients with significant Left Main Stem stenosis at a tertiary cardiac care center

Objective:

Primary objective of this study was to evaluate the impact of significant left main stem (LMS) stenosis on the early outcome of coronary artery bypass graft (CABG) surgery.

Methods:

A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two (2602) patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I (n=2088): without significant LMS disease and Group II (n=514): with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student’s t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ≤ 0.05 was considered as significant difference.

Results:

Out of two thousand six hundred two, 2088 patients were in Non.LMS group (Control Group) and five hundred fourteen were in LMS Group (Study Group). Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 (9.7%) of patients were unstable in LMS group and they needed urgent surgery (p-value <0.0001). Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group (p-value <0.0001, 0.002, 0.003 respectively). Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group (p-value 0.005 and 0.001 respectively). Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen (2.5%) as compared to just 17 out of two thousand eighty eight (0.8%) in control group.

Conclusion:

This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery.

Demographic and Socioeconomic Factors of Patients With Coronary Artery Diseases Undertreatment of Coronary Artery Bypass Grafting, Percutaneous Coronary Intervention and Drug Therapy in Mashhad, Iran

Background:

Considering the importance of preventing cardiovascular diseases, determining the contributing risk factors for ischemic heart disease which leads to atherosclerotic plaque, could be effective in selecting the required interventions.

Objectives:

This study aimed to evaluate socioeconomic factors in patients with Coronary Artery Diseases (CAD) in three treatment groups: Coronary Artery Bypass Grafting (CABG), Percutaneous Coronary Intervention (PCI) and drug therapy. By identifying and comparing the underlying factors in treatment groups, we can gather useful information for future planning and policy making in order to reduce and eliminate the contributing factors.

Patients and Methods:

This cross-sectional study was conducted on 760 patients with CAD referred to cardiovascular health centers in Mashhad, Iran, including Javad-Al-Aeme Heart Hospital, Qaem, Imam Reza and Dr. Shariati educational Hospital. Samples were collected through purposive sampling from January to March 2014. Based on the experts’ opinion, the subjects were categorized into three treatment groups: CABG, PCI, and drug therapy.

Results:

The mean age of total patients was 58.3 ± 11.5 years (P = 0.09). The proportion of rural patients in the PCI (26.7%) and drug therapy (27.5%) groups was twice as high as the CABG group (11.7%) (P < 0.001). The proportion of patients with higher educational level (higher than high school diploma) in the CABG group (35.9%) was higher than PCI and drug therapy groups (26.7%, 24.3%) (P = 0.006). Smoking, drinking and drug abuse were more common in the drug therapy group (P = 0.03, P = 0.02, and P < 0.001, respectively). One-vessel and three-vessel coronary artery diseases were more common in the drug and CABG groups, respectively (P < 0.001).

Conclusions:

In total, application of therapeutic approaches in patients with CAD depends on many factors. In our study not only risk factors such as gender, lifestyle, smoking, alcohol abuse, diabetes and hypertension were associated with the incidence of CAD, but also they were highly correlated with the severity of the disease.

A study of the efficacy of furosemide as a prophylaxis of acute renal failure in coronary artery bypass grafting patients: A clinical trial

BACKGROUND

Renal failure is a frequent event after coronary artery bypass grafting (CABG). Hemodynamic alterations during surgery as well as the underlying disease are the predisposing factors. We aimed to study intermittent furosemide therapy in the prevention of renal failure in patients undergoing CABG.

METHODS

In a single-blind randomized controlled trial, 123 elective CABG patients, 18-75 years, entered the study. Clearance of creatinine, urea and water were measured. Patients were randomly assigned into three groups: furosemide in prime (0.3-0.4 mg/kg); intermittent furosemide during CABG (0.2 mg/kg, if there was a decrease in urinary excretion) and control (no furosemide).

RESULTS

There was a significant change in serum urea, sodium and fluid balance in "intermittent furosemide" group; other variables did not change significantly before or after the operation. Post-operative fluid balance was significantly higher in "intermittent furosemide" group (2573 ± 205 ml) compared to control (1574.0 ± 155.0 ml) (P < 0.010); also, fluid balance was higher in "intermittent furosemide" group (2573 ± 205 ml) compared to "furosemide in prime" group (1935.0 ± 169.00 ml) (P < 0.010).

CONCLUSION

The study demonstrated no benefit from intermittent furosemide in elective CABG compared to furosemide in prime volume or even placebo.

Long-term pulmonary functional status following coronary artery bypass grafting surgery

BACKGROUND

The present study aimed to describe the long-term alterations of pulmonary function and also to describe its association with post-operative pain after coronary artery bypass grafting (CABG) surgery.

METHODS

In this prospective study, thirty non-smoker male patients undergoing isolated on-pump CABG were consecutively included in this study. Pulmonary function measurements were performed, in a sitting position, preoperatively, a week postoperatively, and 6 months after the surgery using a Medical Graphics PF/Dx pulmonary function system. Pain was determined by using visual analog scale (VAS) pain scores with a standardized questionnaire's.

RESULTS

Regarding functional class, all patients had New York Heart Association (NYHA) Class II to III. A week after operation, a severe restrictive pulmonary impairment was revealed with a mean decrease in VC to 60.9 ± 9.2% and in forced expiratory volume in one second (FEV1) to 64.6 ± 12.2% of pre-operative values (P < 0.001). Regarding sternotomy related pain, the mean pain VAS score was preoperatively 3.3 ± 1.5 that reached to 6.2 ± 2.5 and 4.8 ± 2.2 1 week and 6 months after the operation (P < 0.001). The trend of the changes in pain score within 6 months of operation was significantly similar to the trend of the changes in some pulmonary function indices such as FEV% and residual volume (RV).

CONCLUSION

A significant reduction is expected in most pulmonary functional parameters following CABG despite normal pulmonary function state preoperatively. Severe pain originated from sternotomy may be an important factor related to pulmonary dysfunction following CABG.

Mid-Term Patency in Radial Artery and Saphenous Vein After Coronary Artery Bypass Grafting in Asymptomatic Patients Using 128-Slice CT Coronary Angiography

Background:

Patency of the revascularization conduit is an essential predictor of long-standing survival after coronary artery bypass grafting.

Objectives:

We have conducted this study to compare the mid-term patency rates of radial artery (RA), left internal thoracic artery (LITA) and also saphenous vein (SV) grafts in asymptomatic patients following coronary artery bypass graft surgery (CABG) undergoing total IV anesthesia.

Patients and Methods:

In this study, 30 three-vessel disease patients with 104 RA, LITA, and SV grafts used concomitantly for primary isolated non-emergent CABG surgery were assessed. The primary end point was CT angiographic graft patency rate. After 53.5 (24-97) months’ follow-up, graft patency was assessed using 128-slice CT coronary angiography. Logistic regression analysis was used to detect the independent predictors of graft failure.

Results:

A total of 104 grafts, including 30 LITA, 44 SV, and 30 RA grafts, were studied. Cumulative graft patency rates were 93.3% in LITA, 83.3% in RA, and 70.5% in SV grafts. Statistically significant difference was found between the LITA and the SV graft patency rates (P = 0.019), whereas the difference between the RA conduit patency and the LITA or SV graft patency rates did not have any statistical significance (P = 0.424 and P = 0.273, respectively). Independent predictors of RA grafts occlusion were native coronary stenosis < 70% and female gender.

Conclusions:

In our patients, the RA grafts had an acceptable patency rate in 2 to 5 years’ follow-up. Although the SV grafts had a relatively higher patency rate than RA grafts in our asymptomatic patients, the patency rates in RA and SV grafts were close to each other. The RA graft function was poor in the patients with a higher number of risk factors and in the females.

Short, Intermediate and long term outcomes of CABG vs. PCI with DES in Patients With Multivessel Coronary Artery Disease. Meta-Analysis of Six Randomized Controlled Trials

OBJECTIVE

Comparing outcomes of percutaneous coronary intervention (PCI) with drug eluting stent (DES) and Coronary Artery Bypass Grafting (CABG) in patients with multivessel Coronary Artery Disease (CAD) using data from randomized controlled trials (RCT).

BACKGROUND

PCI and CABG are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple RCT have compared outcomes of the two modalities in patients with multivessel CAD.

METHODS

We did a meta-analysis from six RCT in the contemporary era comparing the effectiveness of PCI with DES to at 1 year, 2 years and 5 years respectively.

RESULTS

Compared to CABG, at one year PCI was associated with a significantly higher incidence of TVR (RR= 2.31; 95% CI: [1.80 - 2.96]; P=<0.0001), lower incidence of stroke (RR= 0.35; 95% CI: [0.19 - 0.62]; P=0.0003), and no difference in death (RR= 1.02; 95% CI: [0.77 - 1.36]; P= 0.88) or MI (RR= 1.16; 95% CI: [0.72 - 1.88]; P= 0.53). At 5 years, PCI was associated with a higher incidence of death (RR= 1.3; 95% CI: [1.10 - 1.54]; P= 0.0026) and MI (RR= 2.21; 95% CI: [1.75 - 2.79]; P=<0.0001). While the higher incidence of MI with PCI was noticed in both diabetic and non-diabetics, death was increased mainly in diabetic patients.

CONCLUSION

In patients with multi-vessel CAD, PCI with DES is associated with no significant difference in death or MI at 1 or 2 years. However at 5 years, PCI is associated with higher incidence of death and MI.

Pretreatment with hydroxyurea of the patient with essential thrombocythemia followed by coronary artery bypass surgery

The risk of thrombosis is high in patients with essential thrombocythemia. Special precaution needed for those patients who will undergo Coronary artery bypass grafting. We are reporting a 62 years old patient with ischemic heart disease who was found to have essential thrombocythemia. This report explains the preoperative management and the postoperative risks anticipated due to the treatment.

Expression of uncoupling protein-2 remains increased within hibernating myocardium despite successful coronary artery bypass grafting at 4 wk post-revascularization

BACKGROUND

We have previously shown that mitochondrial uncoupling protein-2 (UCP-2) is increased in a swine model of hibernating myocardium (HM). Although UCP-2 reduces oxidant stress, it can promote inefficiency of the electron transport chain. In this study, we tested whether UCP-2 remains increased in revascularized HM (RHM) after coronary artery bypass grafting (CABG).

METHODS

Seven swine underwent thoracotomy with placement of a constrictor on the left anterior descending artery (LAD). Twelve weeks later, a left internal mammary artery graft was placed on the distal LAD. Four weeks post-CABG, computed tomography angiography documented patent grafts and function. At the terminal study, blood flow to the LAD and remote territories were assessed during high dose dobutamine and mitochondria isolated from both regions for analysis. Comparisons were made to a group of swine with HM who underwent constrictor placement without bypass grafting (n = 4).

RESULTS

During dobutamine infusion, RHM demonstrated lower blood flows (2.44 ± 0.23 versus 3.43 ± 0.30 mL/min/g; P < 0.05) and reduced wall thickening (33 ± 9% versus 52 ± 13%; P < 0.05) compared with remote regions. RHM had lower respiratory control indices (3.7 ± 0.3 versus 4.3 ± 0.4; P < 0.05) with persistently increased UCP-2 content.

CONCLUSIONS

Despite patent grafts, RHM demonstrates a submaximal response to dobutamine infusion and increased mitochondrial UCP-2 expression. These data support the notion that recovery of the mitochondria in RHM is delayed early post-CABG and may contribute to impaired oxygen consumption and contractile reserve during catecholamine challenges.

The effect of intravenous magnesium sulfate and lidocaine in hemodynamic responses to endotracheal intubation in elective coronary artery bypass grafting: a randomized controlled clinical trial

BACKGROUND

There have been many concerns about alteration in hemodynamic parameters within and shortly after endotracheal intubation (ETI) in patients scheduled for elective coronary artery bypass grafting (CABG).

OBJECTIVES

We compared the attenuation effect of magnesium sulfate and lidocaine on hemodynamic responses after ETI, in patients undergoing CABG.

PATIENTS AND METHODS

In this randomized controlled trial 150 patients undergoing elective CABG were enrolled. Included patients were randomly allocated to three groups and received lidocaine (1.5 mg/kg), magnesium sulfate (50 mg/kg within five minute), or normal saline, 90 seconds before ETI. Baseline hemodynamic parameters including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were recorded immediately before anesthesia induction, before intubation, immediately after intubation, and at second and fifth minutes after intubation.

RESULTS

The baseline hemodynamic variables had no deference among the three groups. HR between intubation and five minute after intubation was significantly lower in two groups received lidocaine or magnesium sulfate in comparison with placebo group. Lidocaine induced more than 20% decrease in HR and MAP immediately after intubation; hence, lidocaine group showed significant MAP reduction in comparison with the two other groups.

CONCLUSIONS

Lidocaine induced hemodynamic instability but premedication of magnesium sulfate maintained hemodynamic stability after intubation. Therefore, in patients undergoing CABG who received high-dose intravenous analgesic for general anesthesia, the administration of magnesium sulfate might result in maintaining hemodynamic stability after ETI in comparison with lidocaine.

Efficacy of Combination Therapy of Statin and Vitamin C in Comparison with Statin in the Prevention of Post-CABG Atrial Fibrillation

PURPOSE

Atrial fibrillation (AF) is the most frequent arrhythmia that follows coronary artery bypass graft (CABG). Patients developing postoperative AF (POAF) have significantly higher mortality rates. The consistent prophylactic effectiveness of statins and vitamin C are well-accepted; however, no evaluation on combined therapy has been performed. We aimed at assessing the efficacy of combination therapy with statin and vitamin C in comparison with statin alone in the prevention of post CABG-AF.

METHODS

In a randomized double blind clinical trial, 120 candidates of CABG were recruited in Tabriz Madani Educational Center in a 15-month period of time. Patients were randomized into two groups of 60 receiving oral atorvastatin (40mg) plus oral vitamin C (2g/d operation day and 1g/d for five consequent days) for intervention group and oral atorvastatin (40mg) for control group. Occurrence of post CABG AF was compared between the two groups.

RESULTS

There were 60 patients, 43 males and 17 females with a mean age of 61.0±11.5 (29-78) years, in the intervention group and sixty patients, 39 males and 21 females with a mean age of 60.5±11.3 (39-81) years, in the control group. The post CABG AF occurred in 6 cases (10%) in the interventional group and 15 patients (25%) in the controls (P=0.03, odds ratio=0.33, 95% confidence interval 0.12-0.93).

CONCLUSION

Based on our findings, combination prophylaxis against post CABG AF with oral atorvastatin plus vitamin C is significantly more effective than single oral atorvastatin.

Atrial Fibrillation and Stroke Risk After Coronary Artery Bypass Grafting Surgery

Background: The present multicentre study was aimed at determining the effect of preoperative atrial fibrillation (preop-AF) as stroke risk factor in coronary artery bypass graft surgery (CABG) during the perioperative period. Methods: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish centers. Baseline variables related with perioperative stroke risk were recorded and analysed. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) stroke risk schema was used to stratify stroke risk and compare predicted vs observed neurologic outcomes in this study. Results: 26347 patients were enrolled in the study. Prevalence of preop-AF was 4.2%, and was associated significantly with major cardiovascular comorbidities. The stroke rate was 1.38% (365 strokes), and it was slightly higher for patients with preop-AF vs non preop-AF, 1.82% vs 1.36%, p = 0.2. NNECVDSG schema showed good predictive ability calculating the area under the receiver operating characteristic curve (c-statistic 0.696; 95% CI 0.668 to 0.723). To investigate the associations of baseline preoperative variables with perioperative CABG-stroke a logistic regression model was performed. Preop-AF impact on perioperative stroke was lower that other variables. Preop-AF did not show an adverse impact in the quartiles groups according to NNECVDSG Stroke Risk Index. Conclusion: Risk of perioperative stroke in isolated CABG surgery patients is not significantly increased by preop-AF.

Therapeutic hypothermia following emergent coronary artery bypass grafting after failed percutaneous coronary intervention in a comatose post-cardiac arrest patient

We report the case of 60-yr-old female in which therapeutic hypothermia (TH) was successfully induced maintaining the target temperature of 34℃ for 12 hr despite a risk of hypothermia-induced coagulation abnormalities following an emergent coronary artery bypass grafting (CABG) due to failed percutaneous coronary intervention, who suffered a cardiac arrest. Emergent CABG may be a relative contraindication for TH in post-cardiac arrest patients because hypothermia may increase the risk of infection and bleeding. However, the possibility of an improved neurologic outcome outweighs the risk of bleeding, although major surgery may be a relative contraindication for TH.

The Effects of Positive Airway Pressure Ventilation during Cardiopulmonary Bypass on Pulmonary Function Following Open Heart Surgery

Background:

Intrapulmonary shunt as a result of atelectasis following cardiac surgeries is an important and common postoperative complication that results into pulmonary dysfunction typically lasting more than a week following surgery. Different methods have been provided to prevent these complications.

Objectives:

In order to prevent postoperative pulmonary complications, investigation of the effectiveness of continuous positive airway pressure (CPAP) and intermittent mandatory ventilation (IMV) during cardiopulmonary bypass (CPB) in patients undergoing coronary artery bypass grafting (CABG).

Materials and Methods:

In this prospective interventional study, 300 patients, candidate for elective CABG (On-Pump), were randomly allocated to 3 groups: A, B, C. Group A (CPAP) patients received CPAP at 10 cm H₂O during CPB. Group B (IMV) patients received IMV with a tidal volume of 2 cc/kg and respiratory rate of 15/min and group C (control) patients did not receive any type of ventilation during CPB. Other procedures were similar between groups. Arterial blood samples were taken at 8 moments and arterial blood gas (ABG) analysis were compared between groups. Chest x-rays after CABG were also evaluated with respect to atelectasis.

Results:

The demographic data were similar in between three groups. Graft number, pump time and preoperative ABGs were not significantly different. Postoperative PaO₂ were significantly higher in the CPAP and IMV groups and (A-a) DO2 were significantly lower in these two groups, compared to the control group.

Conclusions:

In the present study, applying positive airway pressure methods (CPAP or IMV) during CPB was associated with better postoperative ABG measurements and (A-a) DO₂.

Coronary artery bypass grafting: a precipitating factor for perioperative diabetic ketoacidosis

Non-Insulin Dependent Diabetes Mellitus (NIDDM) is a common disease entity in patients with Coronary Artery Disease (CAD). Diabetic Ketoacidosis (DKA) is not only one of the major complications of Diabetes Mellitus but also a significant challenging clinical entity for the patients undergoing any elective or emergency surgery. Coronary Artery Bypass Grafting (CABG) being done in a patient with DKA has not been reported. We are presenting a rare case with DKA in whom CABG was carried out in a hospital devoted exclusively to cardiac cases. Insulin was given in very large doses as a part of therapeutic regimen and the outcome was favorable. This report concludes that if a patient undergoing urgent cardiac surgery incidentally develops DKA after induction of anesthesia, then the operation can be carried out provided DKA is managed aggressively. Also, major stress factors like cardio pulmonary bypass (CPB) and hypothermia should be avoided and care should be taken to avoid cerebral edema.

Mid-term outcomes of total arterial revascularization versus conventional coronary surgery in isolated three-vessel coronary disease

Whether arterial conduits are superior to venous grafts in coronary artery bypassing has been debated. The aim of this study was to investigate clinical outcomes after total arterial revascularization versus conventional coronary bypassing using both arterial and venous conduits in isolated three-vessel coronary disease. Between 2003 and 2005, 503 patients who underwent isolated coronary artery bypass grafting for three-vessel coronary disease were enrolled. A total of 117 patients underwent total arterial revascularization (Artery group) whereas 386 patients were treated with arterial and venous conduits (Vein group). Major adverse outcomes (death, myocardial infarction, stroke and repeat revascularization) were compared. Clinical follow-up was complete in all patients with a mean duration of 6.1 ± 0.9 yr. After adjustment for differences in baseline risk factors, risks of death (hazard ratio [HR] 0.96; 95% confidence interval [CI] 0.51-1.82, P = 0.90), myocardial infarction (HR 0.20, 95% CI 0.02-2.63, P = 0.22), stroke (HR 1.29, 95% CI 0.35-4.72, P = 0.70), repeat revascularization (HR 0.64, 95% CI 0.26-1.55, P = 0.32) and the composite outcomes (HR 0.83, 95% CI 0.50-1.36, P = 0.45) were similar between two groups. Since the use of veins does not increase the risks of adverse outcomes compared with total arterial revascularization, a selection of the conduit should be more liberal.

Predictive value of P-wave duration and dispersion in post coronary artery bypass surgery atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common complication of cardiac surgery. Although it is managed easily, it can cause critical hemodynamic instabilities for intensive care patients. This observational study investigated the predictive power of P-wave dispersion (PWD) for the incidence of post cardiac surgery AF.

METHODS

Among patients undergoing isolated coronary artery bypass grafting surgery (CABG), 52 patients were selected randomly. Before the operation, ejection fraction, regional wall motion abnormality, and mitral regurgitation were determined by echocardiography. Angiographic data provided information about stenosed vessels. PWD was measured before and after CABG. The incidence of post-CABG AF was determined by rhythm monitoring.

RESULTS

There were no significant differences in age, sex, stenosed vessels, maximum P-wave duration, the prevalence of hypertension, smoking, mitral regurgitation, and regional wall motion abnormality between post-CABG AF and non-AF groups (P > 0.05). The mean prevalence of diabetes mellitus in post-CABG AF group was more than non-AF group (P = 0.036). The mean ejection fraction in post-CABG AF group was lower than non-AF group (P < 0.005). The mean PWD in AF group vs. non-AF group before CABG was 47.5 vs. 23.7 ms. The mean values of post-surgical PWD in AF and non-AF groups were 48.10 and 24.4 ms, respectively. Before CABG, the mean ejection fraction value and minimum P-wave duration in AF group were lower than non-AF group (P < 0.005). A reverse relation was present between minimum P wave duration and PWD (P < 0.001). There was a negative association between high ejection fraction values and decreased PWD (P = 0.002).

CONCLUSION

Our data suggested minimum P wave duration, PWD, and low ejection fraction are as good predictors of AF in patients undergoing isolated CABG. The absence of differences in age, sex, smoking, hypertension, mitral regurgitation, and regional wall motion abnormality in our study was in contrast with other reports. On the other hand, increased rate of post-CABG AF in our diabetic patients with lower ejection fraction supports other studies. Overall, minimum P wave duration, PWD, and low ejection fraction can be used for patient risk stratification of AF after CABG.

Clinical characteristics and outcomes of patients with acute coronary syndrome and prior coronary artery bypass grafting in a large middle eastern cohort

BACKGROUND

Acute Coronary Syndrome (ACS) can occur in patients with prior coronary artery bypass grafting (CABG). In the Gulf Registry of acute coronary events (Gulf RACE), we identified the clinical characteristics and in-hospital outcomes of these patients.

METHODS

Clinical characteristics and in-hospital outcomes for 461 ACS patients with prior CABG are compared to 7715 ACS patients without prior CABG enrolled from 64 hospitals in 6 Gulf countries over a 6-month period.

RESULTS

The overall incidence of ACS with prior CABG was 5.6% out of 8176 patients. The ACS with prior CABG were older (63 vs 55 years, P<0.0001), had more history of diabetes (62.3 vs 37.6%, P <0.0001), dyslipidemia (70.3 vs 29.5%, P<0.0001), and hypertension (75.7 vs 47.8%, P<0.0001) compared with the non-CABG group. They presented more frequently with dyspnea (14.8 vs 9.5%, P<0.0005), non-ST segment elevation myocardial infarction (41.4 vs 31.6%, P<0.0001) and echocardiographic evidence of left ventricular dysfunction (49.4 vs 29.8%, P<0.0001) than ACS without prior CABG. They had a complicated in-hospital course with more recurrent ischemia (13.9 vs 9.3%, P=0.0011), heart failure (24.1 vs 15.7%), and stroke (2.2 vs 0.6%) compared with those without CABG. The in-hospital mortality rate was 5.6% in the CABG group compared with 3.5% in the ACS without prior CABG group. After adjusting for confounders, prior CABG was independently associated with recurrent ischemia and shock, more in patients presenting with ST elevation than non-ST elevation ACS.

CONCLUSIONS

Patients with ACS and prior CABG are a high-risk group with poor outcomes irrespective of their older age and comorbidities. They should be identified and treated differently to improve their outcomes.