Hiatal hernia after robotic-assisted coronary artery bypass graft surgery

BackgroundThe aim of the present study is to determine the incidence/progression of hiatal hernia (HH) after robotic-assisted coronary artery bypass grafting (RA-CABG) surgery.MethodsWe reviewed the pre- and post-operative computed tomography (CT) of 491 patients who underwent RA-CABG between 2000 and 2017. Post-operative CT was acquired prospectively in a research protocol. CT was reviewed to assess the presence and the size of HH.ResultsWe found 444/491 (90.4%) had pre-operative CT, while 201/491 (40.9%) had post-operative CT. In total, 155/491 (31.6%) had both pre- and long-term post-operative CT with a mean follow-up of 6.2 (±3.5) years. HH was more prevalent on post-operative CT, 64/155 (41.3%) compared to pre-operative CT, 44/155 (28.4%), P<0.0001. The diameter of pre-existing HH 2.8 (±1.8) cm was significantly greater after surgery 3.9 (±2.5) cm, P<0.0001. As well the volume of the pre-existing HH 5.8 (4.4–9.2) mL (quartile) was significantly greater after surgery 14.1 (7.2–64.9) mL, P<0.0001. 20/155 (12.9%) had a newly developed HH after RA-CABG. A binary multivariate regression including HH risk factors showed that male gender is a predictor of developing a HH after RA-CABG with Hazard Ratio of 3.038, confidence interval (1.10–8.43), P=0.033.ConclusionsRA-CABG is associated with an increased risk of developing HH and increases the size of pre-existing HH.     

Long‐term outcomes in patients with normal coronary arteries,nonobstructive, or obstructive coronary artery disease on invasive coronary angiography

BackgroundNormal or near normal coronary arteries (NNCA) or nonobstructive coronary artery disease (CAD) are commonly found on invasive coronary angiography (ICA).HypothesisWe aimed to determine long‐term outcomes by severity of CAD in a contemporary cohort of patients undergoing ICA for evaluation for ischemic heart disease.MethodsWe assessed a consecutive cohort of 925 patients who underwent non‐emergent ICA over 24 months. Cardiac death (CD), nonfatal myocardial infarction (NFMI), late revascularization, and medication use were assessed.ResultsFollow‐up data was available in 850 patients. Of patients without heart failure, at a median of 6.0 years, there was a significant decrease in survival free from CD or NFMI, and from all cardiac events, for those with obstructive CAD compared with patients with NNCAs or nonobstructive CAD (p < .001 for both). No differences between NNCA and nonobstructive CAD patients in rates of CD or NFMI (2.0% vs. 2.1%/year, p = .58) or all cardiac events (2.4% vs. 2.9%/year, p = .84) were observed.ConclusionLong‐term follow‐up in a contemporary cohort of consecutive patients undergoing non‐emergent ICA for detection of CAD showed no difference in annual rates of CD or NFMI, or total cardiac events, in patients with NNCAs versus those with nonobstructive CAD, whereas patients with obstructive CAD had significantly more events. Event rates were low and similar by gender. Use of aspirin, lipid lowering therapy, and beta‐blockers increased in all subgroups after ICA. We speculate this may explain the low incidence of subsequent cardiac events, and similar event rates in patients with NNCA and nonobstructive CAD, even in patients presenting with non‐ST‐elevation MI.     

Association between serum adipsin and plaque vulnerability determined by optical coherence tomography in patients with coronary artery disease

BackgroundEarly identification of vulnerable plaques is important for patients with coronary artery disease (CAD) to reduce acute coronary events and improve their prognosis. We sought to examine the relationship between adipsin, an adipokine secreted from adipocytes, and plaque vulnerability in CAD patients.MethodsA total of 103 plaques from 99 consecutive patients who underwent coronary angiography were assessed by optical coherence tomography. The serum level of adipsin was measured using enzyme-linked immunosorbent assay (ELISA). The accuracy of adipsin for detecting thin-cap fibroatheroma (TCFA) was determined by the area under the receiver operating characteristic curve (AUC).ResultsOf the 99 patients, 49 were classified into the low adipsin group and 50 into the high adipsin group according to the median level of serum adipsin (2.43 µg/mL). The plaques from the high adipsin group exhibited a greater lipid index (2,700.0 vs. 1,975.9° × mm, P=0.015) and an increased proportion of TCFAs (41.2% vs. 21.2%, P=0.028) compared with the low adipsin group. Serum adipsin was found to be negatively correlated with fibrous cap thickness (ρ=−0.322, P=0.002), while it was positively correlated with average lipid arc (ρ=0.253, P=0.015), maximum lipid arc (ρ=0.211, P=0.044), lipid core length (ρ=0.241, P=0.021), lipid index (ρ=0.335, P=0.001), and vulnerability score (ρ=0.254, P=0.014). Furthermore, adipsin had a significant association with TCFAs (OR: 1.290, 95% CI: 1.048–1.589, P=0.016) in the multivariate analysis, while having a moderate diagnostic accuracy for TCFAs (AUC: 0.710, 95% CI: 0.602–0.817, P<0.001).ConclusionsOur findings suggest that serum adipsin is significantly and positively correlated with the incidence of TCFAs. The application of adipsin as a biomarker may offer improvement in the diagnosis of vulnerable plaques and clinical benefits for CAD patients.     

Increased carotid intima–media thickness associated with high hs-CRP levels is a predictor of unstable coronary artery disease

Abstract

Increased values of carotid intima–media thickness (CIMT) and high-sensitivity C-reactive protein (hs-CRP) are predictors of acute coronary events. We analysed the link between CIMT and hs-CRP in cases with coronary artery disease (CAD). From 1 January to 30 June 2012, we evaluated 43 patients with acute coronary syndrome (group A), 50 patients with stable coronary artery disease (group B) and 50 healthy volunteers (group C). All were analysed for CIMT and hs-CRP levels. CIMT values were higher in groups A and B (0.94 ± 0.21 mm, 0.89 ± 0.19 mm, respectively) and lower in group C (0.64 ± 0.09 mm), and this was statistically significant (p < 0.0001). However the values of hs-CRP were higher in group A (1.87 ± 0.36 mg/l) and lower in groups B and C (1.07 ± 0.28 mg/l, 0.97 ± 0.45 mg/l, respectively) and this was also statistically significant (p < 0.0001).     

Reduced Survival in Patients with “Coronary Microvascular Disease”

The syndrome of chest pain, abnormal stress test, and nonflow limiting coronary artery disease (CAD) is common and is attributed to coronary microvascular disease (µVD). It is associated with increased hospital admissions and health care costs. But its impact on long-term survival is not known. Of the 9941 consecutive patients who had an exercise stress test for evaluation of chest pain between May 1991 and July 2007, 935 had both a positive stress test and a coronary angiogram within 1 year of their stress test forming the study cohort. Significant angiographic CAD defined as ≥70% stenosis of an epicardial coronary artery or ≥50% stenosis of the left main coronary artery was present in 324 patients. Rest (n = 611) were considered to have coronary µVD. Compared with patients with significant epicardial CAD, patients with coronary µVD were younger (63 ± 11 vs. 65 ± 10 years, p = 0.002), and had lower left ventricular wall thickness (p < 0.02), systolic blood pressure (BP; p = 0.002), pulse pressure (0.0008), systolic BP with exercise (p = 0.0001), and pulse pressure with exercise (p < 0.0001). Those with coronary µVD had a better survival compared with those with significant epicardial CAD, but worse than that expected for age- and gender-matched population (p < 0.0001). Coronary µVD as a cause of chest pain and positive stress test is common. All-cause mortality in patients with coronary µVD is worse than in an age- and gender-matched population control, but better than those with significant epicardial CAD.     

Right ventricular echocardiographic parameters for prediction of proximal right coronary artery lesion in patients with inferior wall myocardial infarction

Background

Classifying the location of an occlusion in the culprit artery during ST-elevation myocardial infarction is important for risk stratification to optimize treatment.

Objectives

To compare the validity of echocardiographic parameters assessing right ventricular (RV) function for the prediction of proximal right coronary artery (RCA) lesion in patients with inferior wall myocardial infarction.

Methods

The study included 76 patients after their first episode of acute inferior myocardial infarction with significant RCA lesion (43 patients with proximal RCA stenosis and 33 patients with distal RCA stenosis). Full echocardiographic examination was done before revascularization, including RV dimension, tricuspid annular plane systolic excursion, and tissue Doppler imaging of RV free wall at the level of the tricuspid annulus and recording the following variables: peak systolic velocity (Sm), peak early diastolic velocity, peak late diastolic velocity, ejection time (ET), isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT), and myocardial performance index (MPI), which was calculated as (MPI = IVRT + IVCT/ET).

Results

Patients with proximal RCA showed significantly lower Sm (10.44 ± 2.61 cm/s vs. 12.11 ± 2.94 cm/s, p = 0.013) and shorter ET (224.18 ± 49.96 ms vs. 280.90 ± 46.12 ms, p = 0.001). While IVRT, IVCT, and MPI were significantly higher (95.25 ± 19.22 ms vs. 68.48 ± 12.77 ms, p = 0.001; 81.62 ± 23.59 ms vs. 60.90 ± 17.38 ms, p = 0.001; and 0.82 ± 0.222 vs. 0.47 ± 0.10, p = 0.001, respectively) when compared with patients with distal RCA stenosis. Multiple regression analysis including (tricuspid annular plane systolic excursion, Sm, and MPI) showed that the most independent predictors for proximal RCA lesions were MPI (p = 0.0001). The receiver operator characteristic curve for MPI showed areas under the curve of 97% and a confidence interval of 93%. A cut-off value of 0.58 for MPI had a sensitivity of 95% and specificity of 97% for the diagnosis proximal RCA.

Conclusions

The most independent predictors for proximal RCA lesion is MPI.     

Coronary artery size as a predictor of Y-graft patency following coronary artery bypass surgery

This study aims to evaluate the association between target vessel size and graft patency in the right IMA–right coronary territory anastomosis.A total of 402 patients who underwent CABG between 2005 and 2016 using the right IMA Y-graft to the posterolateral branch or posterior descending artery were enrolled. Preoperative coronary angiography was utilized to measure the size of the target coronary arteries in the right territory. Follow-up angiography and computed tomography at 6 to 12 months were used to determine graft patency.Thirty patients (7.5%) were found to have occluded graft. Larger target vessel size was associated with lower risk of graft occlusion (OR: 0.18, 95% CI:0.05–0.62, P = .007). The receiver operating characteristic (ROC) curve showed that the cutoff-value of 1.93 mm was found to have the maximum sum of sensitivity and specificity for graft patency (Area under the curve (AUC): 0.65, P = .01). Excluding patients with right coronary artery total occlusion, the discriminative performance of target vessel size became more prominent (AUC: 0.76, P < .01), with same cutoff value.In the setting of bilateral IMA composite grafting, the patency of right IMA to right coronary territory was influenced by the size of the target coronary artery. The influence of target coronary artery size was prominent in non-total occlusion patients. Careful selection of a target anastomosis site is recommended.     

Prolonged derangements of canine myocardial purine metabolism after a brief coronary artery occlusion not associated with anatomic evidence of necrosis

Changes in myocardial purine metabolism were studied after temporary coronary artery occlusion and subsequent reperfusion in the dog. Sequential myocardial biopsies were performed to allow for measurements of ATP, adenine nucleotide, nucleoside, and base concentrations after 15 min of ischemia, and after 90 min and 72 hr of reperfusion following this period of ischemia. Control, nonischemic sites were also sampled. After 15 min of coronary occlusion, subendocardial ATP concentrations (reported in nmol/mg of protein; mean ± SEM) were depressed in the ischemic zone at 19.9 ± 3.5 compared to 38.1 ± 2.8 in the nonischemic zone (P < 0.001). Subepicardial ATP concentrations also were depressed at 27.0 ± 2.2 in ischemic sites compared to subepicardial nonischemic sites (40.0 ± 4.0, P < 0.005). After 90 min of reperfusion ATP concentrations remained depressed in the previously ischemic subendocardium 26.8 ± 4.2 (P < 0.025 vs. nonischemic sites). After 72 hr of reperfusion, ATP was still depressed in the previously ischemic subendocardium at 29.2 ± 2.5 (P < 0.025 vs. nonischemic) and subepicardium (27.9 ± 3.3, P < 0.05 vs. nonischemic). Total purines were determined as the sum of ATP, ADP, AMP, adenosine, inosine, and hypoxanthine. After 15 min of occlusion, the total purine pool in the ischemic subendocardium tended towards being lower than in the nonischemic zone (42.0 ± 5.9 vs. 53.8 ± 5.2, not significant) but in the ischemic subepicardium the total purine pool was similar to that in the nonischemic zone. After 90 min of reperfusion the previously ischemic subendocardial purine pool was reduced compared to the nonischemic zone (39.0 ± 4.8, P < 0.025). Total purines were also depleted in both the subendocardium and subepicardium of previously ischemic zones after 72 hr of reperfusion (44.5 ± 2.9 and 40.0 ± 4.4, respectively, P < 0.05). Histologic analysis of the previously ischemic tissue revealed no evidence of necrosis. Therefore, brief temporary coronary artery occlusions not associated with anatomic evidence of necrosis may result in prolonged abnormalities of ATP concentration and significant depletion of the total purine pool.     

Ten‐year clinical outcomes in patients with intermediate coronary stenosis according to the combined culprit lesion

BackgroundWe assessed the long‐term clinical outcomes of an intermediate lesion (IL) according to the presence of a combined culprit lesion (CCL).HypothesisLong‐term clinical outcomes of IL may be affected by the presence of a CCL.MethodsAngiographic findings (n = 1096) and medical chart were reviewed. Patients with IL were divided into two groups: IL without CCL group (n = 383, 64.5%) and IL with CCL group (n = 211, 35.5%).ResultsThe major adverse cardiovascular events (MACE) in the IL with CCL group were significantly higher than those in the IL without CCL group (death: 12.3% vs. 7.0%, myocardial infarction: 3.3%vs. 0.5%, stroke: 6.6% vs. 2.6%, and revascularization [RVSC]: 25.1% vs. 7.6%) during a mean follow up period of 118.4 ± 5.5 months. IL related RVSC rate in the IL with CCL group was higher than that in the IL without CCL group (5.7% vs. 2.1%, p = 0.020). RVSC rate related to IL in total subjects was lower than that related to stented lesion (3.4% vs. 6.4%). The important predictors of total MACE in total subjects were the presence of CCL, IL percent diameter stenosis, hypertension, history of percutaneous coronary intervention, blood glucose and ejection fraction. The predictors of IL related RVSC were IL percent diameter stenosis and IL located in the right coronary artery.Conclusion10‐year clinical outcomes of an IL (especially IL without CCL) were better than those of stented lesions. This study suggests that the IL can be safely followed up in sites that do not have ability to assess functional study.     

Robot-assisted coronary artery bypass grafting improves short-term outcomes compared with minimally invasive direct coronary artery bypass grafting

Background

Robot-assisted coronary artery bypass grafts (RACAB) utilizing the da Vinci surgical system are increasingly used and allow the surgeon to conveniently harvest internal mammary arteries (IMAs). The aim of this study was to compare the outcomes of off-pump RACAB and minimally invasive direct coronary artery bypass grafting (MIDCAB) in the short and medium term.

Methods

We performed a retrospective review of 132 patients with single- or multiple-vessel coronary artery disease who underwent minimally invasive off-pump CABG (OPCAB) between May 2009 and May 2014. The patients were divided into two groups based on the surgical approach, MIDCAB and RACAB group. The anastomosis of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) was performed as regular OPCAB through the incision on the beating heart using regular stabilization devices (Genzyme Corporation). The preoperative, intraoperative, postoperative, and follow-up data, including major adverse cardiac and cerebrovascular events (MACCE), were compared.

Results

The preoperative data were similar. RACAB significantly shorten the intensive care unit (ICU) stay and postoperative compared with the MIDCAB group (P<0.05). There were 12 (19.7%) patients treated with a two-stage hybrid procedure in the MIDCAB group and 34 (47.9%) patients in the RACAB group (P=0.001). Thirty-day mortality was 1.6% in the MIDCAB group. There were 9 (14.7%) MIDCAB patients and 2 (2.8%) RACAB patients (P=0.013) that developed new arrhythmia. The two groups showed comparable mid-term survival (P=0.246), but the MACCEs were significantly different (P=0.038).

Conclusions

RACAB may be a valuable alternative for patients requiring single or simple multi-vessel coronary artery bypass grafting (CABG). Although the mid-term mortality outcomes are similar, RACAB improves short-term outcomes and mid-term MACCE-free survival compared with MIDCAB.     

Asian Indians,coronary artery disease,and physical exercise

Objective—To evaluate the relation of physical activity to different clinical and biochemical risk factors for coronary artery disease among people from different ethnic groups with angiographically proven coronary artery disease.
Subjects—British Asians, Indian Asians, and white people suffering from coronary artery disease, and their respective controls.
Interventions—History, physical examination, coronary angiography (at baseline), laboratory investigations.
Main outcome measures—Relation of physical activity level to serum insulin, glucose, cholesterol, triglycerides, and high density lipoproteins, systolic and diastolic blood pressures, and body mass index in patients and controls.
Results—391 male patients were studied, of whom 260 (66.5%) were classified as sedentary. Mean serum insulin at 0, 1, and 2 hours after 75 g oral glucose was higher among the sedentary population (17.1 v 11.6, 88.2 v 62.1, and 57.9 v 36.2 µU/ml, respectively (all p < 0.0001). Mean body mass index was also higher among the sedentary population (25.53 v 23.95, p < 0.0001), as were mean serum triglycerides (1.85 v 1.60 mmol/l, p < 0.01) and systolic and diastolic blood pressures (133.9 v 129.4, p < 0.05, and 81.1 v 79.0, p < 0.01). There was no difference in the mean serum cholesterol and high density lipoprotein between the two groups. British Asians were the most sedentary and Indian Asians the most physically active.
Conclusions—There are marked differences in the level of physical activity among the various ethnic groups in the United Kingdom. In each ethnic group, physical activity reduced mean serum insulin, body mass index, and serum triglycerides and had a favourable effect on systolic and diastolic blood pressures. Promotion of physical activity could be of value for the Asian community in the United Kingdom.

     

Comparative coronary anatomy in six twin pairs with coronary artery disease

OBJECTIVE—To compare the coronary anatomy and the location of coronary lesions in monozygotic and dizygotic twin pairs affected with coronary artery disease.
DESIGN—Coronary angiographic findings were compared with respect to the distribution of coronary blood supply and the location of coronary lesions.
MAIN OUTCOME MEASURES—Distribution of coronary blood supply, diameters and length of proximal coronary arteries.
RESULTS—The lumen diameters of the left main coronary artery, the left anterior descending coronary artery, the circumflex artery, and the right coronary artery, as well as the lengths of the left main coronary artery, showed similar variability within monozygotic and dizygotic twin pairs. With respect to the dominance pattern of coronary blood supply, two of three monozygotic twin pairs differed, while all dizygotic twin pairs were concordant. Concordant and discordant locations of stenoses were found with similar frequency in monozygotic and dizygotic twin pairs.
CONCLUSIONS—The dominance pattern of coronary blood supply and the location of coronary lesions are not strictly hereditary. The high concordance of premature coronary artery disease found in monozygotic twin pairs may largely be related to factors that are independent of the macroanatomic distribution of the coronary blood supply.


Keywords: twin studies; coronary anatomy; coronary lesions     

Predicting adverse cardiovascular outcomes in post‐coronary artery bypass grafting patients using novel ECG frequency analysis of the QRS complex

BackgroundA novel metric called Layered Symbolic Decomposition frequency (LSDf) has been shown to be an independent predictor of ventricular arrhythmia and mortality in patients receiving implantable cardioverter‐defibrillator (ICD) devices. This novel index studies the fragmentation of the QRS complex. However, its generalizability to predict cardiovascular events for other cardiac procedures is unknown. Herein, we investigated the applicability of LSDf as a predictive measure for major adverse cardiovascular events (MACE) in patients receiving coronary artery bypass grafting (CABG).Methods and ResultsOne hundred ninety‐five patients had high‐resolution ECG recorded prior to CABG surgery in 2012/2013 and were followed for a mean duration of 7.32 ± 0.32 years for postoperative cardiovascular outcomes. These outcomes were described as a modified composite of MACE defined as hospitalization for heart failure, ventricular tachycardia, ventricular fibrillation, and cardiovascular death including stroke and cardiac arrest. One hundred seventy‐two patients were included for analysis and 18 patients experienced a postoperative cardiovascular outcome. These patients had significantly increased age (71.3 vs. 64.6 years, p = .007), prolonged QRS duration (113.22 vs. 97.35 ms, p = .003), reduced left ventricular ejection fraction (42.7% vs. 56.5%, p < .001), and lower LSDf percent (13.5% vs. 16.9%, p = .002). Patients with an LSDf below 13.25% were 4.8 (OR 1.7–13.5, p < .001) times more likely to experience a MACE and up to 19.4 (OR 4.2–90.3, p < .001) times more likely to experience a MACE when older than 70 years and an ejection fraction below 50%.ConclusionLayered Symbolic Decomposition frequency may be an applicable metric to predict long‐term cardiovascular outcomes in patients with ischemic heart disease.     

Off-pump coronary artery bypass grafting using a bilateral internal mammary artery Y graft

Objectives To evaluate the outcome of off-pump coronary artery bypass grafting (OPCABG) using a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization. Methods From October 2002 to December 2008, 208 patients (196 males and 12 females) underwent OPCABG using a BIMA Y configuration graft. The average age of the patients was 56.5 ± 11.3 years, with an age range of 33–78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semi-skeletonization technique was used to harvest the two internal mammary arteries (IMAs), and then the free right internal mammary artery was connected end-to-side to the left internal mammary artery (LIMA) in situ to complete the Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery in all patients. Graft patency was assessed intra-operatively with the HT311 transit time flowmeter. Results A total of 728 distal anastomoses were performed in 208 patients, with the average being 3.5 ± 1.3 per person. No one died or experienced recurrent angina within 30 days after the operation. Conclusions OPCABG using the BIMA Y graft was safe and effective to achieve total arterial revascularization. This method avoids surgical operation on the ascending aorta and other incisions.     

Transesophageal echocardiography estimation of coronary sinus blood flow for the adequacy of revascularization in patients undergoing off-pump coronary artery bypass graft

Aims and Objectives:

Physiologically coronary sinus (CS) drains the left coronary artery (LCA) territory. Stenosis of the branches of LCA may decrease the coronary sinus blood flow (CSBF). Any intervention that aims at restoring the flow of the stenosed vessel increases coronary artery flow that should consequently increase the CSBF. Hence, this study was undertaken to assess the CSBF before and after each branch of LCA to determine the adequacy of surgical revascularization in patients undergoing elective off pump coronary artery bypass grafting (OPCAB) using transesophageal echocardiography (TEE).

Materials and Methods:

Thirty consecutive patients scheduled for elective OPCAB were enrolled. CSBF was assessed before and after each branch of LCA revascularization using TEE. Left internal mammary artery (LIMA) Doppler was also obtained post LIMA to left anterior descending (LAD) grafting.

Results:

Hemodynamic and echocardiographic variables were compared by means of Student''s t-test for paired data before and after revascularization. The CSBF per beat (1.28 ± 0.71), CSBF per minute (92.59 ± 59.32) and total velocity time integral (VTI) (8.93 ± 4.29) before LAD grafting showed statistically significant increase to CSBF per beat (1.70 ± 0.89), CSBF per minute (130.72 ± 74.22) and total VTI (11.96 ± 5.68) after LAD revascularization. The CSBF per beat (1.67 ± 1.03), CSBF per minute (131.91 ± 86.59) and total VTI (11.00 ± 5.53) before obtuse marginal (OM) grafting showed statistically significant increase to CSBF per beat (1.91 ± 1.03), CSBF per min (155.20 ± 88.70) and total VTI (12.09 ± 5.43) after OM revascularization. In 9 patients, color flow Doppler of LIMA could be demonstrated which showed diastolic predominant blood flow after LIMA to LAD grafting.

Conclusion:

Demonstration of CSBF was simple and monitoring the trend of CSBF values before and after each graft of LCA territory will guide to determine the adequacy of surgical revascularization.     

Hybrid coronary revascularization vs. percutaneous coronary interventions for multivessel coronary artery disease

OBJECTIVEHybrid coronary revascularization (HCR) combines a minimally invasive surgical approach to the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) for non-LAD diseased coronary arteries. It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery, but there is little information comparing it to isolated PCI for multivessel disease. Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease.METHODSThis cohort study used data from New York’s cardiac surgery and PCI registries in 2010−2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI. Cox proportional hazards methods were used to reduce selection bias. Patients were followed for a median of four years.RESULTSThere was a total of 335 HCR patients (1.2%) and 25,557 PCI patients (98.8%) after exclusions. There was no difference in 6-year risk adjusted survival between HCR and PCI patients (83.17% vs. 81.65%, adjusted hazard ratio (aHR) = 0.90 (95% CI: 0.67−1.20). However, HCR patients were more likely to be free from repeat revascularization in the LAD artery (91.13% vs. 83.59%, aHR = 0.51 (95% CI: 0.34−0.77)). CONCLUSIONSFor patients with multi-vessel coronary artery disease, HCR is rarely performed. There are no differences in mortality rates after four years, but HCR is associated with lower repeat revascularization rates in the LAD artery, presumably due to better longevity in left arterial mammary grafts.

For most patients with multivessel disease coronary artery disease, either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) is the recommended option. The advantage of CABG surgery is generally the durability of the bypass grafts, and CABG surgery is recommended especially among the highest risk patients (e.g., three vessel disease, left main (LM) disease, multivessel disease with proximal left anterior descending artery (LAD) disease).^[1-4] Nevertheless, an advantage of CABG surgery is the superior outcomes achieved with left internal mammary artery (LIMA) grafts to the LAD for patients with LAD disease.^[5-7]Hybrid coronary revascularization (HCR) is an approach that has been developed to combine the main advantages of both CABG surgery and PCI. It consists of using a LIMA anastomosis to the LAD via a minimally invasive CABG surgery approach (no sternotomy) in addition to PCI for other diseased coronary arteries. The rationale for using this approach in lieu of using PCI for all diseased coronary arteries is the potential for more durability of the LAD revascularization as a result of the LIMA to LAD anastomosis. Several studies have compared HCR to CABG surgery, but they are limited with respect to sample size, number of institutions represented, duration, and inability to capture population-based practice.^[8-24] Multi-center studies comparing HCR with PCI, which are arguably more relevant since these two alternatives are the least invasive ones, are extremely limited.^[25,26]The purposes of this study are to: (1) describe the use of HCR and the characteristics of patients undergoing HCR vs. PCI in a population-based setting, and (2) compare short- and medium-term outcomes for HCR and PCI for patients with multi-vessel coronary artery disease accompanied by LAD disease using New York’s clinical cardiac registries.     

Comparison of coronary atherosclerotic disease burden between ST‐elevation myocardial infarction and non‐ST‐elevation myocardial infarction: Non‐culprit Gensini score and non‐culprit SYNTAX score

BackgroundPatients with non‐ST‐elevation myocardial infarction (NSTEMI) have worse long‐term prognoses than those with ST‐elevation myocardial infarction (STEMI).HypothesisIt may be attributable to more extended coronary atherosclerotic disease burden in patients with NSTEMI.MethodsThis study consisted of consecutive 231 patients who underwent coronary intervention for myocardial infarction (MI). To assess the extent and severity of atherosclerotic disease burden of non‐culprit coronary arteries, two scoring systems (Gensini score and synergy between percutaneous coronary intervention with Taxus and cardiac surgery [SYNTAX] score) were modified by subtracting the score of the culprit lesion: the non‐culprit Gensini score and the non‐culprit SYNTAX score.ResultsPatients with NSTEMI had more multi‐vessel disease, initial thrombolysis in myocardial infarction (TIMI) flow grade 2/3, and final TIMI flow grade 3 than those with STEMI. As compared to STEMI, patients with NSTEMI had significantly higher non‐culprit Gensini score (16.3 ± 19.8 vs. 31.2 ± 25.4, p < 0.001) and non‐culprit SYNTAX score (5.8 ± 7.0 vs. 11.1 ± 9.7, p < 0.001).ConclusionsPatients with NSTEMI had more advanced coronary atherosclerotic disease burden including non‐obstruction lesions, which may at least in part explain higher incidence of cardiovascular events in these patients.     

Magnesium causes nitric oxide independent coronary artery vasodilation in humans

OBJECTIVE—To determine how magnesium affects human coronary arteries and whether endothelium derived nitric oxide (EDNO) is involved in the coronary arterial response to magnesium.
DESIGN—Quantitative coronary angiography and Doppler flow velocity measurements were used to determine the effects of the nitric oxide synthase inhibitor N^G-monomethyl-L-arginine (L-NMMA) on magnesium induced dilation of the epicardial and resistance coronary arteries.
SETTING—Hiroshima University Hospital a tertiary cardiology centre.
PATIENTS—17 patients with angiographically normal coronary arteries.
INTERVENTIONS—Magnesium sulfate (MgSO₄) (0.02 mmol/min and 0.2 mmol/min) was infused for two minutes into the left coronary ostium before and after intracoronary infusion of L-NMMA.
MAIN OUTCOME MEASURES—Diameter of the proximal and distal segments of the epicardial coronary arteries and coronary blood flow.
RESULTS—At a dose of 0.02 mmol/min, MgSO₄ did not affect the coronary arteries. At a dose of 0.2 mmol/min, MgSO₄ caused coronary artery dilation (mean (SEM) proximal diameter 3.00 (0.09) to 3.11 (0.09) mm; distal 1.64 (0.06) to 1.77 (0.07) mm) and increased coronary blood flow (79.3 (7.5) to 101.4 (9.9) ml/min, p < 0.001 v baseline for all). MgSO₄ increased the changes in these parameters after the infusion of L-NMMA (p < 0.001 v baseline).
CONCLUSIONS—Magnesium dilates both the epicardial and resistance coronary arteries in humans. Furthermore, the coronary arterial response to magnesium is dose dependent and independent of EDNO.


Keywords: coronary artery; coronary blood flow; magnesium sulfate; nitric oxide     

Predictors and long-term prognosis of left ventricular aneurysm in patients with acute anterior myocardial infarction treated with primary percutaneous coronary intervention in the contemporary era

BackgroundPrimary percutaneous coronary intervention (PCI) has been the standard reperfusion strategy for patients with acute myocardial infarction (AMI) in the contemporary era. Meanwhile, the incidence and prognosis of left ventricular aneurysm (LVA) in AMI patients remain ambiguous. The aim of the current study is to identify the predictor and long-term prognosis of LVA in patients with acute anterior myocardial infarction.MethodsWe prospectively enrolled 942 consecutive patients with acute anterior myocardial infarction who were treated by primary PCI. The baseline characteristics, procedural features, and one-year clinical outcomes were compared between the patients with and without LVA. The primary endpoint of major adverse cardiovascular and cerebrovascular events (MACCEs) was defined as a composite of cardiac death, target vessel revascularization, and ischemic stroke. Multiple logistic regression was applied to predict LVA formation and the receiver operating characteristic (ROC) curves were plotted to evaluate the accuracy of the multivariate analysis model.ResultsThe general incidence of LVA was 15.92%. At one-year clinical follow-up, patients in the LVA group had significantly higher incidence of MACCEs (15.33% vs. 6.44%, P<0.01), mainly driven by an increased incidence of cardiac death (8.00% vs. 2.78%, P<0.01), target vessel revascularization (5.33% vs. 2.27%, P=0.03), and ischemic stroke (4.00% vs. 1.39%, P=0.03). Multivariate analysis found that longer symptom-to-balloon time (S2B) [odds ratio (OR): 1.16, 95% confidence interval (CI): 1.11–1.21, P<0.01], higher initial and residual SYNTAX score (iSS, OR: 1.19, 95% CI: 1.14–1.24, P<0.01; rSS, OR: 1.33, 95% CI: 1.22–1.45, P<0.01), lower left ventricular ejection fraction (LVEF) (OR: 1.15, 95% CI: 1.11–1.18, P<0.01), and persistent ST segment elevation (OR: 1.89, 95% CI: 1.06–3.38, P=0.03) were independent predictors of LVA formation.ConclusionsLVA is still common in patients with acute anterior myocardial infarction in the contemporary PCI era, and the prognosis of these patients was significantly worse during the one-year clinical follow-up. Strategies of prompt reperfusion and complete revascularization may be helpful in preventing LVA formation and improving clinical outcomes.     

Linking soluble vascular adhesion molecule-1 level to calcific aortic stenosis in patients with coronary artery disease

BACKGROUND:

Calcific aortic stenosis (AS) is an atherosclerosis-related process and the most common cause of valve disease requiring surgery.

OBJECTIVE:

To assess the association of inflammatory markers with AS in advanced atherosclerosis.

METHODS:

Consecutive patients with coronary artery disease (CAD) associated with AS were prospectively identified (mean transvalvular aortic gradient of 30 mmHg or greater). Subjects with aortic sclerosis (mean transvalvular aortic gradient of 10 mmHg or less) served as controls. All patients underwent clinical evaluation, echocardiography and coronary angiography.

RESULTS:

One hundred twenty-two patients with AS (85 men) and 101 with aortic sclerosis (76 men) of similar CAD severity were enrolled. The AS patients were older (mean [± SD] 71±7 years versus 66±7 years; P<0.001), had higher soluble vascular adhesion molecule-1 (s-VCAM-1) levels (1533±650 μg/L versus 1157±507 μg/L; P<0.001), but lower soluble intercellular adhesion molecule-1 (s-ICAM-1) (254±81 μg/L versus 293±84 μg/L; P<0.01) and soluble E-selectin (53±28 μg/L versus 62±29 μg/L; P<0.05) levels. The two groups did not differ with respect to C-reactive protein level (3±2.9 mg/L versus 3.4±2.6 mg/L; P not significant). Higher s-VCAM-1 (OR 1.09, 95% CI 1.04 to 1.14; P<0.001) and lower s-ICAM-1 (OR 0.82, 95% CI 0.72 to 0.94; P<0.001) levels were associated with AS after adjustment for age.

CONCLUSION:

Increased s-VCAM-1 levels were associated with calcific AS in patients with significant CAD.