Carotid Artery Stent Placement Prior to Coronary Angioplasty or Coronary Bypass Graft Surgery

Patients with concomitant carotid and coronary artery disease are at high risk of both cardiac and cerebrovascular complications when they undergo revascularization procedures. The best management strategies for patients with concomitant disease have not been determined for certain. Staged surgical procedures with either coronary artery bypass grafting prior to carotid endarterectomy or vice versa appear to be associated with an increased risk of ischemic complications compared to separate procedures. Until recently, there were no convincing data favoring a simultaneous or combined revascularization approach. Carotid artery stenting has emerged as a treatment option in patients with cerebrovascular disease, even in the presence of a high cardiac risk. Recent results in patients with severe concomitant coronary artery disease are encouraging. This report focuses on the treatment of severe carotid artery stenosis by stent implantation in patients with life-threatening comorbidity to emphasize the possibility of this endovascular approach as an alternative treatment option.     

冠状动脉旁路移植术后发生心房颤动的相关因素分析

目的：分析国人冠状动脉旁路移植（ＣＡＢＧ）术后心房颤动（ＡＦ）的高危因素。　　方法：回顾我院近３ 年在体外循环下进行ＣＡＢＧ术患者６８６ 例,对可能与术后ＡＦ发生有关的诸因素进行卡方检验和Ｌｏｇｉｓｔｉｃ多因素回归分析,以找出与ＣＡＢＧ术后ＡＦ发生相关的高危因素。　　结果：６８６例患者中,１４０ 例（２０．４％ ）并发了ＣＡＢＧ术后ＡＦ。ＡＦ的发生与年龄,术前ＡＦ史及术前心房早搏关系密切（Ｌｏｇｉｓｔｉｃ回归Ｐ＝ ０．００３,０．００１,０．０４６）。而与性别,心肌梗塞,体外循环时间,阻断时间,术前术后射血分数等诸因素无关（卡方检验及Ｌｏｇｉｓｔｉｃ Ｐ＞ ０．０５）。　　结论：ＡＦ同样是国人ＣＡＢＧ术后常见并发症。高龄、术前ＡＦ史及术前心房早搏是其高危因素     

Bypass Surgery or Stenting for Left Main Coronary Artery Disease in Patients With Diabetes

Background

The randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial reported a similar rate of the 3-year composite primary endpoint of death, myocardial infarction (MI), or stroke in patients with left main coronary artery disease (LMCAD) and site-assessed low or intermediate SYNTAX scores treated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Whether these results are consistent in high-risk patients with diabetes, who have fared relatively better with CABG in most prior trials, is unknown.

Outcome of Coronary Bypass Surgery Versus Coronary Angioplasty in Diabetic Patients With Multivessel Coronary Artery Disease

Objectives. This study sought to compare the outcome of percutaneous transluminal coronary angioplasty (PTCA) (n = 834) and coronary artery bypass graft surgery (CABG) (n = 1805) in diabetic patients with multivessel coronary disease from an observational database.Background. There is concern about selection of revascularization in diabetic patients with multivessel coronary artery disease.Methods. Data were collected prospectively and entered into a computerized database. Follow-up was by letter or telephone or additional events resulting in readmission.Results. After CABG there were more in-hospital deaths (0.36% vs. 4.99%, p < 0.0001) and a trend toward more Q wave myocardial infarctions than after PTCA. Five- and 10-year survival rates were 78% and 45% after PTCA and 76% and 48% after CABG, respectively (p = 0.47). At 5 and 10 years, insulin-requiring patients had lower survival rates of 72% and 31% after PTCA and 70% and 48% after CABG, respectively (p = 0.54). Multivariate correlates of long-term mortality were older age, low left ventricular ejection fraction, heart failure and hypertension. In the total group, insulin requirement was a correlate of long-term mortality. For the total group, choice of therapy had a multivariate hazard ratio close to 1. In the insulin-requiring subgroup, the multivariate hazard ratio was 1.35 (95% confidence interval 1.01 to 1.79) for PTCA versus CABG. Corrected for baseline differences, 5- and 10-year survival rates were 68% and 36% after PTCA and 75% and 47% after CABG, respectively, in the insulin-requiring subgroup. Nonfatal events were more common after PTCA, especially additional revascularization.Conclusions. This study reveals a high incidence of events in diabetic patients and raises further questions about angioplasty in insulin-requiring diabetic patients with multivessel disease.     

冠状动脉分流器在非体外循环冠状动脉搭桥术中的应用

目的对比研究在非体外循环冠状动脉搭桥术中应用冠状动脉分流器的临床效果。方法 86例不停跳冠状动脉搭桥患者分为两组:应用冠状动脉分流器组(实验组,43例)和不应用冠状动脉分流器组(对照组,43例),术后1~3天监测肌酸激酶同工酶(CK-MB)、心肌肌钙蛋白I(c Tn I)、N末端脑利钠肽前体(NT-pro BNP)等指标,并记录并发症发生率、呼吸机使用时间、监护室入住时间及术后住院时间。结果两组病例均痊愈出院。两组人均冠状动脉搭桥支数3~5支,实验组3.6±0.7支,对照组3.6±0.6支,两组没有显著性差异。实验组术后CKMB、cTn I、NT-pro BNP及并发症发生率低于对照组(P0.05),实验组呼吸机使用时间、监护室入住时间及术后住院时间显著缩短(P0.05)。术后1个月、3个月、6个月两组患者左心室射血分数(LVEF)、左心室舒张期末内径(LVEDD)均显著改善,无心绞痛复发。结论在不停跳冠状动脉搭桥术中,应用冠状动脉分流器可以显著减少心肌缺血损伤,对降低围手术期急性心肌梗死发生率、并发症发生率,保护心脏功能,缩短术后恢复时间均有显著临床效果。     

Exercise Radionuclide Cineangiography for Predicting Long Term Prognosis in Elderly Post Coronary Artery Bypass Graft Patients

Issue. The immediate benefits of coronary artery bypass grafting may only be transient. Recent studies which showed that exercise radionuclide cineangiography studies may predict cardiac events and survival had evaluated post coronary artery bypass grafting patients of all ages. This prospective study was done on an elderly subgroup. Methods. The results of exercise radionuclide cineangiography performed early (4–8 months) post coronary artery bypass grafting were correlated over six years of follow up with mortality, major surgical and nonsurgical cardiac events, and cardiac event free survival in 87 consecutive patients ≥65 years. Results. The rest to peak exercise difference in left ventricular ejection fraction correlated with later cardiac death and the need for surgical interventions, while rest left ventricular ejection fraction correlated only with the latter parameter. Conclusions. Assessment of left ventricular ejection fraction at rest and at exercise has prognostic values after coronary artery bypass grafting in elderly patients. Exercise radionuclide cineangiography carried out soon after coronary artery bypass grafting might be considered an useful tool to assess patient prognosis. The efficacy of exercise radionuclide cineangiography carried out soon after coronary artery bypass grafting should be confirmed in larger and more varied patient subgroups.     

Nonsteroidal Anti-Inflammatory Drugs and Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery

Background

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in perioperative pain management of patients undergoing coronary artery bypass graft surgery. However, the association of periprocedural use of NSAIDs and clinical outcomes after coronary artery bypass graft is understudied.

Validation of Scoring Systems That Predict Outcomes in Patients With Coronary Artery Disease Undergoing Coronary Artery Bypass Grafting Surgery

Several risk stratification scores, based on angiographic or clinical parameters, have been developed to evaluate outcomes in patients with left main coronary artery disease (LMCAD) who undergo coronary artery bypass grafting (CABG). This study aims to validate the predictive ability of different risk scoring systems with regard to long-term outcomes after CABG.This single-center study retrospectively re-evaluated the Synergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) score; EuroSCORE; age, creatinine, and ejection fraction (ACEF) score; modified ACEF score; clinical SYNTAX; logistic clinical SYNTAX score (logistic CSS); and Parsonnet scores for 305 patients with LMCAD who underwent CABG. The endpoints were 5-year rate of all-cause death and major adverse cardio-cerebral events (MACCEs), including cardiovascular (CV) death, myocardial infarction (MI), and stroke and target vessel revascularization (TVR).Compared with the SYNTAX score, other scores were significantly higher in discriminative ability for all-cause death (SYNTAX vs others: P < 0.01). The EuroSCORE ≥6 showed significant outcome difference on all-cause death, CV death, MI, and MACCE (P < .01). Multivariate analysis indicated the SYNTAX score was a non-significant predictor for different outcomes. Adjusted multivariate analysis revealed that the EuroSCORE was the strongest predictor of all-cause death (hazard ratio[HR]: 1.17; P < 0.001), CV death (HR: 1.16; P < 0.001), and MACCE (HR: 1.09; P = 0.01). The ACEF score and logistic CSS were predictive factors for TVR (HR: 0.25, P = 0.03; HR: 0.85, P = 0.01).The EuroSCORE scoring system most accurately predicts all-cause death, CV death, and MACCE over 5 years, whereas low ACEF score and logistic CSS are independently associated with TVR over the 5-year period following CABG in patients with LMCAD undergoing CABG.     

Preservation of Myocardium During Coronary Artery Bypass Surgery

Myocardial protection aims to prevent reversible post-ischemic cardiac dysfunction (myocardial stunning) and irreversible myocardial cell death (myocardial infarction) that occur as a consequence of myocardial ischemia and/or ischemic-reperfusion injury. Although the mortality rate for isolated coronary artery bypass grafting has been markedly reduced during the past decade, myocardial death, as evidenced by elevation in creatine kinase-myocardial band and/or cardiac troponin, is common. This is ascribed to suboptimal myocardial protection during cardiopulmonary bypass or with off-pump technique, early graft failure, distal embolization, and regional or global myocardial ischemia during surgery. An unmet need in contemporary coronary bypass surgery is to find more effective cardioprotective strategies that have the potential for decreasing the morbidity and mortality associated with suboptimal cardioprotection. In the present review article on myocardial protection in contemporary coronary artery bypass surgery, we attempt to elucidate the clinical problems, summarize the outcomes of selected phase III trials, and introduce new perspectives.     

Advanced Care for Patients After Coronary Artery Bypass Graft

There was an increase in respiratory failure after coronary artery bypass graft (CABG) at Baptist Heart Institute during the first three quarters of 2000. Thirteen percent of patients required ventilation over 24 hours. The reintubation rate after initial extubation was 18.3% and the mortality rate in the group was 19.7%. After instituting an advanced care team during the first three quarters of 2002, the prolonged ventilation requirement was 7%, reintubation was 4.2%, and the mortality rate 15.4%. These results suggest that an advanced care team could improve clinical outcome and reduce health care costs.     

Cost-Effectiveness Analysis of Frailty Assessment in Older Patients Undergoing Coronary Artery Bypass Grafting Surgery

BackgroundIn perioperative settings, frailty assessment has been shown to reduce mortality. This study examined the cost effectiveness of frailty assessment among patients aged 65 with coronary artery disease under consideration for coronary artery bypass grafting surgery.MethodsA combined decision tree and Markov model was developed to estimate costs and quality-adjusted life years (QALYs) over a 21-year time horizon. Clinical parameters were obtained from published literature. Utilities were derived from the literature and the Canadian Community Health Survey. Costs were obtained from the Ontario fee schedule and published literature. Sensitivity and scenario analyses were conducted to assess the robustness of the results. Expected value of perfect information (EVPI) analysis was conducted to estimate the value of further research.ResultsThe frailty assessment initiative had a lower average cost than no frailty assessment ($19,567 compared with $20,062). QALYs with frailty assessment were 0.47 years more than with no frailty assessment. Thus, frailty assessment was dominant compared with no frailty assessment. Results were robust to changes in the input parameters. At a willingness to pay (WTP) threshold of $50,000/QALY, there was 100% probability of frailty assessment being cost-effective, and the EVPI per patient was $0. Scenario and sensitivity analysis showed frailty screening remained cost effective when changing the cohort average age, removing health benefits for nonfrail patients, and using subjective judgement to modify effectiveness parameters.ConclusionsFrailty assessment may be good value for money. However, limited availability of geriatric consultation services, may hinder implementation. Thus, the estimated benefits of frailty screening may not be achievable in practice.     

Increased Coronary Artery Disease Severity in Black Women Undergoing Coronary Bypass Surgery

Race and sex disparities are believed to play an important role in heart disease. The purpose of this study was to examine the association between race, sex, and number of diseased vessels at the time of coronary artery bypass grafting (CABG), and subsequent postoperative outcomes.The 13,774 patients undergoing first-time, isolated CABG between 1992 and 2011 were included. Trend in the number of diseased vessels between black and white patients, stratified by sex, were analyzed using a Cochran–Armitage trend test. Models were adjusted for age, procedural status (elective vs. nonelective), and payor type (private vs. nonprivate insurance).Black female CABG patients presented with an increasingly greater number of diseased vessels than white female CABG patients (adjusted P_trend = 0.0021). A similar trend was not observed between black and white male CABG patients (adjusted P_trend = 0.18). Black female CABG patients were also more likely to have longer intensive care unit and hospital lengths of stay than other race–sex groups.Our findings suggest that black female CABG patients have more advanced coronary artery disease than white female CABG patients. Further research is needed to determine the benefit of targeted preventive care and preoperative workup for this high-risk group.