Limitations in the cardiac risk reduction provided by coronary revascularization prior to elective vascular surgery

OBJECTIVE: The objective of this study was to evaluate the proposed cardiac protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) before elective major arterial surgery. METHOD: Preoperative cardiac risk stratification using American College of Cardiology/American Heart Association (ACC/AHA) guidelines was done on 425 consecutive patients undergoing 481 elective major vascular operations at an academic VA Medical Center. The algorithm assumed asymptomatic patients with prior coronary revascularization (CABG, <5 year; PTCA, <2 year) were low cardiac risk. Coronary angiography was done for recurrent symptoms with secondary intervention when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of vascular surgery were compared between patients with and without previous CABG or PTCA by contingency table and logistic regression analyses. RESULTS: Coronary revascularization was classified as recent (CABG, <1 year; PTCA, <6 months) in 35 cases (7%), prior (1 year < or = CABG < 5 year, 6 months < or = PTCA < 2 year) in 45 cases (9%), and remote (CABG, > or = 5 year; PTCA, > or = 2 year) in 48 cases (10%). A larger fraction of patients with previous revascularization possessed pathologic cardiac risk variables and were stratified as high-risk preoperatively than their nonrevascularized counterparts. Outcomes in patients with previous PTCA were similar to those after CABG (P =.7). Significant differences in adverse cardiac events (P =.01) and mortality (P =.05) were found between patients with CABG done within 5 years or PTCA within 2 years (6.3%, 1.3%, respectively), individuals with remote revascularization (10.4%, 6.3%), and nonrevascularized patients stratified at high risk (13.3%, 3.3%) or intermediate/low (2.8%, 0.9%) risk. De novo or recurrent 3-vessel coronary disease by angiography, but not the presence or timing of previous revascularization, was an independent predictor of cardiac events after vascular operations, whereas remote revascularization was associated with fatal outcomes by multivariate analysis. CONCLUSIONS: Previous coronary revascularization (CABG, <5 years; PTCA, <2 years) may provide only modest protection against adverse cardiac events and mortality following major arterial reconstruction.     

Multivessel coronary revascularization and outcomes in kidney transplant recipients

Coronary artery disease is a major cause of morbidity and mortality in the kidney transplant population. We compared the long‐term outcomes of coronary artery bypass graft (CABG) surgery with percutaneous coronary intervention (PCI) for multivessel coronary disease in a contemporary cohort of US kidney transplant recipients. From the U.S. Renal Data System, we identified all adult kidney transplant patients with ≥6 months of Medicare A+B undergoing first recorded multivessel coronary revascularization from 1997 to 2009. The associations of CABG versus PCI with death and the composite of death or myocardial infarction (MI) were compared using proportional hazards regression. Of the 2272 patients included in the study, 1594 underwent CABG and 678 underwent PCI. The estimated 5‐year survival rate was 55% [95% confidence interval (CI) 53% to 57%] following coronary revascularization, with no significant association between revascularization type and death [adjusted hazard ratio (aHR) = 1.08; CI 0.94–1.23] or the composite of death or MI (aHR = 1.07; CI 0.96–1.18). Separate propensity score‐matched analyses yielded similar results. In this analysis of kidney transplant recipients undergoing multivessel coronary revascularization, we found no difference between CABG and PCI in terms of survival or the composite of death and MI.     

Meta-analysis of randomized controlled trials on the treatment of unprotected left main coronary artery disease: one-year outcomes with coronary artery bypass grafting versus percutaneous coronary artery intervention with drug-eluting stent

Abstract Background and aim: Coronary artery bypass surgery (CABG) is the standard treatment for left main coronary artery (LMCA) disease. However, percutaneous coronary intervention using drug‐eluting stents (DES‐PCI) is now widely used and is associated with improved outcomes following coronary revascularization. The goal of this study was to assess early outcomes associated with CABG and DES‐PCI among patients with LMCA disease through a meta‐analysis of randomized controlled trials. Methods and Results: After searching of electronic databases, three randomized controlled trials with 2601 patients were identified. All‐cause death occurred in 3.3% with CABG and 3.6% with DES‐PCI (odds ratio [OR], 0.92; 95% confidence interval [CI]= 0.60 to 1.40; p = 0.76). The incidence of myocardial infarction was 2.6% with CABG and 3.8% with DES‐PCI (OR, 0.67; 95% CI = 0.43 to 1.05; p = 0.10). Target vessel revascularization occurred in 5.1% with CABG and 11.7% with DES‐PCI (OR, 0.40; 95% CI = 0.29 to 0.55; p < 0.0001). Major adverse cardiac and cerebrovascular events (MACCE) occurred in 10.7% with CABG and 15.7% with DES‐PCI (OR, 0.40; 95% CI = 0.29 to 0.55; p < 0.0001). Conclusions: DES‐PCI is a safe alternative to CABG for the management of LMCA disease. However, CABG was superior to DES‐PCI in terms of MACCE and need for target vessel revascularization at one year. Thus, CABG remains the standard of care for the treatment of LMCA disease.     

The impact of bariatric surgery on the risk of coronary revascularization

BackgroundMetabolic surgery is associated with improved cardiovascular risk profile. Randomized and observational studies exploring the impact of bariatric surgery on follow-up coronary revascularization (CR) as a primary endpoint are limited.ObjectivesTo identify the impact of metabolic surgery on the risk of follow-up CR, including percutaneous coronary revascularization (PCI) and coronary artery bypass grafting (CABG)SettingStony Brook Department of Surgery, Stony Brook University Hospital, New York, United States.MethodsA retrospective analysis was performed for patients with obesity between 2006 and September 2015. Patients were divided into those with history of metabolic surgery and those without. Patient were also stratified by bariatric surgery type. All study groups were followed till 2018 and for at least 3 years to monitor the development of the primary endpoint—any CR including PCI or CABG.ResultsThe study population with obesity was 515,307 patients; 95,901 with history of surgery versus 419,406 matched patients without. A total of 12,873 (13.4%) with surgery and 51,478 (12.27%) without were lost to follow-up by 2018. The group with history of surgery had a reduced risk of future CR (hazard ratio [HR], .46; 95% confidence interval [CI]: .42–.50; P < .0001), PCI (HR, .45; 95% CI: .41–.49; P < .0001) and CABG (HR, .49; 95% CI:.42–.56; P < .0001). In subgroup analysis, laparoscopic adjustable gastric banding compared with Roux-en-Y gastric bypass (RYGB) was associated with higher follow-up CR (HR, 1.34; 95% CI: 1.11–1.63; P < .01) and PCI (HR, 1.34; 95% CI: 1.07–1.68; P < .05).ConclusionBariatric surgery is associated with reduced risk of future CR, PCI, and CABG. Upon subgroup analysis, RYGB was associated with reduced risk of PCI and CR.     

Outcome and selection of revascularization strategy in left main coronary artery stenosis

Objectives. To investigate clinical outcome in unselected real-life patients with unprotected left main coronary artery (ULMCA) stenosis and determine factors associated with selection of revascularization strategy. Design. Consecutive patients with ULMCA stenosis at our institution in 2009–2013 (n?=?308) were retrospectively analyzed with propensity score adjusted Cox proportional hazards models for outcome. Baseline characteristics in relation to selection of revascularization strategy were analyzed with multivariate logistic regression. Results. Patients that underwent PCI (n?=?94) had a higher risk of major adverse cardiac and cerebrovascular events (MACCE; adjusted HR 2.13 [95% CI 1.08–4.19]) than patients that had CABG surgery but there was no difference in the combination of death and MI (adjusted HR 1.17 [95% CI 0.50–2.75]). Later year of index angiography, age, Euroscore II and angiographer favoring PCI was associated with PCI as revascularization strategy. Higher SYNTAX score, higher systolic blood pressure and angiographer favoring CABG was associated with CABG. Conclusions. In consecutive patients with ULMCA stenosis PCI is associated with higher MACCE rates than CABG but there is no difference in death and MI. Later year of index angiography, higher age, lower systolic blood pressure, higher predicted per-procedural surgical risk, less complex coronary anatomy and angiographer favoring PCI increased the probability of revascularization with PCI instead of CABG.     

Survival outcomes and adverse events in patients with chronic kidney disease after coronary artery bypass grafting and percutaneous coronary intervention: a meta-analysis of propensity score-matching studies

BackgroundThe present meta-analysis of propensity score-matching studies aimed to compare the long-term survival outcomes and adverse events associated with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD).MethodsElectronic databases were searched for studies comparing CABG and PCI in patients with CKD. The search period extended to 13 February 2021. The primary outcome was all-cause mortality, and the secondary endpoints included myocardial infarction, revascularization, and stroke. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were used to express the pooled effect. Study quality was assessed using the Newcastle–Ottawa scale. The analyses were performed using RevMan 5.3.ResultsThirteen studies involving 18,005 patients were included in the meta-analysis. Long-term mortality risk was significantly lower in the CABG group than in the PCI group (HR: 0.76, 95% CI: 0.70–0.83, p < .001), and similar results were observed in the subgroup analysis of patients undergoing dialysis and for different estimated glomerular filtration rate ranges. The incidence rates of myocardial infarction (OR: 0.25, 95% CI: 0.12–0.54, p < .001) and revascularization (OR: 0.17, 95% CI: 0.08–0.35, p < .001) were lower in the CABG group than in the PCI group, although there were no significant differences in the incidence of stroke between the two groups (OR: 1.24; 95% CI: 0.89–1.73, p > .05). Subgroup analysis among patients on dialysis yielded similar results.ConclusionsOur propensity score matching analysis revealed that, based on long-term follow-up outcomes, CABG remains superior to PCI in patients with CKD.     

我国冠心病治疗两种血运重建方式术后中远期随访结果的Meta分析

【摘要】 目的 检索国内关于PCI和CABG比较的文献,总结随访时间大于24个月病例的随访结果,评价两种心肌血运重建方式的益损,为临床上冠心病治疗决策的制定提供循证医学依据。方法〓制定原始文献的纳入标准、排除标准及检索策略,检索维普中文科技期刊全文数据库、万方医学数据库、中国知网和中国生物医学文献数据库(CBM),提取有关国内两种心肌血运重建方式比较的队列研究文献,评价纳入研究的文献质量,并提取有效数据后采用RevMan 5.2软件进行Meta分析。结果〓纳入研究的共33篇文献,共报道11375例,其中PCI组6125例,CABG组5250例。Meta分析结果显示:围手术期死亡率,PCI组明显低于CABG组(1.22%,4.12%),OR值及其95% CI为0.29(0.19~0.46),P<0.001;随访期全因死亡率,两组差别不明显(3.92%,4.57%),OR值及其95% CI为0.91(0.75~1.10),P=0.33;再次血运重建率,PCI组明显高于CABG组(9.99%,3.77%),OR值及其95% CI为3.57(2.62~4.87),P<0.001;MACCE发生率,PCI组明显高于CABG组(17.94%,12.35%),OR值及其95% CI为1.62(1.33~1.98),P<0.001。结论〓两种心肌的血运重建方式比较,PCI以其围手术期短且不良事件发生率低见长;而CABG的优点是远期效果好,再次血运重建率低,但在做出冠心病治疗决策时,要更多地关注到每种方法的不足,着眼长远。     

Hybrid myocardial revascularization

Background

In patients with advanced coronary artery disease (CAD), coronary artery bypass grafting (CABG) is associated with improved long-term outcomes while percutaneous coronary intervention (PCI) is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach, hybrid myocardial revascularization (HMR).Three strategies for timing of the hybrid revascularization exists, each with their own inherent advantages and shortcomings: (1) CABG followed by PCI, (2) PCI followed by CABG, or (3) simultaneous CABG + PCI in a hybrid suite.

Studies

The results of the first randomized control trial comparing HMR (CABG first) and standard CABG, POL-MIDES (Prospective Randomized PilOt Study EvaLuating the Safety and Efficacy of Hybrid Revascularization in MultIvessel Coronary Artery DisEaSe), show HMR was feasible for 93.9% of patients whereas conversion to standard CABG was required for 6.1%. At 1 year, both groups had similar all-cause mortality (CABG 2.9% vs. HMR 2%) and major adverse clinical event (MACE)-free survival rates (CABG 92.2% vs. HMR 89.8%). Results of observational and comparative studies show that minimally invasive HMR procedures in patients with multivessel CAD carry minimal perioperative mortality risk and low morbidity and do not increase the risk of postoperative bleeding. The advantage they offer in comparison to classical surgical revascularization is indeed faster rehabilitation and patient’s return to normal life.

Conclusion

Hybrid myocardial revascularization has been developed as a promising technique for the treatment of high-risk patients with CAD. Hybrid revascularization using minimally invasive surgical techniques combined with PCI offers to a part of patients an advantage of optimal revascularization of the most important artery of the heart, together with adequate myocardial revascularization in a relatively delicate way. Indeed, to patients with high operative risk of standard surgery, it offers an alternative which should be considered carefully.

     

Die Bedeutung der SYNTAX-Studie für die moderne Koronarchirurgie

Coronary artery bypass graft surgery (CABG) is still considered to be the standard of care for patients with a prognostically relevant pattern of coronary artery disease. New stent designs, including drug-eluting stents (DES) and improvements in percutaneous coronary intervention (PCI) technologies during recent years, challenge CABG in the treatment of coronary three-vessel disease and/or left main stem stenosis. To date, randomized trials have demonstrated significantly higher repeat revascularization rates in PCI patients but comparable results regarding procedural and mid-term survival as well as adverse events like myocardial infarction. In contrast, real world registry data demonstrated a survival benefit of CABG over PCI as the primary treatment option. Recently, 2-year results of the largest comparative randomized trial to date, the SYNTAX trial, were made available. These data demonstrated the superiority of CABG over PCI regarding the combined endpoint of death and major adverse cardiac and cerebrovascular events, including repeat revascularization. There were comparable results in patients with less complex coronary artery disease between PCI and CABG, while patients with more complex coronary pathologies had significantly better results after surgical intervention. These results have led to controversies in all major medical societies and have resulted in intensive and ongoing guideline discussions.     

Differential survival after coronary revascularization procedures among patients with renal insufficiency.

BACKGROUND: Acute myocardial infarction, cardiac arrest, and other cardiac events are the major cause of mortality among patients with renal insufficiency. Previous studies of interventions for coronary artery disease among patients with renal insufficiency have not controlled for potentially confounding factors such as coronary artery disease severity and left ventricular function. This study investigates the comparative survival for patients with renal insufficiency and coronary artery disease following coronary artery bypass graft (CABG) surgery as compared with percutaneous coronary artery intervention (PCI), while controlling for confounding factors. METHODS: This retrospective cohort study of patients undergoing CABG surgery or PCI discharged between 1993 and 1995 uses the New York Department of Health databases and Cox proportional hazards analyses to estimate the mortality risk associated with CABG as compared with PCI for patients with renal insufficiency. Renal function was categorized as creatinine <2.5 mg/dL (N = 58,329), creatinine > or =2.5 mg/dL (N = 840), and end-stage renal disease (ESRD) requiring dialysis (N = 407). RESULTS: Patients with either ESRD or serum creatinine > or =2.5 mg/dL had more severe coronary artery disease and a greater frequency of comorbid conditions as compared with patients with creatinine <2.5 mg/dL. Creatinine > or =2.5 mg/dL and ESRD were both associated with an increased mortality risk among all distributions of coronary artery disease anatomy. Among patients with ESRD, the risk ratio (RR) of mortality for patients undergoing CABG compared with PCI was 0.39 (95% CI, 0.22 to 0.67, P = 0.0006). Among patients with creatinine > or =2.5 mg/dL, CABG surgery did not convey a survival benefit over PCI (RR, 0.86, 95% CI, 0.56 to 1.33, P = 0.50). CONCLUSIONS: This study demonstrates a survival benefit among patients with ESRD undergoing CABG surgery as compared with PCI, while controlling for severity of coronary artery disease, left ventricular dysfunction, and other comorbid conditions. These results suggest that management decisions among patients with coronary artery disease should be made in the context of not only location and severity of coronary artery lesions, but also on the presence and severity of renal dysfunction.     

Is coronary angiography necessary for vascular surgery patients who have positive results of dipyridamole thallium scans?

Purpose: Because dipyridamole thallium (DT) scanning is a useful predictor of perioperative cardiac events, a positive result of a DT scan is frequently the basis for performing more invasive cardiac evaluation and for consideration for performing coronary revascularization procedures before performing peripheral vascular surgery. The rationale for this approach has been that the treatment of anatomically significant coronary artery disease would lower the risk of performing a subsequent vascular operation. However, the benefit of performing aggressive diagnostic and therapeutic cardiac procedures in such patients remains unproved. To examine this issue, data from patients who underwent coronary angiography because of thallium redistribution were compared with data from matched control subjects who underwent peripheral vascular operations without further cardiac evaluation.Methods: The medical records of 70 consecutive patients who underwent coronary angiography because of the presence of two or more segments of redistribution on DT scan were reviewed and compared with 70 other patients matched with respect to age, gender, peripheral vascular operation, and number of segments of redistribution on DT scan who did not undergo additional cardiac evaluation.Results: DT scans were performed on 934 preoperative peripheral vascular surgery patients to help in the assessment of operative risk. Ischemic responses, defined as two or more segments of redistribution, were observed in 297. Of these, 70 underwent cardiac catheterization and 25 underwent coronary revascularization procedures. Adverse outcomes affected 46% of the coronary angiography group and 44% of the control group (p = NS). Patients who underwent coronary angiography and were considered for myocardial revascularization had fewer cardiac events with a subsequent vascular operation than did the control subjects. However, any possible benefit from invasive cardiac evaluation was offset by the three deaths and two myocardial infarctions (MIs) that complicated the cardiac evaluation. There was no significant difference between the angiography group and the matched control subjects with respect to perioperative nonfatal MI (13% vs 9%), fatal MI (4% vs 3%), late nonfatal MI (16% vs 19%), or late cardiac death (10% vs 13%). In long-term follow-up, MIs occurred later in patients who underwent coronary angiography than the control subjects (p = 0.049), but this difference was not associated with an improvement in the overall survival rate.Conclusions: The risks of extended cardiac evaluation and treatment did not produce any improvement in either the perioperative or the long-term survival rate. For most vascular surgery patients who have a positive result of a DT scan, coronary angiography does not provide any additional useful information. (J Vasc Surg 1997;25:975-83.)     

Early and long-term outcomes of coronary artery bypass grafting and percutaneous coronary intervention in patients with left main disease: single-center results of multidisciplinary decision making

Objective

Coronary artery bypass grafting (CABG) is considered the standard treatment for patients with left main disease (LMD). However, percutaneous coronary intervention (PCI) has recently emerged as a treatment option for selected patients. We assessed early and long-term outcomes of patients with LMD who underwent either CABG or PCI in our institution.

Methods

We reviewed the records of 438 patients with LMD who underwent revascularization between January 2005 and December 2010. Treatment modality, chosen by our heart team, was CABG in 409 patients and PCI in 29. Age, prevalence of women, and mean ejection fraction of patients were not significantly different between groups. Mean logistic European system for cardiac operative risk evaluation score was 7.7. Mean follow-up was 37.1 months.

Results

In CABG group, mean number of anastomoses was 4.0 and complete revascularization was achieved in 97.1 %. Bilateral internal thoracic arteries were used in 87.0 %. In PCI group, mean number of stents was 1.3 and complete revascularization was achieved in 44.8 %. Drug-eluting stent was used in 72.4 %. In-hospital mortality was 1.1 % (1.0 %, CABG group vs. 3.4 %, PCI group; p = 0.29). At 3 years, overall survival was 94.3 % (95.3 vs. 81.1 %; p < 0.01) and rate of freedom from major adverse cardiac events and cerebrovascular accidents was 88.9 % (89.8 vs. 77.3 %; p = 0.05).

Conclusions

Our heart team’s approach resulted in favorable overall results in patients with LMD. Multidisciplinary decision making in these high-risk patients can make good long-term outcomes in CABG.     

Surgical Myocardial Revascularization versus Percutaneous Coronary Intervention with Drug-Eluting Stents in Octogenarian Patients

Objective: Our goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization.Methods: We retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006.Results: Of the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis.Conclusion: Octogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.     

Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population.

Debate continues regarding the value of cardiovascular testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective preoperative testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of preoperative cardiac testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. IMPLICATIONS: Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.     

Outcome After Myocardial Revascularization and Renal Transplantation: A 25-Year Single-Institution Experience

BACKGROUND AND OBJECTIVE: Cardiac disease is a common cause of death in renal transplant recipients. This study retrospectively analyzes the results of myocardial revascularization procedures in these patients and makes recommendations for managing coronary atherosclerosis in patients with renal disease who already have a transplanted kidney or who may receive a kidney transplant. METHODS: Patients who had myocardial revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) and renal transplantation at the authors' institution between 1968 and 1994 were analyzed. Patient, procedural, and institutional variables were used for actuarial analyses of survival, as well as multivariate analyses of risk factors for death. RESULTS: Eighty-three of 2989 renal transplant patients required myocardial revascularization either before or after their transplant, and diabetes mellitus was the cause of renal failure in 42% of these patients. Standard coronary angiography, CABG, and PTCA techniques were used without periprocedural renal allograft loss. Actuarial patient survival was 89%, 77%, and 65% at 1, 3, and 5 years after the last procedure (transplantation or revascularization). Cardiac disease was the most common mode of death. Early-phase risk factors for death by multivariate analysis included hypertension and revascularization before 1989. Late-phase risk factors for death included diabetes mellitus, higher number of pre-CABG myocardial infarctions, renal transplantation before 1984, older age, and unstable angina before CABG. CONCLUSIONS: Myocardial revascularization can be performed with acceptable short- and long-term results in patients with renal disease who have renal transplantation either before or after the revascularization procedure. Diabetes mellitus was a highly prevalent condition among these patients, and cardiac disease was their most common mode of death. PTCA and CABG, as performed at this institution, posed little risk for renal allograft loss. Modification of risk factors for coronary atherosclerosis, rigorous cardiac evaluation of patients at risk for coronary artery disease before renal transplantation, and aggressive use of revascularization procedures to decrease the incidence of myocardial infarction are proposed as ways to prolong the survival of renal transplant patients with ischemic heart disease.     

Determinants of late outcome after minimally invasive direct coronary artery bypass

AIM: Minimally invasive direct coronary artery bypass (MIDCAB) is a reliable method to revascularize the left anterior descending (LAD) coronary artery. However, a more consistent body of knowledge is needed to assess factors influencing long-term outcome. With this study, we retrospectively investigated the long-term determinants of survival and freedom from cardiac morbidity and revascularization in patients who underwent MIDCAB. METHODS: From 1997 to 2005, 109 patients underwent MIDCAB. Seventy-five (68.8%) presented isolated LAD disease and 34 (31.2%) multivessel disease. The first 57 patients (53.2%) in the series underwent early postoperative angiographic reinvestigation. All 109 patients were subsequently followed-up at our outpatient clinic. Follow-up (mean 50.7 months, range 3-93) was completed in 100% of cases. RESULTS: No in-hospital deaths occurred; 2 patients (1.8%) experienced perioperative myocardial infarction. At early postoperative angiographic reinvestigation, the anastomotic perfect patency rate was 54/57 (94.7%); survival was 100% and 95.8% at 1 and 5 years, respectively. Overall freedom from repeated revascularization was 95.3% and 88.3% at 1 and 5 years respectively; freedom from LAD revascularization was 95.3% and 91.6% at 1 and 5 years, respectively; cardiac event-free survival was 95.3% and 80.8% at 1 and 5 years respectively. At multivariable analysis (Cox regression), women were found to have a higher risk of repeated LAD revascularization (hazard ratio [HR] 30.24; P<0.001); female sex and left ventricular dysfunction were the only predictors affecting long-term cardiac outcome (hazard ratio 29.35; P<0.001 and 5.1; P<0.001), respectively. CONCLUSIONS: A key factor in the long-term success of MIDCAB seems to be appropriate patient selection. Special attention should be reserved for female patients, as they appear to have a worse cardiac outcome and a higher probability of repeated revascularization on LAD. MIDCAB may represent a viable option for treating multivessel disease when complete revascularization is unfeasible or a hybrid procedure is envisaged.     

Early and late outcomes of coronary artery bypass surgery versus percutaneous coronary intervention with drug-eluting stents for dialysis patients

Abstract Background: Advances in percutaneous coronary intervention (PCI) using drug‐eluting stents (DES) have impacted clinical practice. However, the efficacy of DES for dialysis patients still remains controversial. This study compares the early and long‐term clinical outcomes of coronary artery bypass grafting (CABG) and PCI with DES in dialysis patients. Methods: A retrospective review was performed in 125 dialysis patients treated between 2004 and 2007. Fifty‐eight patients underwent CABG and 67 underwent PCI with DES. The overall death, cardiac death, and cardiac‐related event rates were analyzed using the Kaplan‐Meier method. For the risk‐adjusted comparisons, multivariable logistic and Cox regression analyses were used. Results: The preoperative characteristics of the patients were similar except for the ejection fraction (p = 0.002) and the number of diseased vessels (p < 0.001). The 30‐day mortality was 0 in both groups. The overall survival rates at one, three, and five years were 84.2%, 64.7%, and 56.2% in CABG group and 88.2%, 75.5%, and 61.7% in DES group, respectively (p = 0.202). The rates of freedom from cardiac‐related events at one, three, and five years were 76.6%, 68.1%, and 48.6%, and 63.0%, 31.4%, and 0% in CABG and DES groups (p < 0.001), respectively, including seven (10%) late thromboses in the DES group. Although the risk‐adjusted analysis showed no significant difference for overall and cardiac death rates, the rates of cardiac‐related events and graft/stent failure were significantly higher in the DES group. Conclusions: CABG is superior for revascularization in dialysis patients compared with PCI using DES in terms of freedom from cardiac‐related events. (J Card Surg 2012;27:281‐287)     

Deterioration of regional wall motion immediately after coronary artery bypass graft surgery is associated with long-term major adverse cardiac events

BACKGROUND: Patients undergoing coronary artery bypass graft (CABG) surgery frequently develop wall motion abnormalities diagnosed by intraoperative transesophageal echocardiography. However, the relation between deterioration in wall motion and postoperative morbidity or mortality is unclear. Therefore, the authors hypothesized that deterioration in intraoperative left ventricular regional wall motion immediately after CABG surgery is associated with a higher risk of adverse cardiac events. METHODS: With institutional review board approval, data were gathered from 1,412 CABG surgery patients. Echocardiographic wall motion score (WMS) was derived using a 16-segment model. Outcomes data were gathered for up to 2 yr after surgery. The primary outcome, major adverse cardiac event, was a composite index of myocardial infarction, need for subsequent coronary revascularization, or all-cause mortality during the follow-up period. RESULTS: Two hundred twenty-one patients (16%) had 254 primary outcome events during follow-up. Postbypass WMS did not change in 812 patients (58%), deteriorated in 219 patients (16%), and improved in 368 patients (26%). Kaplan-Meier analysis showed that patients with deterioration in WMS after CABG experienced significantly lower major adverse cardiac event-free survival than patients with either no change or improvement in WMS (P = 0.004). Cox proportional hazards regression modeling revealed a significant association between deterioration in WMS and the composite adverse outcome (hazard ratio, 1.47 [1.06-2.03]; P = 0.02). CONCLUSIONS: The authors confirmed their hypothesis that deterioration in wall motion detected by intraoperative echocardiography after CABG surgery is associated with increased risk of long-term adverse cardiac morbidity. Worsening wall motion after CABG surgery should be considered a prognostic indicator of adverse cardiovascular outcome.     

3-Jahres-Ergebnisse der SYNTAX-Studie

The purpose of the intensively discussed SYNTAX trial was to randomly evaluate the benefit of coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) as the primary treatment option for patients with de novo coronary three vessel and/or left main disease. For operative revascularization, modern surgical strategies were used, while paclitaxel-eluting stents were used for PCI. Comparable to the 1-year results, after 3 years there was a significant advantage of CABG over PCI regarding the cumulative event rate of major adverse cardiac and cerebrovascular events (MACCE, Fig. 1). The 3-year MACCE rate of the 897 surgically treated patients was 20.2% compared to 28.0% for the 903 PCI patients (p<0.001). Analyzing the individual components of MACCE, it was shown that the rate of myocardial infarction during the second (CABG 0.1% vs. PCI 1.2%) and third years (CABG 0.3% vs. PCI 1.2%) after allocation was significantly higher for PCI patients (Fig. 1). The cumulative 3-year rate of repeat revascularization was almost doubled for PCI patients compared to CABG (19.7% vs. 10.7%, p<0.001). In contrast to the 1-year results, after 3 years the difference in cerebrovascular events versus surgery was not significant any more (PCI 2.0% vs. CABG 3.4%, p=0.07). By dividing the 1,800 randomized patients into tertiles of different coronary complexities assessed by the SYNTAX score, a post hoc analysis revealed significantly worse results in more complex coronary pathologies when treated by PCI. In contrast to this, the coronary complexity did not impact surgical results (see Fig. 2). A more detailed analysis also demonstrated unsatisfactory PCI results compared to CABG for patients with isolated 3-vessel disease. However, in patients presenting left main stenosis as an isolated finding or in combination with 1- or 2-vessel disease, there were no significant differences between the two treatment groups. The latter finding, however, gave a push to an intensive debate on the primary treatment option in left main disease favorable for PCI (ostial or shaft lesions) and has recently led to a change in European guideline recommendations to a IIa indication for PCI in left main lesions amenable for PCI.     

Multivessel Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in ESRD

Thirty to sixty percent of patients with ESRD on dialysis have coronary heart disease, but the optimal strategy for coronary revascularization is unknown. We used data from the United States Renal Data System to define a cohort of 21,981 patients on maintenance dialysis who received initial coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1997 and 2009 and had at least 6 months of prior Medicare coverage as their primary payer. The primary outcome was death from any cause, and the secondary outcome was a composite of death or myocardial infarction. Overall survival rates were consistently poor during the study period, with unadjusted 5-year survival rates of 22%–25% irrespective of revascularization strategy. Using multivariable-adjusted proportional hazards regression, we found that CABG compared with PCI associated with significantly lower risks for both death (HR=0.87, 95% CI=0.84–0.90) and the composite of death or myocardial infarction (HR=0.88, 95% CI=0.86–0.91). Results were similar in analyses using a propensity score-matched cohort. In the absence of data from randomized trials, these results suggest that CABG may be preferred over PCI for multivessel coronary revascularization in appropriately selected patients on maintenance dialysis.Cardiovascular disease is the leading cause of death in patients with ESRD.¹ Coronary heart disease affects 30%–60% of patients with ESRD, and it usually involves multiple vessels, proximal lesions, heavy calcifications, or diffuse disease.^2–4 Because of the high burden and poor prognosis of coronary disease in this patient population, optimal management of coronary heart disease—particularly the choice of revascularization modality—is a critical clinical issue.Although there have been several randomized trials comparing multivessel coronary artery bypass grafting (CABG) with multivessel percutaneous coronary intervention (PCI),^5,6 none of these trials included patients with ESRD. Evidence from previous observational studies is mixed; some studies indicate a long-term survival benefit associated with CABG versus PCI,^7–10 whereas other studies show no significant differences in survival.^11–15 These discrepant results may have stemmed, at least in part, from the heterogeneity of the studied populations (e.g., inclusion of patients with single- and multivessel coronary disease and small sample sizes from single institutions). Moreover, most of these studies were performed between the 1970s and early 2000s, and therefore, they do not reflect contemporary practice patterns, such as the use of drug-eluting stents.To address these issues, we used data from the US Renal Data System (USRDS), which collects extensive information for over 95% of patients with ESRD in the United States.¹ We examined the comparative effectiveness of CABG versus PCI between 1997 and 2009 in patients with ESRD on maintenance dialysis. We restricted our analysis to patients undergoing multivessel coronary revascularization to minimize indication bias, because they have the most similar likelihood of receiving either CABG or PCI. We hypothesized that an initial strategy of CABG would be associated with lower risks of mortality and cardiovascular morbidity compared with PCI.