One-year outcome after combined coronary artery bypass grafting and transmyocardial laser revascularization for refractory angina pectoris

Long-term outcomes after coronary artery bypass graft surgery (CABG) plus transmyocardial revascularization (TMR) are largely unknown. We report the results of 30-day and 3-, 6-, and 12-month clinical follow-up after CABG plus TMR in a consecutive series of patients with refractory angina pectoris and ≥1 myocardial ischemic area not amenable to CABG. All patients who underwent CABG plus TMR (n = 169) (mean age 63 ± 10 years, 70% men, 51% with previous CABG, 82% were deemed inoperable at other heart surgery centers due to small vessels or diffuse disease) between March 1996 and February 2000 were clinically followed and end points of interest (survival, stroke, acute myocardial infarction, and revascularization) and angina class were recorded at 30 days and 3, 6, and 12 months after CABG. At 1 year, actuarial survival and event-free survival were 85% and 81%, respectively. At the end of the first year after the procedure, 7 patients (4%) had angina class III/IV versus 152 patients (90%) at baseline (p <0.001). Predictors of major adverse cardiac events were advanced age (odds ratio [OR] 3.4, 95% confidence intervals [CI] 1.2 to 9.4, P = 0.01), prolonged intensive care unit stay (OR 3.3, CI 1.1 to 9.7, p <0.001), new-onset atrial fibrillation (OR 2.8, CI 1.1 to 7.0, P = 0.02), and in-hospital myocardial infarction (OR 1.5, CI 1.3 to 1.7, p <0.001). Thus, procedural success at 30 days and overall event-free and actuarial survival in a high-risk population setting shows that CABG plus TMR is a safe revascularization option for patients with intractable angina pectoris.     

Prognostic value of preoperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery

STUDY OBJECTIVES: Elevated levels of cardiac troponin I (cTnI) have been associated with adverse short-term and long-term outcomes in acute coronary syndrome (ACS) patients and in patients who underwent coronary artery bypass grafting (CABG); however, the prognostic implications of preoperative cTnI determination have not been investigated so far. DESIGN AND SETTING: Retrospective study in a department of cardiothoracic surgery of a university hospital. PATIENTS AND METHODS: A possible correlation between preoperative cTnI levels and major adverse cardiac events (MACE) and in-hospital mortality in CABG patients with non-ST-segment elevation ACS (NSTE-ACS) was investigated. cTnI was determined in 1,978 of 3,124 consecutive CABG patients. Among these, 1,592 patients had preoperative cTnI levels < 0.1 ng/mL and therefore served as control subjects (group 1), 265 patients had NSTE-ACS with cTnI levels from 0.11 to 1.5 ng/mL (group 2), and 121 patients had NSTE-ACS with cTnI levels > 1.5 ng/mL (group 3). cTnI levels, clinical data, MACE, and in-hospital mortality were recorded prospectively. Logistic regression and receiver operating characteristic analyses were applied to determine prognostic cutoff values of cTnI. RESULTS: Perioperative myocardial infarction was found in 5.8% of the patients in group 1, 8.3% of the patients in group 2 (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.9 to 2.5), and 18.2% patients in group 3 (OR, 3.6; 95% CI, 2.1 to 6.2; p < 0.0001, Cochran-Armitage trend test). Low cardiac output syndrome occurred in 1.5% of patients in group 1, 4.2% of patients in group 2 (OR, 2.8; 95% CI, 1.3 to 6.1), and 10.9% patients in group 3 (OR, 6.5; 95% CI, 2.9 to 14.4; p < 0.0001). In-hospital mortality was 1.5% in group 1, 3.0% in group 2 (OR, 2.0; 95% CI, 0.8 to 4.8), but 6.6% in group 3 (OR, 4.6; 95% CI, 1.9 to 11.1; p < 0.0001). Univariate and multivariate logistic regression analyses identified cTnI as the strongest preoperative predictor for MACE and in-hospital mortality, respectively. CONCLUSIONS: Preoperative cTnI measurement before CABG appears as a powerful and independent determinant of short-term surgical risk in patients with NSTE-ACS.     

Comparison of effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in patients with ischemic cardiomyopathy

The REvascularization in Ischemic HEart Failure Trial (REHEAT) is a nonrandomized, case-controlled, prospective study assessing the hypothesis that surgical and percutaneous revascularizations in patients with ischemic cardiomyopathy are associated with comparable improvement in left ventricular ejection fraction (LVEF) and functional status 12 months after myocardial revascularization. The study population consisted of 141 patients with LVEFs of <40% and angiographically confirmed coronary artery disease. The primary end point was improvement in LVEF 12 months after intervention. Secondary end points were in-hospital major adverse events, length of hospitalization, exercise tolerance of treadmill stress testing after 12 months, 1-year survival, 1-year event-free survival, angina, and heart failure severity after 12 months. The case-controlled study included 55 patients who underwent percutaneous coronary intervention (PCI) and 54 who underwent coronary artery bypass grafting (CABG). The incidence of 30-day major adverse events was higher in the CABG group (40.7% vs 9%, p = 0.0003), whereas duration of hospital stay was shorter in the PCI group (6.8 +/- 3.6 vs 9.2 +/- 2.1 days, p = 0.00001). Increase in LVEF was comparable after PCI and CABG (6.0 +/- 7.2% vs 4.4 +/- 9.0% p = 0.12). Long-term functional status based on treadmill stress testing was better after PCI (Student's t test, p = 0.0003) but, according to Canadian Cardiovascular Society and New York Heart Association classifications, was similar in the 2 treatment arms (Wilcoxon test, p <0.01). Long-term survival was significantly better for patients after PCI (Wilcoxon test, p <0.01); however, major adverse event-free survival was better after CABG (Cox-Mantel test, p = 0.0013). In conclusion, PCI and CABG are associated with comparable improvements in LVEF in patients with ischemic cardiomyopathy. PCI offers a better 1-year survival rate than CABG, but the incidence of repeat revascularization is lower with CABG.     

Atrial fibrillation after coronary artery bypass grafting in elderly patients: incidence and risk factor analysis

OBJECTIVE: New-onset atrial fibrillation (AF) is the most frequent arrhythmic complication after coronary artery bypass grafting (CABG). Elderly patients who undergo this operation may have a different risk profile from the general population. The aim of this study was to identify risk factors for post-CABG AF in the elderly population. METHODS: Between September 2001 and December 2005, 426 elderly patients (age >/= 65 years) underwent CABG at our center. Ninety-one developed post-CABG AF (AF group), and the other 335 (no-AF group) did not develop this complication. Multivariate analysis (odds ratio, +/- 95 % CI, P value) was used to identify independent clinical predictors of post-CABG AF. RESULTS: The incidence of post-CABG AF in elderly patients during the study period was 21.4 %. Multivariate analysis identified age (OR 1.07, P < 0.009), age >/= 75 years (OR 1.77, P < 0.042), preoperative renal insufficiency (OR 5.09, P < 0.035), EuroSCORE (OR 1.18, P < 0.038), and cross-clamping time (OR 1.02, P < 0.012) as predictors of AF occurrence. The AF group had a significantly longer mean intensive care unit (ICU) stay (3.8 +/- 4.7 vs. 2.5 +/- 1.3 days for AF vs. no-AF; P = 0.0001), and a significantly higher proportion of patients with prolonged (>/= 6 days) ICU stays (8.8 % vs. 3.2 %, respectively; P = 0.033). Hospital mortality was 3.2 % in the no-AF group and 2.2 % in the AF group ( P = 0.74). CONCLUSION: This study of elderly patients reveals some novel predictors of post-CABG AF, most notably preoperative renal insufficiency and EuroSCORE. It is important to identify risk factors for post-CABG AF in all patient groups as this knowledge might lead to better prevention of this problem and its potential consequences.     

Coronary angioplasty versus bypass surgery in patients >70 years old matched for ventricular function

Objectives. This study compared the relative risks and benefits of coronary angioplasty and coronary artery bypass graft surgery in patients >70 years old.Background. Few objective, comparative data exist to guide the clinician in the decision to use bypass surgery or angioplasty in elderly patients.Methods. The study was a case-control, retrospective analysis of 195 consecutive patients who underwent bypass surgery in 1987 and 1988 and were compared with a concurrent cohort of 195 coronary angioplasty-treated patients. The groups were matched for left ventricular function, age and gender mix.Results. The in-hospital morbidity and mortality rates were significantly lower in the coronary angioplasty-treated patients. Mean postprocedural hospital stay was 4.8 and 14.3 days for angioplasty and surgical group patients, respectively (p < 0.001). In-hospital death occurred in 2% of angioplasty-treated patients compared with 9% of surgically treated patients (p = 0.007). Serious in-hospital stroke occurred in no patient in the angioplasty group and in 5% of patients in the surgical group (p < 0.0001). Q wave infarction occurred in 1% of angioplasty-treated patients and 6% of bypass-treated patients (p = 0.01). The 5-year actuarial survival rate was similar in the two groups: 63% in the angioplasty group, 65% in the bypass group (p = NS). However, surgical group patients experienced less recurrent angina, required fewer repeat revascularization procedures and had fewer Q wave infarctions during follow-up compared with angioplasty group patients.Conclusions. When performed in patients >70 years old, angioplasty and coronary bypass surgery result in similar longterm survival rates but otherwise distinctly different clinical courses.     

Atrial fibrillation after beating heart surgery

Postoperative atrial fibrillation (AF) is a frequent adverse event after coronary artery bypass grafting (CABG) and may negatively affect the early clinical outcome. We sought to investigate the risk factors, prevalence, and prognostic implications of postoperative AF in patients submitted to CABG without cardiopulmonary bypass (off-pump). The study population comprised 969 patients, 645 men (67%) and 324 women (33%) who had off-pump CABG at the Washington Hospital Center from January 1987 to May 1999. Preoperative AF patients were excluded (n = 15). Two hundred six patients (age 69 +/- 10 years, 137 men [66%]) developed AF, whereas 763 patients (age 61 +/- 12 years, 508 men [67%]) did not. Predictors of AF included age >75 years (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.9 to 4.5; p <0.001), history of stroke (OR 2.1, CI 1.2 to 3.7; p = 0. 007), postoperative pleural effusion requiring thoracentesis (OR 3.2, CI 1.0 to 9.4; p = 0.03), and postoperative pulmonary edema (OR 5.1, CI 1.2 to 21; p = 0.02). Minimally invasive direct CABG was associated with a lower incidence of AF (OR 0.4, CI 0.3 to 0.7; p <0. 001). AF was associated with a prolonged postoperative hospital stay (9 +/- 6 days AF vs 6 +/- 5 days no AF, p <0.001). In-hospital mortality was significantly higher in AF patients (3% AF vs 1% no AF, p = 0.009). Patients with persistent AF had a higher postoperative in-hospital stroke rate than patients without persistent AF (9% vs 0. 6%, p <0.001). AF after beating heart surgery is associated with a higher in-hospital morbidity, mortality, and prolonged hospital stay. A minimally invasive surgical approach (minimally invasive direct CABG) is associated with a lower risk of AF.     

Outcomes of cardiac surgery in patients > or = 80 years: results from the National Cardiovascular Network

OBJECTIVES: The purpose of this study was to evaluate characteristics and outcomes of patients age > or =80 undergoing cardiac surgery. BACKGROUND: Prior single-institution series have found high mortality rates in octogenarians after cardiac surgery. However, the major preoperative risk factors in this age group have not been identified. In addition, the additive risks in the elderly of valve replacement surgery at the time of bypass are unknown. METHODS: We report in-hospital morbidity and mortality in 67,764 patients (4,743 octogenarians) undergoing cardiac surgery at 22 centers in the National Cardiovascular Network. We examine the predictors of in-hospital mortality in octogenarians compared with those predictors in younger patients. RESULTS: Octogenarians undergoing cardiac surgery had fewer comorbid illnesses but higher disease severity and surgical urgency than younger patients. Octogenarians had significantly higher in-hospital mortality after cardiac surgery than younger patients: coronary artery bypass grafting (CABG) only (8.1% vs. 3.0%), CABG/aortic valve (10.1% vs. 7.9%), CABG/mitral valve (19.6% vs. 12.2%). In addition, they had twice the incidence of postoperative stroke and renal failure. The preoperative clinical factors predicting CABG mortality in the very elderly were quite similar to those for younger patients with age, emergency surgery and prior CABG being the powerful predictors of outcome in both age categories. Of note, elderly patients without significant comorbidity had in-hospital mortality rates of 4.2% after CABG, 7% after CABG with aortic valve replacement (CABG/AVR), and 18.2% after CABG with mitral valve replacement (CABG/MVR). CONCLUSIONS: Risks for octogenarians undergoing cardiac surgery are less than previously reported, especially for CABG only or CABG/AVR. In selected octogenarians without significant comorbidity, mortality approaches that seen in younger patients.     

Factors affecting the management of outcome in elderly patients with acute myocardial infarction particularly with regard to reperfusion. Data from the French regional RICO survey

BACKGROUND: Acute myocardial infarction (AMI) in elderly patients is often unrecognized and associated with poor prognosis. OBJECTIVES: To investigate management and efficacy of reperfusion therapy to the elderly patients with AMI. METHODS: From the January 1, 2001 to October 31, 2002, 964 patients with AMI were included in the French regional RICO survey. The patients were divided into three groups: younger (<70 years old), elderly (70-79 years old) and very elderly (>or=80 years old). RESULTS: Distribution of groups was 56, 27, and 16%, respectively. The longest time delay to first request for medical attention was found in the very elderly group (30 and 55 vs. 90 min, respectively, p < 0.05). Rate of lysis fell significantly with increasing age (35, 22 and 9%, respectively, p < 0.001) but the time delay to lysis was similar for the 3 groups. The proportion of patients who benefited from primary percutaneaous transluminal coronary angioplasty decreased with age (21, 15, 11%, respectively, p < 0.001), but time delay to balloon angioplasty was similar and no difference in mortality rate was observed between the three groups after reperfusion. The incidence of in-hospital cardiovascular events (cardiogenic shock and recurrent myocardial infarction/ischemia) and in-hospital mortality increased with age (5, 13, 17%, respectively, p < 0.001). Moreover, multivariate analysis showed that only ejection fraction and Killip >1 were independent predictive factors for in-hospital cardiovascular mortality, respectively (OR 5.15, 95% CI 2.08-12.74, p < 0.0001 and OR 3.81, 95% CI 1.90-7.65, p < 0.0001), whereas age, sex, diabetes and anterior location were not significant. CONCLUSION: Our data in an unselected population indicate that very elderly patients were characterized by increased pre-hospital delays and less frequent utilization of reperfusion therapy, although no difference in the mortality in reperfused patients could be observed between the three age groups.     

75岁以上冠心病患者冠状动脉旁路移植疗效分析

目的 探讨高龄患者行冠状动脉旁路移植术(CABG)的安全性及围术期管理。方法 选择2015年1月至2020年10月于山东济宁医学院附属医院接受CABG手术的年龄≥75岁患者112例,其中男性83例,女性29例,年龄75～89（77.2±1.9）岁,根据不同的手术方法,分为对照组（体外循环）和观察组（非体外循环）,对两组患者的术前、围术期并发症及病死率情况进行回顾性分析。结果 两组术前情况、手术时间、桥血管数、病死率对比无显著差异（P>0.05);观察组引流量、围术期输血量低,呼吸机辅助时间、住ICU时间短,并发症少,与对照组差异显著(P<0.05)。结论 高龄患者行CABG安全有效,非体外循环CABG输血量少,并发症发生率低,更利于患者恢复。     

Coronary artery stenting in the elderly: short-term outcome and long-term angiographic and clinical follow-up

Objectives. This study sought to compare the short- and long-term outcomes of elderly patients undergoing coronary artery stenting with those of younger patients and to determine the long-term clinical outcome and survival of elderly patients post stent implantation.Background. Elderly patients undergoing coronary revascularization are considered a high-risk group. Few data exist that relate the results of stenting in treating coronary artery disease in the elderly population.Methods. All elderly patients ≥75 years of age who underwent coronary artery stenting between March 1993 and July 1997 (n = 137) at our center were compared to the patients <75 who underwent coronary artery stenting during the same time period (n = 2,551). Long-term clinical follow-up and survival were determined for the elderly group.Results. Elderly patients presented with lower ejection fractions (54% vs. 58%, p = 0.0001), more unstable angina (47% vs. 28%, p = 0.0001), and more multivessel disease (78% vs. 62%, p = 0.0001) than younger patients. These older patients had higher rates of procedure related complications including procedural myocardial infarction (MI) (2.9% vs. 1.7%, p = 0.2), emergency CABG (3.7% vs. 1.4%, p = 0.04), and death (2.2% vs. 0.12%, p = 0.0001). Angiographic follow-up, obtained in both groups, demonstrated significantly higher restenosis rates in the elderly versus younger patients (47% vs. 28%, p = 0.0007). Longer term clinical follow-up, which was obtained only in the elderly group, showed that at a mean follow-up period of 12 months post coronary stenting, elderly survival free from death, MI, revascularization and angina was 54% and that their overall survival was 91%. Subanalysis of the elderly patients who died showed much higher incidence of combined unstable angina (80%), prior MI (60%), lower ejection fraction (46%), multivessel disease (100%) and complex lesions (100%) than the overall group.Conclusions. Elderly patients who undergo coronary artery stenting have significantly higher rates of procedural complications and worse six month outcomes than younger patients, especially those who present with combined unstable angina, history of MI, EF < 50%, multivessel disease and complex lesions. Overall survival in the elderly population at 12 months postcoronary artery stenting was 91% and event-free survival was 54%.     

Predictors of perioperative mortality after coronary artery bypass grafting in the elderly

BACKGROUND: Coronary artery bypass grafting (CABG) is associated with higher operative risk in the elderly compared to younger patients. The aim of this study was to evaluate risk factors for perioperative mortality after CABG in the elderly. METHODS: We investigated 325 consecutive patients aged 75 or over undergoing isolated CABG at our institution. We analyzed the patients' characteristics and perioperative outcome. Patients were divided into survivors and non-survivors; risk factors and complications were compared. Based on this, we performed a multivariate logistic regression analysis to determine independent risk factors for perioperative mortality. RESULTS: Non-survivors of CABG more often suffered from concomitant extracardiac atherosclerosis (non-survivors, 62.2 %; survivors, 40.6 %; p = 0.013) as well as from renal insufficiency preoperatively (non-survivors, 35.1 %; survivors 8.0 %; p < 0.0001). A trend towards higher incidences of impaired left ventricular function (non-survivors, 37.8 %; survivors, 29.9 %; p = 0.105) and a history of recent myocardial infarction (non-survivors, 29.7 %; survivors, 17.0 %; p = 0.061) were found in non-survivors compared to survivors. Furthermore, non-survivors more often underwent CABG with cardiopulmonary bypass (CPB non-survivors, 96.1 %; survivors 70.6 %; p = 0.0005). Multivariate logistic regression analysis revealed that preoperatively impaired renal function (OR: 2.857, p < 0.0001), use of CPB (OR: 5.952, p = 0.0175), extracardiac atherosclerosis (OR: 1.581, p = 0.0228), and recent myocardial infarction (OR: 1.574, p = 0.0405) were independent risk factors for perioperative mortality. Comparison of patients undergoing CABG with or without CPB reveals that patients operated without CPB had a higher preoperative risk than patients undergoing CABG with CPB. CONCLUSION: These results show that besides impaired renal function, extracardiac atherosclerosis, and history of recent myocardial infarction, the use of CPB is a major risk factor for CABG in the elderly. Perioperative mortality and morbidity can be significantly reduced if CPB is avoided.     

The impact of new-onset atrial fibrillation on in-hospital mortality following cardiac surgery

BACKGROUND: The impact of new-onset postoperative atrial fibrillation (NAF) on in-hospital mortality (IHM) following cardiac surgery is unknown. METHODS: All patients without preoperative atrial fibrillation undergoing isolated coronary artery bypass graft surgery (CABG) and concomitant CABG and valve surgery were identified (n = 7,347). The association between NAF and IHM was determined using logistic regression modeling. Also, propensity score analysis was used to create two matched subgroups of patients with and without NAF (n = 2,015 in each group). The secondary outcomes examined were stroke, myocardial infarction (MI), intra-aortic balloon pump use, GI complications, deep sternal wound infection (DSWI), septicemia, renal failure, and length of stay. RESULTS: NAF developed in 2,047 patients (27.9%). NAF was not an independent predictor of IHM (odds ratio, 0.8; 95% confidence interval, 0.6 to 1.2; p = 0.3). In multivariate analysis, NAF was associated with age >/= 60 years, combined procedures, preoperative MI within 7 days of surgery, COPD, cerebrovascular disease, and male gender. Propensity-adjusted results revealed no difference in IHM between NAF vs no-NAF patients (2.9% vs 3.5%, respectively; Bonferroni-corrected p = 0.99). However, GI complications (4.2% vs 2.1%), DSWI (1.3% vs 0.4%), septicemia (4.0% vs 1.1%), renal failure (7.6% vs 4.3%), and length of stay (8 days vs 6 days) were significantly increased in patients with NAF. CONCLUSION: NAF following cardiac surgery is not associated with increased IHM.     

Clinical outcome of percutaneous transluminal coronary rotational atherectomy in patients with end-stage renal disease.

The clinical results of percutaneous transluminal coronary rotational atherectomy (PTCRA) in dialysis patients were retrospectively evaluated in comparison with coronary artery bypass grafting (CABG). From 1997 to 2001, 44 consecutive dialysis patients with 61 lesions underwent PTCRA and 55 consecutive dialysis patients underwent CABG. The initial success rate of PTCRA was 98%. The PTCRA group had a shorter hospital stay (13+/-17 vs 60+/-35 days, p=0.0001) and a lower rate of complications (11% vs 42%, p=0.001) than the CABG group. Although neither event-free survival without death nor myocardial infarction (MI) was significantly different between the CABG and PTCRA groups during the mean follow-up period of 21+/-14 months, 20 patients (45%) in the PTCRA group needed repeat revascularization of the target lesion. In conclusion, PTCRA may be a safe alternative modality for revascularization of high-risk CABG candidates, with excellent short-term results although the long-term outcome is inferior to that of CABG because of the higher restenosis rate.     

Emergency Coronary Artery Bypass Grafting: Indications and Outcomes from 2003 through 2013

Emergency coronary artery bypass grafting (CABG) is associated with increased in-hospital mortality rates and adverse events. This study retrospectively evaluated indications and outcomes in patients who underwent emergency CABG.The Society of Thoracic Surgeons database for a single center (Jewish Hospital) was queried to identify patients undergoing isolated CABG. Univariate analysis was performed.From January 2003 through December 2013, 5,940 patients underwent CABG; 212 presented with emergency status. A high proportion of female patients (28.2%) underwent emergency surgery. Emergency CABG patients experienced high rates of intra-aortic balloon pump support, bleeding, dialysis, in-hospital death, and prolonged length of stay. The proportion of emergency coronary artery bypass grafting declined during years 2008–2013 compared with 2003–2007 (2.2% vs. 4.5%, P < 0.001), but the incidence of angiographic accident (5.3% vs. 29.2%) increased as an indication.Ongoing ischemia remains the most frequent indication for emergency CABG, yet the incidence of angiographic accident has greatly increased. In-hospital mortality rates and adverse events remain high. If we look specifically at emergency CABG cases arising from angiographic accident, we find that 14 (15%) of all 93 emergency CABG deaths occurred in that subset of patients. Efforts to improve outcomes should therefore be focused on this high-risk group.     

Early and late results of coronary artery bypass grafting in the elderly

This study is a review of our experience with elderly patients, who have undergone coronary artery bypass grafting (CABG). Of 357 patients who underwent elective CABG from April 1982 to May 1986, 50 patients (14.0%) were 65 years old or older. The incidence of preoperative cardiac conditions in the elderly was almost the same as that in patients less than 65 years of age. The incidence of noncardiac preoperative conditions in the older patients, such as diabetes mellitus, renal dysfunction, concomitant malignant disease, atherosclerotic lesion of the ascending aorta, was significantly higher than that in the younger age group. Early surgical mortality was 4.0% (2 cases) in the older group, and 1.3% (4 cases) in the younger group. There was no significant difference in statistics. The incidence of major postoperative complications was not significantly different between the two age groups, except that of cerebral infarction, which was significantly higher in the elderly group (6.0% vs 0.3%, p less than 0.001). The rate of a long postoperative hospital stay was also significantly higher in the older group (43.8% vs 30.0%, p less than 0.05). Long-term results, such as late mortality, symptom-free rate and graft patency, showed no significant differences between the two age groups. It is concluded that CABG can be performed in selected older patients with relatively low mortality and morbidity. Special attention should be paid to prevent perioperative cerebral infarction.     

Off-pump coronary artery bypass grafting for patients with left main disease

BACKGROUND: Multivessel off-pump coronary artery bypass grafting (CABG) has been performed with favorable results in our institute. In this study, we analyzed the outcomes in patients who underwent off-pump CABG for left main disease, since the surgical outcomes for such patients have not been clarified. METHODS: Between March 1, 1999 and July 30, 2002, a total of 147 patients with left main disease (112 males and 35 females, mean age 66.9 +/- 9.8 years) underwent off-pump CABG. Perioperative and follow-up data were entered into a structured database and the results were analyzed. RESULTS: Urgent or emergent surgery was performed in 25 patients (17.0%), and a preoperative intra-aortic balloon pump was used in 12 patients (8.2%). The mean number of bypass grafts was 3.2 +/- 1.0, and complete revascularization was performed in 127 patients (86.4%). There were 4 incidences of intraoperative conversion from off-pump to on-pump surgery. The mean intubation period, intensive care unit stay and postoperative hospital stay were 9.4 +/- 13.0 h, 2.3 +/- 1.4 days and 13.4 +/- 7.3 days, respectively. There was 1 hospital death (0.7%). Postoperative myocardial infarction was observed in 2 patients (1.4%), postoperative stroke in 1 (0.7%), prolonged ventilator support in 5 (3.4%) and mediastinitis in 3 (2.0%). During the follow-up period of 2.1 +/- 1.0 years, there were 4 deaths and 7 cardiac events. The actuarial 3-year survival rate was 97.0%, and the event-free rate was 94.3%. CONCLUSION: Our observations support off-pump CABG as a surgical option with a favorable outcome for patients with left main disease.     

Impact of early and delayed stroke on in-hospital and long-term mortality after isolated coronary artery bypass grafting

Stroke after coronary artery bypass grafting (CABG) is an infrequent, yet devastating complication with increased morbidity and mortality. We sought to determine risk factors for early (intraoperatively to 24 hours) and delayed (>24 hours to discharge) stroke and to identify their impact on long-term mortality after CABG. We studied 4,140 consecutive patients who underwent isolated CABG from 1992 to 2003. Long-term survival data (mean follow-up 7.4 years) were obtained from the National Death Index. Independent predictors for stroke and in-hospital mortality were determined by multivariate logistic regression analysis including all available preoperative, intraoperative, and postoperative risk factors. Independent predictors for long-term mortality were determined by multivariate Cox regression analysis. One hundred two patients (2.5%) developed early stroke and 36 patients (0.9%) delayed stroke. Independent predictors for early stroke were age, recent myocardial infarction, smoking, femoral vascular disease, body mass index, reoperation for bleeding, postoperative sepsis and/or endocarditis, and respiratory failure, whereas those for delayed stroke were female gender, white race, preoperative renal failure, respiratory failure, and postoperative renal failure. Early stroke was an independent predictor for in-hospital (odds ratio 3.49, 95% confidence interval [CI] 1.56 to 7.80, p = 0.002) and long-term (hazard ratio 1.70, 95% CI 1.30 to 2.21, p <0.001) mortalities. Delayed stroke was not an independent predictor for in-hospital (odds ratio 0.90, 95% CI 0.23 to 3.51, p = 0.878) or long-term (hazard ratio 0.66, 95% CI 0.38 to 1.17, p = 0.156) mortality. In conclusion, risk factors for early in-hospital stroke differ from those of delayed in-hospital stroke after CABG. Early stroke is an independent predictor for in-hospital and long-term mortalities, suggesting the need for a more frequent follow-up and appropriate pharmacologic therapy after discharge.     

Comparison of thrombolytic therapy and primary coronary angioplasty with liberal stenting for inferior myocardial infarction with precordial ST-segment depression: Immediate and long-term results of a randomized study

Objectives. The aim of the study was to compare randomly assigned primary angioplasty and accelerated recombinant tissue plasminogen activator (rt-PA), in patients with “high-risk” inferior acute myocardial infarction (ST-segment elevation in the inferior leads and ST-segment depression in the precordial leads).Background. The ST-segment depression in the precordial leads is a marker of severe prognosis in patients with inferior myocardial infarction. The comparative outcome of treatment with primary angioplasty or lysis with accelerated rt-PA has not been investigated.Methods. One hundred and ten patients within 6 h of symptoms were randomized to either treatment. To assess the in-hospital and 1-year outcome of both treatments the following results were compared: death or nonfatal infarction, recurrence of angina, left ventricular ejection fraction (LVEF), and the need for repeat target vessel revascularization (TVR).Results. In patients treated with angioplasty (55) and rt-PA (55) the rate of in-hospital mortality and reinfarction was 3.6% versus 9.1% (p= 0.4). Recurrence of angina was 1.8% versus 20% (p = 0.002), new TVR was used in 3.6% versus 29.1% (p = 0.0003), and the LVEF (%) at discharge was 55.2 ± 9.5 versus 48.2 ± 9.9 (p = 0.0001). There were no hemorrhagic strokes, no emergency coronary artery bypass graft (CABG) and identical (5.5%) need for blood transfusions. At 1 year, the incidence of death, reinfarction or repeat TVR was 11% in the percutaneous transluminal coronary angioplasty (PTCA) group versus 52.7% in the rt-PA group (log-rank 22.38, p < 0.0001).Conclusions. Primary angioplasty is superior to accelerated rt-PA in terms of both myocardial preservation and reduction of in-hospital complications in patients with inferior myocardial infarction and precordial ST-segment depression. Primary angioplasty also yields a better long-term event-free survival.     

Long-term prognosis after coronary revascularization in patients with end-stage renal disease on dialysis: comparison of percutaneous coronary intervention and coronary artery bypass grafting

OBJECTIVES: To investigate the optimal method of coronary revascularization in patients on dialysis. METHODS: We retrospectively analyzed 145 patients on dialysis who underwent percutaneous coronary intervention (PCI) (81 patients) or coronary artery bypass grafting (CABG) (64 patients). Survival and non-fatal cardiac event-free rates were compared between the two groups by the Kaplan-Meier method. The impact of independent predictors on survival and non-fatal cardiac event-free rates were examined by the Cox regression model. RESULTS: The number of diseased vessels was smaller and ejection fraction was greater in the PCI group compared with the CABG group (1.74 +/- 0.67 vs 2.56 +/- 0.61, p < 0.0001 and 61.1 +/- 14.3% vs 50.6 +/- 17.4%, p = 0.001). The 1-year and 5-year survival rates of the PCI group were significantly higher than those of the CABG group (93.8 +/- 2.7% and 66.6 +/- 5.7% vs 76.0 +/- 5.4% and 44.8 +/- 6.5%, p = 0.0065). However, CABG was not an independent predictor of death by multivariate analysis (p = 0.06). The 1-year and 5-year non-fatal cardiac event-free rates of the PCI group were significantly lower than those of the CABG group (63.7 +/- 5.4% and 34.7 +/- 5.8% vs 83.2 +/- 4.9% and 66.8 +/- 7.4%, p = 0.0003). PCI was an independent predictor of non-fatal cardiac event by multivariate analysis (p = 0.007). CONCLUSIONS: PCI was associated with a higher incidence of non-fatal cardiac events, but survival rate was better after PCI than after CABG. PCI is very important and acceptable as a method of coronary revascularization in patients on dialysis.     

In hospital observation of patients with acute coronary syndrome without ST elevation and multivessels coronary artery disease treated with early invasive strategy. Comparison of results of percutaneous coronary intervention and coronary artery by-pass grafting

Acute coronary syndromes (ACS) without persistent ST-segment elevation are the main cause of hospitalization, morbidity and mortality. The objective of this study was to compare clinical and angiographic parameters as well as in-hospital results of treating 307 consecutive patients with ACS without persistent ST-segment elevation with either PCI or CABG. Inclusion criteria were: rest angina within the last 24 hours, ST-segment depression (> 0.5 mm), T-wave inversion (> 1 mm) in at least two leads, positive serum cardiac markers. PCI was performed in 75.9% of patients and 24.1% of patients underwent CABG. Both groups did not differ as to age, sex, history of diabetes, arterial hypertension, heart failure, smoking and ejection fraction. Positive troponin was significantly more frequent in the PCI group. 51% of PCI patients and 80% of CABG patients had complete revascularization (p = 0.00001). Independent predictors of in-hospital death in the CABG group were: inability to determine culprit vessel during coronary angiography due to lesions' severity (OR 13.65; 95% CI 9.40-15.20; p = 0.007) and heart failure (OR 15.58; 95% CI 12.29-18.01; p = 0.003). In the PCI group these independent predictors were: Braunwald's IIIC unstable angina (OR 5.48; 95% CI 3.10-7.17; p = 0.04) and diabetes (OR 2.22; 95% CI 1.07-3.90; p = 0.003). In-hospital mortality rate was significantly higher in the CABG group (8.1% vs 1.7% p < 0.01). Patients with multivessel coronary artery disease and ACS without ST-segment elevation treated with PCI have better in-hospital outcome than patients assigned to CABG, but the rate of complete revascularization is lower.