A prediction model for coronary artery abnormalities in children with Kawasaki disease older than 5 years

Abstract Objective: Reliably prediction models for coronary artery abnormalities (CAA) in children aged > 5 years with Kawasaki disease (KD) are still lacking. This study aimed to develop a nomogram model for predicting CAA at 4 to 8 weeks of illness in children with KD older than 5 years. Methods: A total of 644 eligible children were randomly assigned to a training cohort (n = 450) and a validation cohort (n = 194). The least absolute shrinkage and selection operator (LASSO) analysis was used for optimal predictors selection, and multivariate logistic regression was used to develop a nomogram model based on the selected predictors. Area under the receiver operating characteristic curve (AUC), calibration curves, Hosmer-Lemeshow test, Brier score, and decision curve analysis (DCA) were used to assess model performance. Results: Neutrophil to lymphocyte ratio, intravenous immunoglobulin resistance, and maximum baseline z-score ≥ 2.5 were identified by LASSO as significant predictors. The model incorporating these variables showed good discrimination and calibration capacities in both training and validation cohorts. The AUC of the training cohort and validation cohort were 0.854 and 0.850, respectively. The DCA confirmed the clinical usefulness of the nomogram model. Conclusions: A novel nomogram model was established to accurately assess the risk of CAA at 4-8 weeks of onset among KD children older than 5 years, which may aid clinical decisionmaking.

Além do Escore GRACE SCA: É Necessário um Modelo Diferente para Homens e Mulheres após IAMCSST? / Beyond the GRACE ACS Score: Do We Need a Different Model for Men and Women after STEMI?

Resumo Fundamento As mulheres, em comparação aos homens, apresentam piores resultados após a síndrome coronariana aguda (SCA). No entanto, ainda não está claro se o sexo feminino em si é um preditor independente de tais eventos adversos. Objetivo Este estudo tem como objetivo avaliar a associação entre o sexo feminino e a mortalidade hospitalar após infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Métodos Conduzimos um estudo de coorte retrospectivo, recrutando pacientes consecutivos com IAMCSST, internados em um hospital terciário de janeiro de 2018 a fevereiro de 2019. Todos os pacientes foram tratados de acordo com as recomendações das diretrizes atuais. Modelos de regressão logística multivariada foram aplicados para avaliar a mortalidade hospitalar utilizando variáveis de GRACE. A precisão do modelo foi avaliada usando o índice c. Um valor de p < 0,05 foi estatisticamente significativo. Resultados Dos 1.678 pacientes com SCA, 709 apresentaram IAMCSST. A população era composta por 36% de mulheres e a idade média era de 61 anos. As mulheres tinham maior idade (63,13 anos vs. 60,53 anos, p = 0,011); apresentavam hipertensão (75,1% vs. 62,4%, p = 0,001), diabetes (42,2% vs. 27,8%, p < 0,001) e hiperlipidemia (34,1% vs. 23,9%, p = 0,004) mais frequentemente; e apresentaram menor probabilidade de serem submetidas a intervenção coronária percutânea (ICP) por acesso radial (23,7% vs. 46,1%, p < 0,001). A taxa de mortalidade hospitalar foi significativamente maior em mulheres (13,2% vs. 5,6%, p = 0,001), e o sexo feminino permaneceu em maior risco de mortalidade hospitalar (OR 2,79, IC de 95% 1,15-6,76, p = 0,023). Um modelo multivariado incluindo idade, sexo, pressão arterial sistólica, parada cardíaca e classe de Killip atingiu 94,1% de precisão na previsão de mortalidade hospitalar, e o índice c foi de 0,85 (IC de 95% 0,77-0,93). Conclusão Após ajuste para os fatores de risco no modelo de previsão do GRACE, as mulheres continuam em maior risco de mortalidade hospitalar.

Abstract Background Women, in comparison to men, experience worse outcomes after acute coronary syndrome (ACS). However, whether the female sex per se is an independent predictor of such adverse events remains unclear. Objective This study aims to assess the association between the female sex and in-hospital mortality after ST-elevation myocardial infarction (STEMI). Methods We conducted a retrospective cohort study by enrolling consecutive STEMI patients admitted to a tertiary hospital from January 2018 to February 2019. All patients were treated per current guideline recommendations. Multivariable logistic regression models were applied to evaluate in-hospital mortality using GRACE variables. Model accuracy was evaluated using c-index. A p-value < 0.05 was statistically significant. Results Out of the 1678 ACS patients, 709 presented with STEMI. The population consisted of 36% women, and the median age was 61 years. Women were older (63.13 years vs. 60.53 years, p = 0.011); more often presented with hypertension (75.1% vs. 62.4%, p = 0.001), diabetes (42.2% vs. 27.8%, p < 0.001), and hyperlipidemia (34.1% vs. 23.9%, p = 0.004); and were less likely to undergo percutaneous coronary intervention (PCI) via radial access (23.7% vs. 46.1%, p < 0.001). In-hospital mortality rate was significantly higher in women (13.2% vs. 5.6%, p = 0.001), and the female sex remained at higher risk for in-hospital mortality (OR 2.79, 95% CI 1.15-6.76, p = 0.023). A multivariate model including age, sex, systolic blood pressure, cardiac arrest, and Killip class was 94.1% accurate in predicting in-hospital mortality, and the c-index was 0.85 (95% CI 0.77-0.93). Conclusion After adjusting for the risk factors in the GRACE prediction model, women remain at higher risk for in-hospital mortality.

Comparison of Early and Mid-Term Outcomes After Classic and Modified Morrow Septal Myectomy in Patients with Hypertrophic Obstructive Cardiomyopathy

ABSTRACT Introduction: The aim of our study is to compare the early and mid-term outcomes of patients with hypertrophic obstructive cardiomyopathy who underwent classic and modified Morrow septal myectomy. Methods: Between 2014 and 2019, 48 patients (24 males; mean age 49.27±16.41 years) who underwent septal myectomy were evaluated. The patients were divided into two groups - those who underwent classic septal myectomy (n=28) and those who underwent modified septal myectomy (n=20). Results: Mitral valve intervention was higher in the classic Morrow group than in the modified Morrow group, but there was no significant difference (P=0.42). Mortality was found to be lower in the modified Morrow group than in the classic Morrow group (P=0.01). In both groups, the mean immediate postoperative gradient was significantly higher than the mean of the 3rd and 12th postoperative months. The preoperative and postoperative gradient difference of the modified Morrow group was significantly higher than of the classic Morrow group (P<0.001). Conclusion: Classic Morrow and modified Morrow procedures are effective methods for reducing left ventricular outflow tract obstruction. The modified Morrow procedure was found to be superior to the classic Morrow procedure in terms of reducing the incidence of mitral valve intervention with the reduction of the left ventricular outflow tract gradient.

Difference Between Cardiopulmonary Bypass Time and Aortic Cross-Clamping Time as a Predictor of Complications After Coronary Artery Bypass Grafting

ABSTRACT Introduction: Along with cardiopulmonary bypass time, aortic cross-clamping time is directly related to the risk of complications after heart surgery. The influence of the time difference between cardiopulmonary bypass and cross-clamping times (TDC-C) remains poorly understood. Objective: To assess the impact of cardiopulmonary bypass time in relation to cross-clamping time on immediate results after coronary artery bypass grafting in the Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) II. Methods: Analysis of 3,090 patients included in REPLICCAR II database was performed. The Society of Thoracic Surgeons outcomes were evaluated (mortality, kidney failure, deep wound infection, reoperation, cerebrovascular accident, and prolonged ventilation time). A cutoff point was adopted, from which the increase of this difference would affect each outcome. Results: After a cutoff point determination, all patients were divided into Group 1 (cardiopulmonary bypass time < 140 min., TDC-C < 30 min.), Group 2 (cardiopulmonary bypass time < 140 min., TDC-C > 30 min.), Group 3 (cardiopulmonary bypass time > 140 min., TDC-C < 30 min.), and Group 4 (cardiopulmonary bypass time > 140 min., TDC-C > 30 min.). After univariate logistic regression, Group 2 showed significant association with reoperation (odds ratio: 1.64, 95% confidence interval: 1.01-2.66), stroke (odds ratio: 3.85, 95% confidence interval: 1.99-7.63), kidney failure (odds ratio: 1.90, 95% confidence interval: 1.32-2.74), and in-hospital mortality (odds ratio: 2.17, 95% confidence interval: 1.30-3.60). Conclusion: TDC-C serves as a predictive factor for complications following coronary artery bypass grafting. We strongly recommend that future studies incorporate this metric to improve the prediction of complications.

Identificação de Potenciais Biomarcadores Cruciais em IAMCSST por Meio de Análise Bioinformática Integrada / Identification of Potential Crucial Biomarkers in STEMI Through Integrated Bioinformatic Analysis

Resumo Fundamento O infarto do miocárdio com elevação do segmento ST (IAMCSST) é uma das principais causas de doenças cardiovasculares fatais, que têm sido a principal causa de mortalidade em todo o mundo. O diagnóstico na fase inicial beneficiaria a intervenção clínica e o prognóstico, mas ainda falta a exploração dos biomarcadores do IAMCSST. Objetivos Neste estudo, conduzimos uma análise bioinformática para identificar potenciais biomarcadores cruciais no progresso do IAMCSST. Métodos Obtivemos GSE59867 para pacientes com IAMCSST e doença arterial coronariana estável (DACE). Genes diferencialmente expressos (GDEs) foram selecionados com o limiar de -log2fold change- > 0,5 e p < 0,05. Com base nesses genes, conduzimos análises de enriquecimento para explorar a relevância potencial entre genes e para rastrear genes centrais. Posteriormente, os genes centrais foram analisados para detectar miRNAs relacionados e DAVID para detectar fatores de transcrição para análise posterior. Finalmente, o GSE62646 foi utilizado para avaliar a especificidade dos GDEs, com genes demonstrando resultados de AUC superiores a 75%, indicando seu potencial como candidatos a biomarcadores. Posteriormente, os genes centrais foram analisados para detectar miRNAs relacionados e DAVID para detectar fatores de transcrição para análise posterior. Finalmente, o GSE62646 foi utilizado para avaliar a especificidade dos GDEs, com genes demonstrando resultados de AUC superiores a 75%, indicando seu potencial como candidatos a biomarcadores. Resultados 133 GDEs entre DACE e IAMCSST foram obtidos. Em seguida, a rede PPI de GDEs foi construída usando String e Cytoscape, e análises posteriores determinaram genes centrais e 6 complexos moleculares. A análise de enriquecimento funcional dos GDEs sugere que as vias relacionadas à inflamação, metabolismo e imunidade desempenham um papel fundamental na progressão de DACE para IAMCSST. Além disso, foram previstos miRNAs relacionados, has-miR-124, has-miR-130a/b e has-miR-301a/b regularam a expressão do maior número de genes. Enquanto isso, a análise dos fatores de transcrição indica que EVI1, AML1, GATA1 e PPARG são os genes mais enriquecidos. Finalmente, as curvas ROC demonstram que MS4A3, KLRC4, KLRD1, AQP9 e CD14 exibem alta sensibilidade e especificidade na previsão de IAMCSST. Conclusões Este estudo revelou que imunidade, metabolismo e inflamação estão envolvidos no desenvolvimento de IAMCSST derivado de DACE, e 6 genes, incluindo MS4A3, KLRC4, KLRD1, AQP9, CD14 e CCR1, poderiam ser empregados como candidatos a biomarcadores para IAMCSST.

Abstract Background ST-segment elevation myocardial infarction (STEMI) is one of the leading causes of fatal cardiovascular diseases, which have been the prime cause of mortality worldwide. Diagnosis in the early phase would benefit clinical intervention and prognosis, but the exploration of the biomarkers of STEMI is still lacking. Objectives In this study, we conducted a bioinformatics analysis to identify potential crucial biomarkers in the progress of STEMI. Methods We obtained GSE59867 for STEMI and stable coronary artery disease (SCAD) patients. Differentially expressed genes (DEGs) were screened with the threshold of -log2fold change- > 0.5 and p <0.05. Based on these genes, we conducted enrichment analysis to explore the potential relevance between genes and to screen hub genes. Subsequently, hub genes were analyzed to detect related miRNAs and DAVID to detect transcription factors for further analysis. Finally, GSE62646 was utilized to assess DEGs specificity, with genes demonstrating AUC results exceeding 75%, indicating their potential as candidate biomarkers. Results 133 DEGs between SCAD and STEMI were obtained. Then, the PPI network of DEGs was constructed using String and Cytoscape, and further analysis determined hub genes and 6 molecular complexes. Functional enrichment analysis of the DEGs suggests that pathways related to inflammation, metabolism, and immunity play a pivotal role in the progression from SCAD to STEMI. Besides, related-miRNAs were predicted, has-miR-124, has-miR-130a/b, and has-miR-301a/b regulated the expression of the largest number of genes. Meanwhile, Transcription factors analysis indicate that EVI1, AML1, GATA1, and PPARG are the most enriched gene. Finally, ROC curves demonstrate that MS4A3, KLRC4, KLRD1, AQP9, and CD14 exhibit both high sensitivity and specificity in predicting STEMI. Conclusions This study revealed that immunity, metabolism, and inflammation are involved in the development of STEMI derived from SCAD, and 6 genes, including MS4A3, KLRC4, KLRD1, AQP9, CD14, and CCR1, could be employed as candidate biomarkers to STEMI.

A Relação entre o Índice de Imuno-Inflamação Sistêmica e Isquemia com Artérias Coronárias Não Obstrutivas em Pacientes Submetidos à Angiografia Coronária / The Relationship between the Systemic Immune-Inflammation Index and Ischemia with Non-Obstructive Coronary Arteries in Patients Undergoing Coronary Angiography

Resumo Fundamento: A isquemia com artéria coronária não obstrutiva (INOCA) é uma doença cardíaca isquêmica que inclui principalmente disfunção microvascular coronariana e/ou vasoespasmo coronariano epicárdico devido à disfunção vascular coronariana subjacente e pode ser observada mais comumente em pacientes do sexo feminino. O índice de inflamação imunológica sistêmica (SII, relação plaquetas × neutrófilos/linfócitos) é um novo marcador que prediz resultados clínicos adversos na doença arterial coronariana (DAC). Objetivo: Este estudo tem como objetivo investigar a relação entre INOCA e SII, um novo marcador associado à inflamação. Métodos: Um total de 424 pacientes (212 pacientes com INOCA e 212 controles normais) foram incluídos no estudo. Amostras de sangue venoso periférico foram recebidas de toda a população do estudo antes da angiografia coronária para medir o SII e outros parâmetros hematológicos. Em nosso estudo o valor de p<0,05' foi considerado estatisticamente significativo. Resultados: O valor de corte ideal do SII para prever o INOCA foi 153,8, com sensibilidade de 44,8% e especificidade de 78,77% (Área sob a curva [AUC]: 0,651 [IC 95%: 0,603-0,696, p=0,0265]). Suas curvas ROC foram comparadas para avaliar se o SII tinha um efeito preditivo adicional valor sobre os componentes. O valor da AUC do SII foi significativamente maior do que o do linfócito (AUC: 0,607 [IC 95%: 0,559-0,654, p = 0,0273]), neutrófilos (AUC: 0,559 [IC 95%: 0,511-0,607, p = 0,028]) e plaquetas (AUC: 0,590 [IC 95%: 0,541-0,637, p = 0,0276]) em pacientes INOCA. Conclusões: Verificou-se que um nível elevado de SII estava independentemente associado à existência de INOCA. O valor do SII pode ser usado como um indicador para adicionar aos métodos tradicionais e caros comumente usados na previsão do INOCA.

Abstract Background: Ischemia with the non-obstructive coronary artery (INOCA) is an ischemic heart disease that mostly includes coronary microvascular dysfunction and/or epicardial coronary vasospasm due to underlying coronary vascular dysfunction and can be seen more commonly in female patients. The systemic immune-inflammation index (SII, platelet × neutrophil/lymphocyte ratio) is a new marker that predicts adverse clinical outcomes in coronary artery disease (CAD). Objective: This study aims to investigate the relationship between INOCA and SII, a new marker associated with inflammation. Methods: A total of 424 patients (212 patients with INOCA and 212 normal controls) were included in the study. Peripheral venous blood samples were received from the entire study population prior to coronary angiography to measure SII and other hematological parameters. In our study, the value of p<0.05' was considered statistically significant. Results: The optimal cut-off value of SII for predicting INOCA was 153.8 with a sensitivity of 44.8% and a specificity of 78.77% (Area under the curve [AUC]: 0.651 [95% CI: 0.603-0.696, p=0.0265]). Their ROC curves were compared to assess whether SII had an additional predictive value over components. The AUC value of SII was found to be significantly higher than that of lymphocyte (AUC: 0.607 [95% CI: 0.559-0.654, p = 0.0273]), neutrophil (AUC: 0.559 [95%CI: 0.511-0.607, p=0.028]) and platelet (AUC: 0.590 [95% CI: 0.541-0.637, p = 0.0276]) in INOCA patients. Conclusions: A high SII level was found to be independently associated with the existence of INOCA. The SII value can be used as an indicator to add to the traditional expensive methods commonly used in INOCA prediction.

Fenómeno de Milking secundario a puente intramiocárdico en paciente con bloqueo trifascicular

Introducción: los puentes intramiocárdicos son una modificación anatómica de la circulación coronaria que consisten en secciones anormales en el espesor del miocardio que al formar segmentos tunelizados e incorporarse al epicardio, provocan un ordeñamiento vascular llamado fenómeno de Milking durante la compresión sistólica extrínseca, el cual es responsable de las manifestaciones clínicas y las alteraciones electrocardiográficas. Se describe un caso clínico con el objetivo de comunicar a la comunidad científica las características clínicas, eléctricas y coronariográficas de una paciente con síndrome coronario agudo con bloqueo trifascicular y fenómeno de Milking por puente intramiocárdico. Caso clínico: mujer de56 años, con antecedentes de hipertensión arterial, obesidad e historia de ingresos frecuentes por episodios de angina inestables; fue admitida por angina inestable aguda más bloqueo trifascicular y se confirmó puente intramiocárdico en el segmento medio distal de la arteria descendente anterior izquierda. La optimización de la terapia antiisquémica se basó en Carvedilol, previa implantación de marcapaso permanente. Discusión: los puentes intramiocárdicos causan reducción dinámica de la luz del vaso epicárdico coronario y cuando resulta mayor del 50% condiciona el fenómeno de Milking, el cual es más frecuente en los segmentos medio y distal de la arteria descendente anterior izquierda, su evolución es favorable y responden a la terapéutica con ß bloqueadores de forma adecuada. Conclusiones: la correlación diagnóstica facilitó la aplicación de una conducta invasiva con estimulación transvenosa permanente que permitió iniciar tratamiento betabloqueante lo cual no hubiera sido posible por el trastorno de la conducción intraventricular.

Introduction: Intramyocardial bridges are an anatomical modification of the coronary circulation consisting of abnormal sections in the thickness of the myocardium that, when forming tunnel segments and incorporating into the epicardium, cause vascular milking, the so-called milking phenomenon, during extrinsic systolic compression, which is responsible for the clinical manifestations and electrocardiographic alterations. A clinical case is described with the aim of providing the scientific community with the clinical, electrical and coronary angiographic characteristics of a patient with acute coronary syndrome with trifascicular block and milking phenomenon due to intramyocardial bridging. Case Report: A 56-year-old woman with a history of hypertension, obesity, and frequent admissions for episodes of unstable angina was admitted for acute unstable angina plus trifascicular block and intramyocardial bridging was confirmed in the distal middle segment of the left anterior descending artery. Optimization of anti-ischemic therapy was based on carvedilol after implantation of a permanent pacemaker. Discussion: Intramyocardial bridges cause a dynamic reduction of the coronary epicardial vessel lumen and when it is greater than 50% it causes a milking phenomenon, which is more frequent in the middle and distal segments of the left anterior descending artery, its evolution is favorable and responds adequately to ß-blocker therapy. Conclusions: The diagnostic correlation facilitated the application of an invasive approach with permanent transvenous stimulation, allowing the initiation of beta-blocker treatment, which would not have been possible due to the intraventricular conduction disorder.

Introdução: As pontes intramiocárdicas são uma modificação anatómica da circulação coronária constituída por secções anómalas na espessura do miocárdio que, ao formarem segmentos em túnel e ao incorporarem-se no epicárdio, provocam a ordenha vascular, o chamado fenómeno de ordenha, durante a compressão sistólica extrínseca, responsável pelas manifestações clínicas e alterações electrocardiográficas. Descreve-se um caso clínico como objetivo de dar a conhecer à comunidade científica as características clínicas, eléctricas e coronariográficas de um doente com síndrome coronário agudo com bloqueio trifascicular e fenómeno de milking por bridging intramiocárdico. Relato de Caso: Mulher de 56 anos, com antecedentes de hipertensão arterial, obesidade e internamentos frequentes por episódios de angina instável, foi internada por angina aguda instável com bloqueio trifascicular e confirmação de ponte intramiocárdica no segmento médio distal da artéria descendente anterior. A otimização da terapêutica anti-isquémica foi baseada no carvedilol após implantação de pacemaker definitivo. Discussão: As pontes intramiocárdicas provocam uma redução dinâmica do lúmen do vaso epicárdico coronário e quando esta é superior a 50% provoca um fenómeno de ordenha, mais frequente nos segmentos médio e distal da artéria descendente anterior, a sua evolução é favorável e responde adequadamente à terapêutica com ß-bloqueantes. Conclusões: A correlação diagnóstica facilitou a aplicação de uma abordagem invasiva com estimulação transvenosa permanente, permitindo o início do tratamento com beta-bloqueadores, o que não teria sido possível devido ao distúrbio de condução intraventricular.

Relationship between platelet-related parameters and new-onset atrial fibrillation after coronary bypass surgery

SUMMARY OBJECTIVE: Inflammation plays a key role in the pathogenesis of postoperative atrial fibrillation after coronary artery bypass graft surgery. In this study, we aimed to investigate the changes in mean platelet volume and platelet values during the spring and autumn seasons in patients who underwent isolated coronary artery bypass graft surgery and the possible effect of these occurrences on postoperative atrial fibrillation. METHODS: Consecutive patients who underwent elective isolated coronary bypass surgery at our clinic in the spring and autumn months, between August 2020 and July 2022, were retrospectively included in this study. Variables were evaluated according to the spring and autumn seasons. Patients who did not develop in-hospital postoperative atrial fibrillation were identified as Group 1, and those who did constituted Group 2. RESULTS: A total of 622 patients were included in the study. The patients were divided into two groups: those who were operated on in the spring (n=277, median age=62 years, male gender ratio=77.3%) and those who were operated on in the autumn (n=345, median age=61 years, male gender ratio=81.4%). There was no statistically significant difference between the patients operated on in both seasons in terms of age, gender, hypertension rates, and the frequency of chronic obstructive pulmonary disease. In multivariate analysis, being over 70 years old (OR: 1.934, 95% confidence interval (CI) 1.489-2.995, p<0.001), having a left ventricular ejection fraction below 30% (OR: 1.550, 95%CI 1.190-2.236, p=0.012), and having chronic obstructive pulmonary disease (OR: 1.663, 95%CI 1.339-2.191, p<0.001) were found to be independent predictors in predicting the development of postoperative atrial fibrillation. CONCLUSION: In this study, we first demonstrated that mean platelet volume and platelet mass index values were higher in patients in the autumn months. Additionally, for the first time in the literature, we showed that there is a significant relationship between platelet mass index value and the development of postoperative atrial fibrillation in patients who underwent isolated coronary artery bypass graft.

Association Between Body Mass Index, Obesity, and Clinical Outcomes Following Coronary Artery Bypass Grafting in Brazil: An Analysis of One Year of Follow-up of BYPASS Registry Patients

ABSTRACT Objective: To investigate the association between body mass index (BMI), obesity, clinical outcomes, and mortality following coronary artery bypass grafting (CABG) in Brazil using a large sample with one year of follow-up from the Brazilian Registry of Cardiovascular Surgeries in Adults (or BYPASS) Registry database. Methods: A multicenter cohort-study enrolled 2,589 patients submitted to isolated CABG and divided them into normal weight (BMI 20.0-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obesity (BMI > 30.0 kg/m2) groups. Inpatient postoperative outcomes included the most frequently described complications and events. Collected post-discharge outcomes included rehospitalization and mortality rates within 30 days, six months, and one year of follow-up. Results: Sternal wound infections (SWI) rate was higher in obese compared to normal-weight patients (relative risk [RR]=5.89, 95% confidence interval [CI]=2.37-17.82; P=0.001). Rehospitalization rates in six months after discharge were higher in obesity and overweight groups than in normal weight group (χ2=6.03, P=0.049); obese patients presented a 2.2-fold increase in the risk for rehospitalization within six months compared to normal-weight patients (RR=2.16, 95% CI=1.17-4.09; P=0.045). Postoperative complications and mortality rates did not differ among groups during time periods. Conclusion: Obesity increased the risk for SWI, leading to higher rehospitalization rates and need for surgical interventions within six months following CABG. Age, female sex, and diabetes were associated with a higher risk of mortality. The obesity paradox remains controversial since BMI may not be sufficient to assess postoperative risk in light of more complex and dynamic evaluations of body composition and physical fitness.

The Efficacy of Tranexamic Acid in Reducing Perioperative Drainage in Cardiac Surgery with Cardiopulmonary Bypass

ABSTRACT Introduction: Although cardiopulmonary bypass procedures remain a critical treatment option for heart disease, they come with risks, including hemorrhage. Tranexamic acid is known to reduce morbidity and mortality in surgical hemorrhage. Objective: This study aimed to evaluate the efficacy of tranexamic acid, which is routinely used to treat hemorrhage, in decreasing the amount of intraoperative and postoperative drainage. Method: A total of 80 patients who underwent cardiac surgery with cardiopulmonary bypass were included in this retrospective study. Forty patients who received tranexamic acid during the operation were assigned to Group 1, while 40 patients who did not receive tranexamic acid were assigned to Group 2. Patient data were collected from the hospital computer system and/or archive records after applying exclusion criteria, and the data were recorded. Statistical analyses were then performed to compare the data. Results: Age, sex, height, weight, body surface area, flow, and ejection fraction percentages, preoperative hematological parameters, and intraoperative variables (except tranexamic acid) were similar between the groups (P>0.05). However, there were statistically significant differences between the groups in terms of intraoperative (through the heart-lung machine) and postoperative red blood cell transfusion rates, intraoperative and postoperative bleeding drainage amounts, as well as postoperative hematocrit, hemoglobin, platelet, and red blood cell levels (P<0.05). Conclusion: We concluded that intraoperative and postoperative use of tranexamic acid in patients who underwent coronary artery bypass grafting with cardiopulmonary bypass has positive effects on hematological parameters, reducing blood product use, and bleeding drainage amount.

Prediction of Vasoactive-Inotropic Score on Prolonged Mechanical Ventilation in Adult Congenital Heart Disease Patients After Surgical Treatment Combined with Coronary Artery Bypass Grafting

ABSTRACT Introduction: This study aimed to investigate the predictive value of the vasoactive-inotropic score (VIS) at different time points for postoperative prolonged mechanical ventilation (PMV) in adult congenital heart disease patients undergoing surgical treatment combined with coronary artery bypass grafting. Methods: Patients were divided into two groups that developed PMV or not. The propensity score matching method was applied to reduce the effects of confounding factors between the two groups. VIS at different time points (VIS at the end of surgery, VIS6h, VIS12h, and VIS12h max) after surgery were recorded and calculated. The value of VIS in predicting PMV was analyzed by the receiver operating characteristic (ROC) curve, and multivariate logistic regression was used to analyze independent risk factors. Results: Among 250 patients, 52 were in the PMV group, and 198 were in the non-PMV group. PMV rate was 20.8%. After propensity score matching, 94 patients were matched in pairs. At each time point, the area under the ROC curve predicted by VIS for PMV was > 0.500, among which VIS at the end of surgery was the largest (0.805). The optimal cutoff point for VIS of 6.5 could predict PMV with 78.7% sensitivity and 72.3% specificity. VIS at the end of surgery was an independent risk factor for PMV (odds ratio=1.301, 95% confidence interval 1.091~1.551, P<0.01). Conclusion: VIS at the end of surgery is an independent predictor for PMV in patients with adult congenital heart disease surgical treatment combined with coronary artery bypass grafting.

Effects of Preoperative Nutritional Status and Lymphocyte Count on the Development of Early-term Atrial Fibrillation After Coronary Artery Bypass Grafting: A Retrospective Study

ABSTRACT Introduction: Although there are publications in the literature stating that parameters related to the nutritional status of patients are associated with the clinical outcomes of those with coronary artery disease, it is also stated that there is insufficient data on the relationship between nutritional indices and long-term outcomes and major adverse cardiovascular events in patients undergoing isolated coronary artery bypass grafting. Methods: This retrospective study was conducted with patients who underwent isolated elective on-pump coronary artery bypass grafting in our hospital. Patients who underwent emergency coronary artery bypass grafting or those with known atrial fibrillation in the preoperative period were excluded. Patients were analyzed and compared in two groups according to the development of postoperative atrial fibrillation. Results: The data of 93 coronary artery bypass grafting patients (71 [76%] males) with a mean age of 62.86 ± 9.53 years included in the study were evaluated. Both groups had similar preoperative ejection fraction value, hemoglobin level, age, number of distal bypasses, and postoperative mortality rates. Although the mean cardiopulmonary bypass and aortic cross-clamping times were higher in Group 1, they were not statistically significant. In our study, the mean prognostic nutrition index value was 51.76 ± 3002. Conclusion: According to our study results, there was no statistically significant difference between prognostic nutrition index values and the development of atrial fibrillation after coronary artery bypass grafting, which is similar to some publications in the literature. We think that it would be beneficial to conduct randomized studies involving more patients on this subject.

Evaluation of the Patients with Recurrent Angina After Coronary Artery Bypass Grafting

ABSTRACT Introduction: In this study, we aimed to evaluate the most common causes of recurrent angina after coronary artery bypass grafting (CABG) and our treatment approaches applied in these patients. Methods: We included all patients who underwent CABG, with or without percutaneous coronary intervention after CABG, at our hospital from September 2013 to December 2019. Patients were divided into two groups according to the time of onset of anginal pain after CABG. Forty-five patients (58.16 ± 8.78 years) had recurrent angina in the first postoperative year after CABG and were specified as group I (early recurrence). Group II (late recurrence) comprised 82 patients (58.05 ± 8.95 years) with angina after the first year of CABG. Results: The mean preoperative left ventricular ejection fraction was 53.22 ± 8.87% in group I, and 54.7 ± 8.58% in group II (P=0.38). No significant difference was registered between groups I and II regarding preoperative angiographic findings (P>0.05). Failed grafts were found in 27.7% (n=28/101) of the grafts in group I as compared to 26.8% (n=51/190) in group II (P>0.05). Twenty-four (53.3%) patients were treated medically in group I, compared with 54 (65.8%) patients in group II (P=0.098). There was a need for intervention in 46.6% (n=21) of group I patients, and in 34.1% (n=28) of group II patients. Conclusion: Recurrent angina is a complaint that should not be neglected because most of the patients with recurrent angina are diagnosed with either native coronary or graft pathology in coronary angiography performed.

Comparison of the Effects of Full Median Sternotomy vs. Mini-Incision on Postoperative Pain in Cardiac Surgery: A Meta-Analysis

ABSTRACT Introduction: It is not yet clear whether cardiac surgery by mini-incision (minimally invasive cardiac surgery [MICS]) is overall less painful than the conventional approach by full sternotomy (FS). A meta-analysis is necessary to investigate polled results on this topic. Methods: PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05). Results: In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95). Conclusion: MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision.

Association of Estimated Glucose Disposal Rate With the Stenosis Severity of Coronary Artery Disease： A Cross-sectional Study / 中山大学学报(医学科学版)

ObjectiveTo investigate the association between estimated glucose disposal rate （eGDR） and the severity of coronary heart disease. MethodsWe conducted a hospital-based cross-sectional study that included 1258 patients （mean age： 62（53-68） years） who underwent coronary angiography for suspected coronary artery disease （53.9% were male）. Insulin resistance level （IR） was calculated according to eGDR formula： eGDR = 21.158 - （0.09 × WC） - （3.407 × hypertension） - （0.551 × HbA1c） ［hypertension （yes = 1 / no = 0）， HbA1c = HbA1c （%）］. Subjects were grouped according to the eGDR quantile. CAD severity was determined by the number of narrowed vessels： no-obstructive CAD group （all coronary stenosis were<50%， n=704）， Single-vessel CAD group （only one involved major coronary artery stenosis≥50%， n=205）， Multi-vessel CAD group （two or more involved major coronary arteries stenosis≥50%， n=349）； Multivariate logistic regression model was used to analyze the association between eGDR and CAD severity. The linear relationship between eGDR and CAD in the whole range of eGDR was analyzed using restricted cubic spline. Subgroup analyses were used to assess the association between eGDR and CAD severity in different diabetic states. Receiver operating characteristic （ROC） curve analysis were used to evaluate the value of eGDR in improving CAD recognition. ResultsA decrease in the eGDR index was significantly associated with an increased risk of CAD severity （OR： 2.79； 95%CI： 1.72~4.55； P<0.001）. In multivariate logistic regression models， individuals with the lowest quantile of eGDR （T1） were 2.79 times more likely to develop multi-vessel CAD than those with the highest quantile of eGDR （T3） （OR： 2.79； 95%CI： 1.72~4.55； P<0.001）. Multivariate restricted cubic spline analysis showed that eGDR was negatively associated with CAD and multi-vessel CAD （P-nonlinear>0.05）. In non-diabetic patients， compared with the reference group （T3）， the T1 group had a significantly increased risk of CAD （OR： 1.42； 95% CI： 1.00~2.01； P<0.05） and multi-vessel CAD （OR： 1.86； 95%CI： 1.21~2.86； P<0.05）. No statistical association was found between eGDR and CAD in diabetic patients. In ROC curve analysis， when eGDR was added to traditional model for CAD， significant improvements were observed in the model's recognition of CAD and multi-vessel CAD. ConclusionOur study shows eGDR levels are inversely associated with CAD and CAD severity. eGDR， as a non-insulin measure to assess IR， could be a valuable indicator of CAD severity for population.

Learning Curve for Using Endoscopic Saphenous Vein Harvesting in Coronary Artery Bypass Grafting / 中山大学学报(医学科学版)

ObjectiveTo investigate the application of endoscopy in obtaining the great saphenous vein （GSV） during coronary artery bypass grafting （CABG） and explore the learning curve， with a particular focus on common challenges encountered during the learning process and their impact on early clinical outcomes. MethodsA retrospective analysis was conducted on clinical data from 83 patients who underwent off-pump CABG with endoscopic GSV harvesting at the First Affiliated Hospital of Zhengzhou University from July 2013 to April 2014. Patients were categorized into four groups based on the chronological order of their hospitalization： Group A （novice group， n=20）， Group B （proficient group， n=20）， Group C （progressive group， n=20）， and Group D （mature group， n=23）. Differences in perioperative and midterm follow-up outcomes among the groups were analyzed to determine the learning curve period. ResultsThe study population had a mean age of （60.22±8.06） years and a mean body weight of （69.77±11.66） kg. Comorbidities included hypertension （24 cases）， diabetes （26 cases）， and subacute cerebral infarction （14 cases）. The novice group exhibited significantly shorter GSV length-to-harvest time ratio relative to the other three groups （P<0.001） and a significantly higher incidence of main vein damage （P=0.006）. However， there was no statistically significant difference in graft patency at the 1-year follow-up. ConclusionThorough and reliable technical training in endoscopic GSV harvesting is essential to minimize vascular injury caused by novice operators. Approximately 20 cases of hands-on experience and a careful self-analysis of procedural challenges are likely required to achieve proficiency in GSV harvesting.

Predictive Value of Serum Albumin Levels for Coronary Artery Calcification in Patients with Early Chronic Kidney Disease / 中山大学学报(医学科学版)

ObjectiveTo explore the correlation between serum albumin levels and coronary artery calcification （CAC） in patients with early-stage chronic kidney disease （CKD）， as well as the value of serum albumin levels in predicting the incidence and severity of CAC. MethodsThe study included 391 early-stage CKD patients who underwent coronary computed tomography angiography （CTA） at Sun Yat-sen Memorial Hospital of Sun Yat-sen University between January 2019 and December 2022. Demographic and biochemistry data， as well as the coronary CTA results， were collected. Based on the coronary artery calcification score （CACS）， all patients were divided into non-CAC group （CACS=0， n=184） and CAC group （CACS>0， n=207）. All patients were further divided into 3 groups based on the serum albumin levels： group A （serum albumin levels<35 g/L， n=30）， group B （35 g/L≤ serum albumin levels< 40 g/L， n=198） and group C （serum albumin levels≥ 40 g/L， n=163）. Univariate and multivariate binary logistic regression analyses were conducted to investigate the association between serum albumin levels and CAC in early-stage CKD patients. Differences in CAC among groups were analyzed by using post-hoc multiple comparisons and ordinal logistic regression model analysis. ResultsPatients with CAC had significantly lower serum albumin levels than those without CAC （P<0.05）. There was a negative correlation between serum albumin levels and CACS in early-stage CKD patients （P<0.01）， as serum albumin decreased in levels， CAC increased in severity. ConclusionsOur study shows that early-stage CKD patients with lower serum albumin levels have a higher incidence of CAC. Low serum albumin level is an independent risk factor for CAC progression.

Clinical application and strategy of total-arterial coronary artery bypass grafting / 中国胸心血管外科临床杂志

@#Since the advent of coronary artery bypass grafting (CABG), the selection of bypass conduits has always been one of the most controversial topics in this field. Arterial conduits have received extensive attention due to their excellent biological features and high patency. In recent years, the application of arterial grafting and total arterial grafting in China keeps increasing in recent years, but there is still a gap compared to the Europe and America. Previous clinical studies have indicated the benefits of the total arterial grafting in terms of patency and long-term outcomes, but the advantage of multiple arterial grafting over other procedures is still in need to be confirmed with high-quality randomized controlled trials. This article reviews the clinical application and strategy of total-arterial CABG, aiming to provide objective reference for future clinical research and application.