Clinical features and long-term prognosis of diabetic patients with low or intermediate complexity coronary artery disease post percutaneous coronary intervention / 中华心血管病杂志

Objective: To investigate the clinical features and long-term prognostic factors of diabetic patients with low or intermediate complexity coronary artery disease (CAD) post percutaneous coronary intervention (PCI). Methods: This was a prospective, single-centre observational study. Consecutive diabetic patients with SYNTAX score (SS)≤32 undergoing PCI between January and December 2013 in Fuwai hospital were included in this analysis. The patients were divided into two groups based on SS, namely SS≤22 group and SS 23-32 group. Multivariate Cox regression analysis was performed to identify independent factors related to poor 5-year prognosis. The primary outcomes were cardiac death and recurrent myocardial infarction, the secondary outcomes were all cause death and revascularization. Results: Of the 3 899 patients included in the study, 2 888 were men (74.1%); mean age was 59.4±9.8 years. There were 3 450 patients in the SS≤22 group and 449 patients in the SS 23-32 group. Compared with SS≤22 group, the incidence of revascularization was higher in SS 23-32 group (18.9% (85/449) vs. 15.2% (524/3450), log-rank P=0.019). There was no significant difference in all-cause death, cardiac death and recurrent myocardial infarction between the two groups (log-rank P>0.05). Multivariate Cox regression analysis showed that age (HR=1.05, 95%CI 1.02-1.08, P<0.001), chronic obstructive pulmonary disease (HR=3.12, 95%CI 1.37-7.07, P=0.007) and creatinine clearance rate (CCr)<60 ml/min (HR=3.67, 95%CI 2.05-6.58, P<0.001) were independent risk factors for 5-year cardiac death, while left ventricular ejection fraction (HR=0.94, 95%CI 0.91-0.96, P<0.001) was a protective factor. Previous PCI (HR=2.04, 95%CI 1.38-3.00, P<0.001), blood glucose level≥11.1 mmol/L on admission (HR=2.49, 95%CI 1.32-4.70, P=0.005) and CCr<60 ml/min (HR=1.85, 95%CI 1.14-2.99, P=0.012) were independent risk factors for 5-year recurrent myocardial infarction. The SS of 23-32 was independently associated with risk of revascularization (HR=1.54, 95%CI 1.09-2.16, P=0.014), after adjusting for residual SS. Residual SS was not a risk factor for 5-year prognosis. Conclusions: In diabetic patients with low-or intermediate complexity CAD, SS 23-32 is associated with increased risk of 5-year revascularization; the clinical characteristics of the patients are associated with the long-term mortality and recurrent myocardial infarction, but not related to revascularization.

Lower Baseline LDL Cholesterol Affects All-cause Mortality in Patients with First Percutaneous Coronary Intervention / 生物医学与环境科学（英文）

OBJECTIVE@#Foreign studies have reported that coronary artery disease (CAD) patients with high baseline low-density lipoprotein cholesterol (LDL-C) may have a good prognosis, which is called the "cholesterol paradox". This study aimed to examine whether the "cholesterol paradox" also exists in the Chinese population.@*METHODS@#A total of 2,056 patients who underwent the first percutaneous coronary intervention (PCI) between 2014 and 2016 were enrolled in this retrospective cohort study and classified into two groups based on baseline LDL-C = 2.6 mmol/L (100 mg/dL). The outcomes of interest included major adverse cardiovascular events (MACE), all-cause mortality, recurrent nonfatal myocardial infarction, unexpected coronary revascularization, or any nonfatal stroke.@*RESULTS@#All-cause mortality occurred in 8 patients (0.7%) from the low-LDL-C group and 12 patients (2.4%) in the high-LDL-C group, with a significant difference between the two groups (adjusted hazard ratio: 4.030, 95% confidence interval: 1.088-14.934; P = 0.037). However, no significant differences existed for the risk of MACE or other secondary endpoints, such as unexpected revascularization, nor any nonfatal stroke in the two groups.@*CONCLUSION@#In this study, a high baseline LDL-C was not associated with a low risk of clinical outcomes in CAD patients undergoing first PCI, which suggested that the "cholesterol paradox" may be inapplicable to Chinese populations.

Enfermedad coronaria: factores de riesgo y supervivencia a 10 años en la cirugía coronaria / Risk factors associated with 10-year survival after coronary artery bypass grafting

Background: Coronary artery bypass grafting (CABG) is the treatment of choice for a broad spectrum of patients with coronary disease. Aim: To describe global survival and factors associated with lower long-term survival in patients operated with isolated CABG. Material and Methods: Analysis of a cohort of patients who underwent CABG between January 2006 and December 2008 at a public hospital. The database and operation records of 1.003 cardiac surgeries were reviewed. Of these, an isolated CABG was performed in 658 patients aged 62 ± 9 years including 516 male (78%). Survival data were obtained from the Chilean Civil Registry Office and a complete ten-year follow up was accomplished. Survival was analyzed with Kaplan-Meier method with log-rank test and Cox regression. Results: Operative mortality occurred in 13 patients (2%). Survival at 1, 3, 5 and 10 years was 97, 94, 91 and 76%, respectively. One, 3, 5 and 10-year free of cardiovascular death survival was 98, 97, 95 y 89%, respectively. Factors associated with long-term survival were chronic kidney disease in hemodialysis (Hazard ratio (HR) 7.9; 95% confidence intervals (CI) 4.6-13.6), chronic obstructive pulmonary disease (HR 2.3; 95% CI 1.4-3.7), chronic arterial occlusive disease (HR 2.2; 95% CI 1.4-3.4) and diabetes mellitus (HR 1.9; 95% CI 1.4-2.6). According to EuroSCORE, 10-year survival was 86, 75 and 62% (p < 0.01) in low, medium and high-risk patients, respectively. Conclusions: These patients had a 10-year survival comparable to large international series. Groups associated with lower 10-year survival were identified.

Clinical-epidemiological profile of health users who have undergone a Percutaneous Coronary Intervention / Perfil clínico-epidemiológico de usuários de saúde submetidos à Intervenção Coronária Percutânea

Background: Coronary artery disease represents the condition with the highest prevalence worldwide. The treatment of this disease is through Percutaneous Coronary Intervention (PCI). Aiming: To outline the clinical epidemiological profile of health users who have undergone PCI, in a Hospital in the state of Rio Grande do Sul. Methods: Exploratory research, with a quantitative approach carried out on 188 medical records of health users who were submitted to elective or emergency PCI, with the use of stents or not in the year 2018. Values of p <0.05 represented significant statistical differences. Results: Users with a diagnosis of unstable angina (n = 16; 17.8%), diagnostic symptoms of unstable angina (n = 61; 67.8%) and a diagnosis of angina pectoris (n = 52; 57.8%) presented significantly more likely to be submitted to the PCI in elective way (p <0.001). Users diagnosed with Acute Myocardial Infarction - AMI (n = 59; 60.2%) and symptoms with evolution greater than 24 hours (n = 30; 30.6%) and less than 24 hours (n = 24; 24.5%), with dyslipidemia (n = 38; 38.8%) and who underwent catheterization on the same day (n = 87; 88.8%) are significantly more likely to perform emergency surgery (p <0.05). In addition, the data showed that the diagnosis of unstable angina potentiates new cardiomyopathies (n = 9, 47.4%; p <0.001) and restenosis (n = 5; 26.3%; p = 0.002). Conclusion: It is necessary to create strategies to strengthen the Health Care Network (HCN) with actions for prevention, promotion and rehabilitation to health, aiming quality in diagnosis, treatment and rehabilitation.

ntrodução: A doença arterial coronariana representa a afecção de maior prevalência mundial. O tratamento desta doença se dá pela intervenção coronária percutânea (ICP). Objetivo: Delinear o perfil clínico-epidemiológico dos usuários de saúde submetidos à ICP em um Hospital do estado do Rio Grande do Sul. Métodos: Pesquisa exploratória, de abordagem quantitativa realizada em 188 prontuários de usuários de saúde submetidos à ICP eletiva ou de urgência com uso de stent ou não no ano de 2018. Valores de p< 0,05 representaram diferenças estatísticas significativas. Resultados: Usuários com diagnóstico de angina instável (n=16; 17,8%), sintomas diagnósticos de angina instável (n= 61; 67,8%) e diagnóstico de angina pectoris (n=52; 57,8%) apresentaram significativamente maior probabilidade de serem submetidos à ICP em caráter eletivo (p<0,001). Usuários com diagnóstico para infarto agudo do miocárdio (n=59; 60,2%) e sintomatologia com evolução maior que 24 horas (n=30; 30,6%) e menor que 24 horas (n=24; 24,5%), com dislipidemia (n=38; 38,8%) e que fizeram cateterismo no mesmo dia (n=87; 88,8%) são significativamente mais propensos a realizar cirurgia de urgência (p<0,05). Além disso, os dados evidenciaram que o diagnóstico de angina instável potencializa novas cardiomiopatias (n=9, 47,4%; p<0,001) e reestenose (n=5; 26,3%; p= 0,002). Conclusão: É necessário criar estratégias para fortalecer a Rede de Atenção à Saúde (RAS) com ações de prevenção, promoção e reabilitação à saúde, visando a qualidade no diagnóstico, tratamento e reabilitação.

Application of SYNTAX and its Derivative Scores in the Selection of Revascularization Strategies for Complex Coronary Heart Disease / 中国医学科学杂志(英文版)

Complex coronary heart disease (CHD) has become a hot spot in medicine due to its complex coronary anatomy, variable clinical factors, difficult hemodynamic reconstruction, and limited effect of conservative drug treatment. Identifying complex CHD and selecting optimal treatment methods have become more scientific as revascularization technology has improved, and coronary risk stratification scores have been introduced. SYNTAX and its derivative scores are decision-making tools that quantitatively describe the characteristics of coronary lesions in patients based on their complexity and severity. The SYNTAX and its derivative scores could assist clinicians in rationalizing the selection of hemodynamic reconstruction treatment strategies, and have demon-strated outstanding value in evaluating the prognosis of patients with complex CHD undergoing revascularization treatment. The authors in this article summary the practical application of SYNTAX and its derivative scores in complex CHD in order to deepen the understanding of the relationship between the choice of different revascularization strategies and SYNTAX and its derived scores in complex CHD and provide a further reference for clinical treatment of complex CHD.

Associação entre a Gravidade da Doença Arterial Coronariana e Câncer de Pulmão: Um Estudo Piloto Transversal / Association between the Severity of Coronary Artery Disease and Lung Cancer: A Pilot Cross-Sectional Study

Resumo Fundamento A relação direta entre a doença arterial coronariana (DAC) e o câncer de pulmão não é bem conhecida. Objetivo Investigar a associação entre a gravidade anatômica da DAC e do câncer de pulmão. Métodos Trezentos pacientes, incluindo 75 recém-diagnosticados com câncer de pulmão e 225 pacientes correspondentes sem câncer, foram submetidos à angiografia coronária durante a internação, sem intervenção coronária percutânea (ICP) prévia nem enxerto de bypass da artéria coronária (CABG). O escore SYNTAX foi utilizado para avaliar a gravidade da DAC. Uma pontuação alta no escore foi definida como > 15 (o maior quartil do escore SYNTAX). O teste de tendência de Cochran-Armitage foi utilizado para verificar a distribuição dos escores dos pacientes. Uma análise de regressão logística foi utilizada para avaliar a associação entre a gravidade da DAC e o câncer de pulmão. Os valores de p foram estabelecidos quando o nível de significância era 5%. Resultados A tendência de distribuição dos escores SYNTAX dos pacientes por quartis foi diferente entre aqueles com câncer de pulmão e controles (do quartil mais baixo ao mais alto: 20,0%; 20,0%; 24,0%; 36,0% vs. 26,7%; 26,2%; 25,8%; 21,3%; p=0,022). A pontuação no escore SYNTAX foi mais alta em pacientes com câncer do que nos pacientes controle (36,0% vs. 21,3%, p=0,011).O maior quartil do escore demonstrou mais riscos de desenvolver câncer de pulmão em comparação ao quartil mais baixo (OR: 2.250, IC95%: 1.077 a 4.699 ; P -trend= 0,016). Após ajustes, os pacientes no maior quartil do escore SYNTAX tinham mais risco de desenvolver câncer de pulmão (OR: 2.1o49, IC95%: 1.008 a 4.584; P -trend= 0,028). Pacientes com escores SYNTAX alto (> 15) tinham 1.985 mais chances de ter câncer de pulmão (IC95%: 1.105-3.563, P= 0,022). Conclusão A gravidade anatômica da DAC está associada ao risco de câncer de pulmão, o que indica que um rastreamento completo deste tipo de câncer possa ser mais significativo entre pacientes com DAC.

Abstract Background The direct relationship between coronary artery disease (CAD) and lung cancer is not well known. Objective To investigate the association between the anatomical severity of CAD and lung cancer. Methods Three-hundred study patients, including 75 recently diagnosed lung cancer patients and 225 matched non-cancer patients, underwent coronary angiography during hospitalization without previous percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The SYNTAX score (SXscore) was used to assess the severity of CAD. A high SXscore (SXhigh) grade was defined as SXscore > 15 (the highest quartile of the SXscore). The Cochran-Armitage test for trend was used to assess the distribution of patients' SXscores. Logistic regression analysis was used to assess the association between the severity of CAD and lung cancer. P-values were set when significance level was 5%. Results The distribution trend of patients' SXscore by quartiles was different between lung cancer patients and control patients (from the lowest to the highest quartile: 20.0%, 20.0%, 24.0%, 36.0% vs. 26.7%, 26.2%, 25.8%, 21.3%, p=0.022). The SX high rate was higher in lung cancer patients than in control patients (36.0% vs. 21.3%, p=0.011).The highest quartile of the SXscore showed higher risk of lung cancer in comparison to the lowest quartile (OR: 2,250, 95%CI: 1,077 to 4,699 ; P-trend= 0.016). After adjustment, patients in the highest quartile of the SXscore had higher risk of lung cancer (OR: 2,149, 95%CI: 1,008 to 4,584; P-trend= 0.028). Patients with high SXscore (> 15) had 1,985 times more chances of having lung cancer (95%CI: 1,105-3,563, P= 0.022). Conclusions The anatomical severity of CAD is associated with the risk of lung cancer, which indicates that a thorough lung cancer screening may be significant among severe CAD patients.

Impact of prolonging dual antiplatelet therapy on long-term prognosis of elderly patients with coronary heart disease complicated with diabetes mellitus undergoing drug-eluting stent implantation / 中华心血管病杂志

Objective: To explore and compare the effect of standard or prolonged dual antiplatelet therapy (DAPT) on the long-term prognosis of elderly patients with coronary heart disease complicated with diabetes mellitus after drug-eluting stent (DES) implantation. Methods: Consecutive patients with diabetes mellitus, ≥65 years old, underwent DES implantation, and had no adverse events within 1 year after operation underwent percutaneous coronary intervention (PCI) from January to December 2013 in Fuwai Hospital were enrolled in this prospective cohort study. These patients were divided into three groups according to DAPT duration: standard DAPT duration group (11 ≤ DAPT duration≤ 13 months) and prolonged DAPT duration group (13<DAPT duration≤ 24 months; DAPT duration>24 months). All the patients were followed up at 1, 6 months, 1, 2 and 5 years in order to collect the incidence of major adverse cardiovascular and cerebrovascular events (MACCE), and type 2 to 5 bleeding events defined by the Federation of Bleeding Academic Research (BARC). MACCE were consisted of all cause death, myocardial infarction, target vessel revascularization or stroke. The incidence of clinical adverse events were compared among 3 different DAPT duration groups, and Cox regression model were used to analyze the effect of different DAPT duration on 5-year long-term prognosis. Results: A total of 1 562 patients were enrolled, aged (70.8±4.5) years, with 398 female (25.5%). There were 467 cases in standard DAPT duration group, 684 cases in 13<DAPT duration≤ 24 months group and 411 cases in DAPT duration>24 months group. The patients in standard DAPT duration group and the prolonged DAPT duration groups accounted for 29.9% (467/1 562) and 70.1% (1 095/1 562), respectively. The 5-year follow-up results showed that the incidence of all-cause death in 13<DAPT duration≤ 24 months group (4.8%(33/684) vs. 8.6%(40/467),P=0.011) and DAPT duration>24 month group(4.1%(17/411) vs. 8.6%(40/467),P=0.008) were significantly lower than in standard DAPT group. The incidence of myocardial infarction in 13<DAPT duration≤ 24 months group was lower than in standard DAPT duration group (1.9%(13/684) vs. 5.1%(24/467),P=0.002). The incidence of MACCE in 13<DAPT duration≤ 24 months group was the lowest (standard DAPT duration group, 13<DAPT duration≤ 24 months group and DAPT duration>24 month group were 19.3% (90/467), 12.3% (84/684), 20.2% (83/411), respectively, P<0.001). There was no significant difference in the incidence of stroke and bleeding events among the three groups (all P>0.05). Multivariate Cox analysis showed that compared with the standard DAPT group, prolonged DAPT to 13-24 months was negatively correlated with MACCE (HR=0.601, 95%CI 0.446-0.811, P=0.001), all-cause death (HR=0.568, 95%CI 0.357-0.903, P=0.017) and myocardial infarction (HR=0.353, 95%CI 0.179-0.695, P=0.003). DAPT>24 months was negatively correlated with all-cause death (HR=0.687, 95%CI 0.516-0.913, P=0.010) and positively correlated with revascularization (HR=1.404, 95%CI 1.116-1.765, P=0.004). There was no correlation between prolonged DAPT and bleeding events. Conclusions: For elderly patients with coronary heart disease complicated with diabetes mellitus underwent DES implantation, and had no MACCE and bleeding events within 1 year after operation, appropriately prolonging of the DAPT duration is related to the reduction of the risk of cardiovascular adverse events. Patients may benefit the most from the DAPT between 13 to 24 months. In addition, prolonging DAPT duration does not increase the incidence of bleeding events in this patient cohort.

Predictive value of left ventricular ejection fraction for the occurrence of postoperative myocardial infarction after coronary endarterectomy in patients with diffuse coronary artery disease / 中华心血管病杂志

Objective: To investigate the predictive value of ejection fraction for the postoperative myocardial infarction after coronary endarterectomy (CE) in patients with diffuse coronary artery disease (DCAD). Methods: Patients who underwent cardiac artery bypass graft (CABG) surgery and CE in Beijing Anzhen Hospital affiliated to Capital Medical University from May 2018 to December 2020 were enrolled in this prospective observational study. Baseline features including age, sex and echocardiography parameters were obtained. Left ventricular ejection fraction(EF) was measured by echocardiography. The patients were divided into postoperative myocardial infarction (PMI) group and non-PMI group according to PMI occurrence. Linear regression analysis, logistic regression model, and receiver operating characteristic(ROC) curve were used to analyze the correlation between left ventricular ejection fraction and PMI and the influencing factors. Results: A total of 120 patients were enrolled in the study. There were 32 patients (27%) in the PMI group (male 27(84%), age (62±8)), inferior myocardial infarction occurred in 24 (75%) patients. There were 88 patients (73%) in the non-PMI group (male 70(80%), age (62±8)). EF (55% (49%, 64%) vs. 62% (55%, 67%), P=0.01) was significantly lower in the PMI group than in the non-PMI group. Perioperative TNI, IABP use and length of hospitalization were significantly higher in the PMI group than in the non-PMI group. Multivariate logistic regression showed that lower EF was an independent risk factor of PMI (OR=0.93, 95%CI: 0.89-0.98, P=0.01) after adjusting age, sex and body mass index. ROC curve analysis showed that EF<60% could sufficiently predict the occurrence of PMI (AUC= 0.67, sensitivity 64%, specificity 69%, P=0.01). Linear regression analysis showed that left ventricular end-diastolic diameter (OR=-0.52, 95%CI:-1.13-0.60, P<0.001), graft flow in left anterior descending (OR=-0.20, 95%CI:-0.15-0.01, P=0.02) and history of diabetes (OR=-0.28, 95%CI:-8.25-1.85, P=0.002) were negatively correlated with preoperative EF value. Conclusion: Lower preoperative EF is an independent risk factor for PMI after CABG and CE in DCAD patients, closely related to the left ventricular end-diastolic diameter, graft flow in left anterior descending artery and diabetes mellitus.

Evaluations of antioxidant enzyme activities, total sialic acid and trace element levels in coronary artery bypass grafting patients

Abstract Introduction: In this study, patients before and after cardiac surgery with cardiopulmonary bypass (CPB) and control subjects were evaluated for erythrocyte glutathione peroxidase, catalase and superoxide dismutase enzyme activities, in addition to glutathione, malondialdehyde, serum total sialic acid, lipid-bound sialic acid, total antioxidant status, trace elements and mineral levels. The correlation of these variables with coronary artery disease (CAD) was also assessed. Methods: A total of 30 CAD patients and 30 control subjects were included in the study. CAD patients were divided into three groups: before surgery (BS), first day after surgery (1st day AS) and seventh day after surgery (7th day AS). Results: Malondialdehyde (MDA) and total sialic acid (TSA) levels were significantly higher in CAD (BS) than in the control group (P<0.05, P<0.05). In addition, GSH and TAS levels were significantly lower in the 1st day AS group than in the control group (P<0.001, P<0.01). Moreover, Co, Cu, Mg, Se, V and Zn levels were significantly lower in CAD (BS) group than in the control group (P<0.01, P<0.01, P<0.01, P<0.01, P<0.05, P<0.001). Conclusions: It was concluded that the levels of LDL-C, total cholesterol, triglycerides and CRP significantly associated with parameters, as well as Cu, Ca and SOD activity, should be measured together to monitor CAD. It is also considered that measuring TSA and MDA might be an appropriate choice for biomarkers of CAD.

Multivessel woven coronary artery disease

Abstract Woven coronary disease is a rare pathology with unknown etiology. Although initially considered benign, recent publications report myocardial ischemia caused by the affected vessel. Since most patients are asymptomatic, long-term follow-up to understand its behavior is mandatory. We report a multivessel woven disease case with documented ischemia that was submitted to coronary artery bypass grafting and remained asymptomatic for two years of follow-up.

Long-Term Neurophysiological Outcomes in Patients Undergoing Coronary Artery Bypass Grafting

Abstract Introduction: This study aims to evaluate late postoperative neurophysiological outcomes in patients after coronary artery bypass grafting (CABG). Methods: Forty-five male patients with stable coronary artery disease aged 45-69 years underwent extended neuropsychological assessment using the software Status PF and electroencephalographical examination 3-5 days before CABG and 5-7 years after CABG. Postoperative decline in cognitive functions was determined by a 20% decrease in the cognitive indicator compared to that at baseline on 20% of the tests included in the Status PF battery. Statistical analysis was performed using the software STATISTICA 10.0. Multiple regression was used to identify demographic, clinical, and electroencephalographical variables associated with adverse cognitive outcomes. Results: Cognitive decline was observed in 54% of the patients in the long-term postoperative period. Five to seven years after CABG, all patients have shown an increase in the theta rhythm power compared to the preoperative values, which is most pronounced in the frontal and temporal areas of the right hemisphere (P=0.04), along with a decrease in the alpha rhythm in the posterior areas of the cortex (P=0.005). Multiple regression has reported that the main predictors of cognitive impairment are slower mean alpha frequency, decreased theta-2 rhythm with eyes closed in the right temporal area, and increased theta-2 rhythm with eyes open in the left temporal area (F(5.39)=8.81; P<0.00007; adjusted R-squared=0.57). Conclusion: Our findings indicate that 54% of the patients suffer from postoperative cognitive decline associated with increased theta and decreased alpha rhythms 5-7 years after CABG.

Cirugía de revascularización miocárdica versus angioplastía en el tratamiento de la enfermedad coronaria de tres vasos y tronco de la coronaria izquierda / Coronary artery bypass grafting or percutaneous coronary intervention in patients with severe three vessel disease

Recent randomized controlled trials confirmed the beneficial outcomes with coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI) in patients with severe three-vessel coronary artery and left main disease. An increased long-term survival after CABG is associated with a reduction in spontaneous myocardial infarction and repeat revascularization rates. While PCI treats only flow-limiting lesions, CABG treats the whole coronary artery, preventing events in the future. Due to different clinical and anatomic factors affecting the outcomes, the heart team should formulate treatment assignment recommendations.

Association between SYNTAX II Score and late saphenous vein graft failure in patients undergoing isolated coronary artery bypass graft surgery

SUMMARY OBJECTIVE: Coronary artery bypass graft (CABG) surgery is a well-established treatment modality for patients with multivessel coronary artery disease (CAD). Syntax II Score has been established as novel scoring system with better prediction of postprocedural outcomes. This study aimed to investigate the prognostic value of SYNTAX II Score for predicting late saphenous vein graft (SVG) failure in patients undergoing isolated CABG. METHODS: The records of 1,875 consecutive patients who underwent isolated CABG with at least one SVG were investigated. Those who underwent coronary angiography and SVGs angiography at least 1 year after the CABG were included. Patients were divided into two groups based on the presence or absence of SVG failure. For each group, predictors of late SVG failure and subsequent clinical outcomes were analyzed. RESULTS: According to this study, the presence of hypertension, higher rates of repeat revascularization, and higher SYNTAX II Scores were found to be independent predictors of late SVG failure. In addition, the prognostic value of SYNTAX II Score was found to be significantly higher than anatomical SYNTAX Score in terms of predicting late SVG failure and major adverse cardiovascular and cerebrovascular event. CONCLUSIONS: There was a strong association between SYNTAX II Score and late SVG failure in patients undergoing isolated CABG.

Patients Submitted to Myocardial Revascularization with the Use of Bilateral Internal Thoracic Arteries: Diabetics vs. Non-Diabetics

Abstract Introduction: Use of bilateral internal thoracic artery (BITA) as graft in coronary artery bypass grafting (CABG) is controversial because it is related to higher in-hospital mortality, incidence of sternal wound-related infection, and an increase in surgical time. The primary objective of this study is to evaluate in-hospital mortality and mortality within 30 days from discharge. The secondary objective is to evaluate the occurrence of deep sternal wound infection in a 90-day follow-up. Methods: This is a retrospective review of the medical records of 152 patients undergoing elective CABG with the use of BITA and cardiopulmonary bypass (CPB). These patients were divided into two groups, diabetics and non-diabetics. Patients with acute myocardial infarction and concomitant valvular disease were not included in the sample. Results: Preoperative characteristics did not show significant differences between the groups, which allowed a comparative analysis. The variables electrocardiography time and aortic clamping time were higher in the diabetic group, with a significant statistical difference (P<0.0001). In-hospital mortality occurred in three patients, and there was no mortality up to 30 days in both groups. There was no significant difference in the primary end point between groups (P=0.56). Deep sternal wound infection was present in only one patient and showed no significant difference in the secondary outcome between groups (P=0.40). Conclusion: We did not observe a higher mortality and occurrence of deep sternal wound infection with the use of BITA in diabetic patients compared to non-diabetics, even with greater CPB and aortic clamping times in diabetics.

The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery

Abstract Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross‐clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.

The effects of preoperative coronary collateral circulation on cardiac-related events after coronary artery bypass graft surgery

Abstract Introduction: This study aimed to evaluate the effects of coronary collateral circulation (CCC) in patients who had undergone coronary artery bypass grafting (CABG). Methods: A total of 127 patients who had undergone CABG (2011-2013) were enrolled into this study and follow-up was obtained by phone contact. Patients were categorized into two groups according to preoperative CCC using the Rentrop method. Percutaneous coronary intervention (PCI), recurrent myocardial infarction (MI), stroke, heart failure (HF), and mortality rates were compared between groups. Clinical outcome was defined as combined end point including death, PCI, recurrent MI, stroke, and HF. Results: Sixty-two of 127 patients had poor CCC and 65 had good CCC. There were no differences in terms of PCI, recurrent MI, and HF between the groups. Stroke (seven of 62 [11.3%] and one of 65 [1.5%], P=0.026) and mortality (19 of 62 [30.6%] and 10 of 65 [15.4%], P=0.033) rates were significantly higher in poor CCC group than in good CCC group. In Kaplan-Meier analysis, survival time was not statistically different between the groups. Presence of poor CCC resulted in a significantly higher combined end point incidence (P=0.011). Conclusion: Stroke, mortality rates, and combined end point incidence were significantly higher in poor CCC patients than in the good CCC group.

Total arterial coronary bypass graft surgery is associated with better long-term survival in patients with multivessel coronary artery disease: a systematic review with meta-analysis

Abstract Introduction: The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. Results: Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. Conclusion: This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Síndrome de ALCAPA em uma Mulher Jovem / ALCAPA Syndrome in a Young Woman

Mulher de 18 anos com histórico de síncope, angina e palpitações há um ano. Uma indicação crucial era artéria coronária direita dilatada na ecocardiografia transtorácica. Os achados da tomografia computadorizada resultaram no diagnóstico da origem anômala da artéria coronariana esquerda proveniente da síndrome da artéria pulmonar.(AU)

Inappropriate screening of obstructive coronary artery disease during pre-anesthesia assessment of candidates for non-cardiac surgery

Preoperative evaluation in elective surgeries has been associated with successful surgical treatment. However, there is no solid scientific evidence that screening for coronary artery disease (CAD) reduces surgical risk. The aims of this study were to describe the frequency of inappropriate investigation of obstructive CAD induced by pre-anesthetic assessment in individuals without cardiovascular symptoms (candidates for low- to intermediate-risk surgeries) and to evaluate predictors of this conduct. We performed a retrospective evaluation of medical records of anesthesiology services from patients undergoing pre-anesthesia assessment between May 2015 and May 2016, including those with functional capacity ≥4 metabolic equivalents without a diagnosis of heart disease. A total of 778 medical records (47±16 years of age, 62.6% female) were studied. A private hospital performed 50.1% of the surgeries and 60.4% were of intermediate risk. Only 2.7% (95%CI: 1.7-4.1%) were screened for CAD, and 91% of these requests were mediated by cardiology consultations performed during pre-anesthetic testing visits. Factors associated with screening for CAD were hypertension, diabetes, moderate systemic disease (ASA III), cardiac consultation, previous diagnosis of CAD, and admission to a private hospital. Independent predictors were private hospitals (OR: 3.9; 95%CI: 1.3-11.0), ASA III (OR: 5.3; 95%CI: 1.7-16.2), and hypertension (OR: 3.8; 95%CI: 1.5-9.8). The frequency of inappropriate requests for CAD screening in asymptomatic individuals without untreated systemic diseases was low in pre-anesthetic visits. Although infrequent, screening for CAD is more common in the private setting, in patients with poorer health status, and is usually prescribed during cardiology consultation.