Single versus double stenting for unprotected left main coronary artery bifurcation lesions: a systematic review and meta-analysis.

OBJECTIVES: We conducted a meta-analysis to assess outcomes for a single-stent (SS) strategy versus a double-stent (DS) strategy in treatment of distal unprotected left main coronary artery (ULMCA) lesions in the drug-eluting stent (DES) era. BACKGROUND: Routine use of DES implantation has contributed to improved outcomes in patients undergoing percutaneous coronary intervention (PCI) for disease involving the ULMCA. However, PCI for ULMCA bifurcation lesions continues to be technically demanding and is an independent predictor of poor outcomes. While a number of stenting techniques have been described, the optimal strategy remains unknown. METHODS: SS treatment was defined as stenting of the main branch alone and DS treatment as stenting of both the main and side branches. Our co-primary endpoints were major adverse cardiovascular events (MACE), and its individual components. RESULTS: We identified 7 observational studies involving 2328 patients. Mean duration of follow-up was 32 months. We adopted the random effect model when computing the combined odds ratio (OR). There was decreased risk of MACE with SS strategy (20.4%) versus DS strategy (32.8%) (OR, 0.51; 95% confidence interval [CI], 0.35-0.73). There was also decreased target vessel/target lesion revascularization (TLR/TVR) with SS strategy (10.1%) versus DS strategy (24.3%) (OR, 0.35; 95% CI, 0.25-0.49). CONCLUSION: Compared to the DS strategy of percutaneous ULMCA bifurcation intervention, an SS approach may be associated with better outcomes.

Prognostic impact of intra-aortic balloon pump insertion before versus after cardiac surgical intervention in a veteran population.

BACKGROUND: The relative prognostic impact of intra-aortic balloon pump (IABP) placement before versus after cardiac surgery is not well defined. METHODS: We reviewed data from all cardiac surgical patients who received perioperative IABP support at a veterans' hospital between April 1992 and April 2008. We compared outcomes between patients who received an IABP before surgery (BS, n = 36) and after surgery (AS, n = 28). RESULTS: The AS group had higher operative morbidity (71% vs 42%) and mortality (43% vs 14%) rates than the BS group (P < .02 for both). Furthermore, survival rates were lower in the AS group than in the BS group at 1 year (50% vs 83%) and 3 years (46% vs 80%) (log-rank test, P < .004). CONCLUSIONS: Patients who require IABP after cardiac surgery may have worse outcomes than patients who receive IABP support before surgery. In both groups, after an early peak in mortality, the midterm outcomes were characterized by a reassuring plateau in the survival rates.

Impact of alpha 1-adrenergic antagonist use for benign prostatic hypertrophy on outcomes in patients with heart failure.

Previous clinical trials have shown that alpha(1)-adrenergic antagonists are not effective in subjects with heart failure (HF) and might increase HF rates when used for hypertension. However, alpha(1)-adrenergic antagonists may be prescribed to subjects with HF who have symptomatic benign prostatic hyperplasia. We sought to determine any association between alpha(1)-adrenergic antagonist use, commonly prescribed for benign prostatic hyperplasia, and the clinical outcomes of subjects with HF receiving contemporary therapy. An existing database of 388 subjects with decompensated HF admissions from 2002 to 2004 at the Veterans Affairs Hospital was analyzed according to the use of alpha(1)-adrenergic antagonists at discharge. Covariate-adjusted Cox proportional hazard models were used to examine any association with future admissions for decompensated HF and total mortality. Alpha-1-adrenergic antagonist therapy was prescribed in 25% of our HF population, predominantly for benign prostatic hyperplasia, and was not associated with significant increases in the combined risk of all-cause mortality and rehospitalization for HF (hazard ratio 1.24, 95% confidence interval 0.93 to 1.65, p = 0.14), HF hospitalization (hazard ratio 1.20, 95% confidence interval 0.85 to 1.70, p = 0.31), or all-cause mortality (hazard ratio 1.10, 95% confidence interval 0.78 to 1.56, p = 0.57). In patients not receiving beta-blocker therapy, alpha(1)-adrenergic antagonist therapy was significantly associated with increased HF hospitalizations (hazard ratio 1.94, 95% confidence interval 1.14 to 3.32, p = 0.015). In conclusion, in patients with chronic HF, the use of alpha(1)-adrenergic antagonists was significantly associated with more HF hospitalizations when prescribed without concomitant beta blockade. Thus, background beta-blocker therapy appears to be protective against the potential harmful effects of alpha(1)-adrenergic antagonist therapy in patients with HF.

Reduction in BNP levels with treatment of decompensated heart failure and future clinical events.

BACKGROUND: Brain natriuretic peptide (BNP) levels correlate with outcomes in patients with heart failure (HF). We sought to compare the relationship between absolute and relative changes in BNP with future clinical events, and whether serial BNP measurements add prognostic information in patients treated for decompensated HF. METHODS AND RESULTS: In 203 patients treated for HF, increasing tertiles of BNP levels after treatment had a hazard ratio of 1.4 (1.1-1.7, P < .01) and increasing tertiles of percent reduction in BNP, had a hazard ratio of 0.7 (0.6-0.9, P = .005), respectively, for the combined end point of total mortality or readmission for HF. Higher baseline BNP levels did not decrease to lower BNP levels as often as lower BNP levels (P < .001). Follow-up BNP performed better in a model, incorporating age, ejection fraction, prior HF hospitalization, New York Heart Association Class, race, use of beta-blockers and renin-angiotensin axis inhibitors and renal insufficiency, than did baseline BNP or percent reduction in BNP. More BNP measurements other than the follow-up BNP did not improve the fit of the model further. CONCLUSIONS: These results suggest that both lower absolute BNP levels and greater percentage reduction in BNP with treatment of decompensated HF are associated with better event-free survival. Advocating a threshold BNP to which patients should be treated may not be possible given that high BNP levels tend not to decrease to levels associated with better outcomes during the short period of treatment. More BNP measurements do not add prognostic information beyond that provided by a single BNP level after treatment.

Does the level of experience of residents affect outcomes of coronary artery bypass surgery?

BACKGROUND: At our institution, coronary artery bypass grafting (CABG) operations are performed by staff surgeons or by first- or second-year cardiothoracic residents under the direct supervision of attending surgeons. We evaluated the influence of surgical seniority on outcomes. METHODS: Using prospectively collected data from our departmental database, we identified all primary, isolated CABG operations (n = 1,042) performed between July 1997 and April 2007. Operations were then stratified according to the seniority of the primary surgeon: first-year cardiothoracic resident (CT1), second-year cardiothoracic resident (CT2), or staff surgeon. Data were examined for any association between seniority and surgical outcomes. RESULTS: Staff, CT2, and CT1 surgeons performed 47 (4%), 610 (59%), and 385 (37%) cases, respectively. Efficiency was correlated with experience: for CT1, CT2, and staff surgeons, respectively, operative times averaged 345, 313, and 302 minutes; perfusion times averaged 118, 106, and 96 minutes; and cross-clamp times averaged 68, 58, and 57 minutes (p < 0.05 for all comparisons). The incidences of major morbidity (10.1%, 12.3%, 12.8%) and operative mortality (0.8%, 1.5%, 2.1%) were similar after operations performed by CT1, CT2, and staff surgeons, respectively (p > 0.15 for all). In univariate and multivariate analyses, the seniority of the primary surgeon did not independently predict morbidity or perioperative mortality. On follow-up (mean, 1,485 +/- 1,015 days), there was no significant difference in patient survival (log-rank, p = 0.64). CONCLUSIONS: Lower academic seniority was associated with longer CABG operative times but did not affect outcomes. Thus, training residents to perform CABG is safe and is characterized by progressive improvement in their technical efficiency.

The July effect and cardiac surgery: the effect of the beginning of the academic cycle on outcomes.

BACKGROUND: The effect of the time of the academic year on cardiac surgical outcomes is unknown. METHODS: Using prospectively collected data, we identified all (n = 1,673) cardiac surgical procedures performed at our institution between October 1997 and April 2007. Morbidity and mortality rates were compared between 2 periods of the academic year, one early (July 1-August 31, n = 242) and one later in the year (September 1-June 30, n = 1,431). A prediction model was constructed by using stepwise logistic regression modeling. RESULTS: Morbidity rates did not differ significantly between the early (12.8%) and later periods (15.4%) (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.54-1.28; P = 0.3). Additionally, there was no significant difference in operative mortality between the early (1.2%) and later periods (3.5%) (OR, 0.28; 95% CI, 0.07-1.19; P = 0.06). CONCLUSIONS: The early and later parts of the academic year were associated with similar risk-adjusted outcomes. Further studies are needed to determine whether our findings are applicable to other academic cardiac centers.

Does the use of bilateral internal mammary artery grafts impact survival of veterans undergoing coronary artery bypass surgery?

BACKGROUND: The impact of bilateral internal mammary artery (BIMA) versus single left internal mammary artery (LIMA) grafts on long-term survival in veterans after coronary artery bypass graft (CABG) surgery is unknown. METHODS: A review of prospectively collected data identified all patients (n = 784) who underwent primary isolated CABG surgery from December 1991 through December 1998. Grafting was performed with LIMA in 713 (90.9%) patients and with BIMA in 71 (9.1%) patients. We identified 66 propensity-matched patient pairs. RESULTS: The matched cohort was all male. The mean follow-up was 9.7 +/- 3.8 years. Comparing matched patients showed no significant survival benefit for the BIMA group versus the LIMA group at 5 years (89% versus 86%) and 10 years (73% versus 69%) (P = .99). Factors associated with decreased survival were advanced age, higher New York Heart Association heart failure class, and diabetes. CONCLUSIONS: Using BIMA grafting instead of LIMA grafting had no significant survival benefit for male veterans who underwent CABG surgery. Further study is needed to fully evaluate the role of BIMA grafting in this unique patient population.