Emulated Trial for Discharge Prescription of Guideline-Directed Medical Therapy and 15-Year Survival After Coronary Artery Bypass Graft Surgery.

OBJECTIVES: To explore admission and discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agents, statins, and ß-blockers, after coronary artery bypass graft (CABG) surgery and to reveal its association with long-term survival. PATIENTS AND METHODS: This is a prospective cohort study-based emulated trial of patients undergoing elective or semi-elective isolated CABG surgery in 7 cardiothoracic units in Israel from January 1, 2004, to December 31, 2007, and followed up until December 31, 2020, for all-cause mortality. RESULTS: Only 59.2% of 968 patients (n=573) were discharged on GDMT after CABG surgery. Admission GDMT use conferred a 7 times greater likelihood of discharge GDMT prescription (odds ratio, 7.07; 95% CI, 5.04 to 9.91; P<.001), with no sex differences observed. After applying inverse probability of treatment weighting, baseline characteristics were well balanced between groups. During a median follow-up of 13.7 years, a Cox regression model with propensity score-adjusted inverse probability of treatment weighting revealed lower mortality in patients with discharge GDMT prescription who underwent CABG surgery than in their counterparts (hazard ratio, 0.75; 95% CI, 0.60 to 0.93; P=.008). CONCLUSION: The use of aggregate GDMT before surgery conferred a greater likelihood of GDMT prescription upon discharge, which, in turn, is associated with better long-term survival. Educational efforts of pertinent medical professionals are needed to minimize preventive treatment gaps. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00356863.

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis.

Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.

Coronary Artery Bypass Grafting Following Acute Coronary Syndrome: Impact of Gender.

The impact of gender on clinical outcomes after coronary artery bypass grafting (CABG) has generated conflicting results. We investigated the impact of gender, on 30 day mortality, complications and late survival in patients with acute coronary syndrome (ACS) undergoing CABG. The study included 1308 patients enrolled from the biennial Acute Coronary Syndrome Israeli Survey between 2000 and 2016, who were hospitalized for ACS and underwent CABG. Of them, 1045 (80%) were men and 263 (20%) women. While women were older and had more hypertension and hyperlipidemia, they demonstrated less diabetes mellitus, previous ischemic heart disease, smoking, and fewer implicated coronary arteries. Women presented with more atypical symptoms as compared to men (26.3% vs 19.4%, p = 0.017). Overall multivariable-adjusted 30 day mortality was higher in women than in men (OR 2.47 95% CI 1.19-5.1, p = 0.015). Among patients with ST-elevation myocardial infarction (STEMI) or non-STEMI, women had a higher 10 year mortality rate than men (42.5% vs 19.2%, log-rank p < 0.001 and 31.5% vs 20.7%, log-rank, p = 0.012). However, in patients with unstable angina pectoris on admission, these differences were not seen (16.9% vs 13.4%, log-rank p = 0.540). Multivariable analysis demonstrated that female gender was a significant predictor for 10 year mortality (HR 1.39, 95% CI 1.02-1.9, p = 0.038). In a real-life setting, women constitute an independent predictor for short- and long-term mortality following ACS treated by CABG surgery. The reasons for a higher mortality in women should be further investigated as well as specific and/or more intensive therapies after CABG in this high-risk group of patients.

Repair with annuloplasty only of balanced bileaflet mitral valve prolapse with severe regurgitation.

OBJECTIVES: Repair of severe mitral valve and mitral regurgitation (MR) in patients with degenerative bileaflet pathology can be challenging. Initial results with a ring-only repair (ROR) approach have shown promising results, but long-term outcomes in larger series are lacking. We report on outcomes of ROR in severe MR secondary to bileaflet prolapse, including Barlow's disease. METHODS: Eighty patients with degenerative multi-segment bileaflet disease underwent ROR for severe MR with a predominantly central regurgitant jet indicating balanced bileaflet prolapse. The main outcome measure of this study was long-term recurrent MR probability. Secondary outcomes were late mortality, reoperation and in-hospital complications. RESULTS: The mean age was 53 ± 15 years and 54% were males. The mean ejection fraction was 59.2 ± 6.6, 24% and 40% had atrial fibrillation. Barlow's disease was found in 77% of the patients. Minimally invasive surgery was performed in 15 patients (19%). There were no perioperative mortalities or cerebrovascular events in the entire cohort. Post-repair mild outflow tract obstruction (systolic anterior motion) was observed in 4 patients (5%) after ROR. In a mean follow-up of 60 ± 48 months, there was 1 case of death. At follow-up, there was 1 (1%) reoperation due to recurrent MR, and 4 patients who had recurrent moderate or more MR. The 10-year freedom from recurrent MR was 97%. None had severe MR at the latest follow-up. CONCLUSIONS: In patients with severe MR and a central regurgitant jet secondary to balanced multi-segment bileaflet mitral valve prolapse, ROR is a simple and efficient approach providing excellent long-term results without a substantial risk of systolic anterior motion.

Three-dimensional Video Assistance Improves Early Results in Minimally Invasive Mitral Valve Surgery.

Compared with the mid-sternotomy approach, minimally invasive mitral valve surgery is usually associated with longer surgical times. The increasing use of new technology has facilitated this procedure and shortened its duration, which may further improve surgical results. Since 2004, 152 patients have undergone minimally invasive mitral valve repair. Video-assisted 2D technology was used for the first 112 patients, while video-assisted 3D technology was used for the remaining 40 patients. All patients were divided into three groups: group 1 - the first 50 patients (learning curve using 2D technology); group 2 - 62 patients (past the learning curve using 2D technology); and group 3 - 40 patients (3D technology). Mean patient age was 50 ± 12 years. There was no in-hospital mortality and no conversions to mid-sternotomy. Cardiopulmonary bypass and cross-clamp times were significantly shorter in group 3 compared with groups 2 and 1, respectively (108 ± 19 vs. 124 ± 22 vs. 139 ± 27, p < 0.001; and 76 ± 14 vs. 86 ± 18 vs. 97 ± 18, p < 0.001). Intraoperative echocardiography revealed higher freedom from more than mild residual mitral regurgitation after the first pump-run in group 3 compared to group 2 (97.5% vs. 90.3%, p = 0.04). Patients in the 3D group had less postoperative bleeding (p = 0.026) and a higher glomerular filtration rate before discharge (p < 0.001) compared with the 2D groups. No significant differences were observed in ventilation time (p = 0.066) and intensive care unit duration (p = 0.071). We concluded that in minimally invasive mitral valve repair, 3D video-assisted technology may provide shorter surgical times compared to 2D video-assisted technology.

Local prolonged release of antibiotic for prevention of sternal wound infections postcardiac surgery-A novel technology.

INTRODUCTION: Sternal wound infection (SWI) is a devastating postcardiac surgical complication. D-PLEX100 (D-PLEX) is a localized prolonged release compound applied as a prophylactic at the completion of surgery to prevent SWI. The D-PLEX technology platform is built as a matrix of alternating layers of polymers and lipids, entrapping an antibiotic (doxycycline). The objective of this study was to assess the safety profile and pharmacokinetics of D-PLEX in reducing SWI rates postcardiac surgery. METHOD: Eighty-one patients were enrolled in a prospective single-blind randomized controlled multicenter study. Sixty patients were treated with both D-PLEX and standard of care (SOC) and 21 with SOC alone. Both groups were followed 6 months for safety endpoints. SWI was assessed at 90 days. RESULTS: No SWI-related serious adverse events (SAEs) occurred in either group. The mean plasma Cmax in patients treated with D-PLEX was about 10 times lower than the value detected following the oral administration of doxycycline hyclate with an equivalent overall dose, and followed by a very low plasma concentration over the next 30 days. There were no sternal infections in the D-PLEX group (0/60) while there was one patient with a sternal infection in the control group (1/21, 4.8%). CONCLUSION: D-PLEX was found to be safe for use in cardiac surgery patients. By providing localized prophylactic prolonged release of broad-spectrum antibiotics, D-PLEX has the potential to prevent SWI postcardiac surgery and long-term postoperative hospitalization, reducing high-treatment costs, morbidity, and mortality.

Clinical and Echocardiographic Outcomes after Aortic Valve Repair in Patients with Bicuspid or Unicuspid Aortic Valve.

BACKGROUND: Unicuspid and bicuspid aortic valve (BAV) are congenital cardiac anomalies associated with valvular dysfunction and aortopathies occurring at a young age. OBJECTIVES: To evaluate our experience with aortic valve repair (AVr) in patients with bicuspid or unicuspid aortic valves. METHODS: Eighty patients with BAV or unicuspid aortic valve (UAV) underwent AVr. Mean patient age was 42 ± 14 years and 94% were male. Surgical technique included: aortic root replacement with or without cusp repair in 43 patients (53%), replacement of the ascending aorta at the height of the sino-tubular junction with or without cusp repair in 15 patients (19%), and isolated cusp repair in 22 patients (28%). RESULTS: The anatomical structure of the aortic valve was bicuspid in 68 (85%) and unicuspid in 12 patients (15%). Survival rate was 100% at 5 years of follow-up. Eleven patients (13.7%) underwent reoperation, 8 of whom presented with recurrent symptomatic aortic insufficiency (AI). Late echocardiography in the remaining 69 patients revealed mild AI in 63 patients, moderate recurrent AI in 4, and severe recurrent AI in 2. Relief from recurrent severe AI or reoperations was significantly lower in patients who underwent cusp repair compared with those who did not (P = 0.05). Furthermore, the use of pericardial patch augmentation for the repair was a predictor for recurrence (P = 0.05). CONCLUSIONS: AVr in patients with BAV or UAV is a safe procedure with low morbidity and mortality rates. The use of a pericardial patch augmentation was associated with higher repair failure.

Pericardial Patch Augmentation Is Associated With a Higher Risk of Recurrent Aortic Insufficiency.

BACKGROUND: This study assessed early and late clinical outcomes in patients who underwent aortic valve repair or an aortic valve-sparing operation and investigated predictors for failure. METHODS: Of 227 consecutive patients who underwent aortic valve repair or a valve-sparing operation in our department between 2004 and 2016, 81 (36%) underwent aortic root replacement with or without cusp repair, 97 (42%) ascending aorta replacement with or without cusp repair, and 49 (22%) isolated aortic valve repair. Clinical and echocardiographic follow-up was complete. RESULTS: One patient (0.4%) died in-hospital. Mean clinical and echocardiographic follow-up was 69 ± 40 months (range, 1 to 147 months) and 53 ± 40 months (range, 1 to 147 months), respectively. Fifteen patients (6.6%) died during follow-up, with an overall 5-year survival rate of 94.4%. Recurrent significant (≥3) aortic insufficiency developed in 20 patients (8.8%), 17 of whom underwent reoperation, with a 5-year freedom from reoperation rate of 88%. Predictors for recurrent significant aortic insufficiency or reoperation were greater preoperative aortic insufficiency (grade III to IV vs I to II; relative risk [RR], 1.97; p = 0.023), cusp repair (RR, 2.92; p = 0.001), higher European System for Cardiac Operative Risk Evaluation score (RR, 1.16; p = 0.006), and valve repair with pericardial patch augmentation (RR, 2.34; p = 0.032). CONCLUSIONS: Aortic valve repair and valve-sparing operations can be performed with good early and late clinical outcomes. In our experience, however, the rate of recurrent aortic insufficiency was significant, especially in patients who underwent cusp augmentation with glutaraldehyde-treated autologous pericardial patch.

The Leaflex™ Catheter System - a viable treatment option alongside valve replacement? Preclinical feasibility of a novel device designed for fracturing aortic valve.

AIMS: To demonstrate the feasibility of the Leaflex™ Catheter System, a novel percutaneous device for fracturing valve calcification using mechanical impact in order to regain leaflet mobility. METHODS AND RESULTS: Radiographic analysis of calcium patterns in 90 ex vivo human aortic valve leaflets demonstrated that 82% of leaflets had a typical "bridge" or "half-bridge" pattern, which formed the basis for the catheter design. The therapeutic effect was quantified in 13 leaflets showing a reduction of 49±16% in leaflet resistance to folding after treatment. A pulsatile flow simulator was then used with 11 ex vivo valves demonstrating an increase in aortic valve area of 35±12%. Using gross pathology and histology on fresh calcified leaflets, we then verified that mechanical impacts do not entail excessive risk of embolisation. In vivo safety and usability were then confirmed in the ovine model. CONCLUSIONS: We demonstrated preclinically that it is feasible to improve valve function using the Leaflex™ technology. Once demonstrated clinically, such an approach may have an important role as preparation for or bridging to TAVI, as destination treatment for patients where TAVI is clinically or economically questionable and, in the future, maybe even as a means to slow disease progression in asymptomatic patients.

A controlled intervention to increase participation in cardiac rehabilitation.

BACKGROUND: Cardiac rehabilitation programs are greatly underutilized. DESIGN: This study was a multicenter interventional controlled cohort study. METHODS: From cardiothoracic departments of five medical centers, 520 coronary artery bypass graft (CABG) patients (386 men) were enrolled in the control arm and 504 CABG patients (394 men) in the intervention arm of our study. A 1-hour seminar to medical staff on the benefits of cardiac rehabilitation followed the control phase and preceded the intervention phase. Patients in the intervention arm received written and oral explanations on cardiac rehabilitation benefits and eligibility, and a follow-up telephone call 2 weeks after hospital discharge. Patients in both study arms were interviewed in the hospital prior to CABG surgery and in their homes a year later. RESULTS: Rates of participation in cardiac rehabilitation were 16.5% (86/520) for the control arm and 31.0% (156/504) for the intervention arm (p < 0.001). Factors strongly associated with participation in cardiac rehabilitation were: belonging to the intervention arm (OR: 2.06 95% CI: 1.46-2.90, p < 0.0001), male sex, average or above average income, sports related physical activity before surgery, younger age and BMI > 30 kg/m(2). Particularly high increases in participation rates following the implementation were observed among subpopulations of 10 years or less education and those reporting below average income. "Lack of knowledge" regarding cardiac rehabilitation was the reason most commonly stated for not participating in a cardiac rehabilitation program. CONCLUSION: Participation in cardiac rehabilitation almost doubled following a low cost intervention with significant effects on subpopulations that have been underrepresented in cardiac rehabilitation programs.

Drug-eluting stents compared with bilateral internal thoracic artery grafts for diabetic patients.

BACKGROUND: Diabetic patients with multivessel coronary artery disease who undergo coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI) are at greater risk of late morbidity and mortality than nondiabetic patients. We questioned earlier comparisons of these two approaches that showed no differences in survival rates. This study compares drug-eluting stents (DES) and bilateral internal thoracic artery (BITA) grafting in diabetic patients with multivessel coronary artery disease. METHODS: All diabetic patients who underwent left-sided arterial revascularization with BITA grafting between January 2002 and May 2006 were evaluated. Their outcomes were compared with those of diabetic patients who underwent PCI with DES (Cypher). The Cox proportional hazards model defined predictors of outcome events after forcing propensity score with patients' characteristics into the model. RESULTS: The outcomes of 226 BITA patients were compared with those of 271 DES patients (mean follow-up 62 months). The 5-year reintervention-free survival (Kaplan-Meier 86% versus 65%, log rank p = 0.000) and major adverse cardiovascular events-free survival (81% versus 54%, p = 0.001) were significantly better in the BITA group. Assignment to the PCI group was associated with decreased adjusted survival (hazard ratio 3.01, 95% confidence interval: 1.59 to 5.73, p = 0.000) and increased risk of target vessel reinterventions (hazard ratio 7.00, 95% confidence interval: 3.1 to 15.70). The adjusted risk of major adverse cardiovascular events increased with the number of DES-treated vessels. CONCLUSIONS: This is the first demonstration of significantly better long-term adjusted survival and outcomes of diabetic patients who underwent CABG with BITA grafting compared with diabetic patients who underwent PCI with DES.

Midterm results of mitral valve repair: closed versus open annuloplasty ring.

BACKGROUND: Closed and open annuloplasty rings are both used for mitral valve repair. This study compared the clinical and echocardiographic results in patients with degenerative mitral disease undergoing MV repair with closed semirigid rings vs open bands. METHODS: Between 2004 and 2008, 377 patients (mean age, 59 + or - 12 years) underwent mitral valve repair. Valve pathology was degenerative in 273 (72%). Closed rings were used in 163 (60%) and open rings in 110 (40%). Patients had similar characteristics and comorbidities. In addition to annuloplasty, repair techniques included leaflet resection (48% and 77%, p < 0.01), artificial chordal (55% and 36%, p < 0.01), and edge-to-edge repair (4% and 4%, p = 0.79), in closed and open groups, respectively. RESULTS: One patient in each group died (0.7%). Mean follow-up was 19 + or - 14 (closed group) and 34 + or - 15 months (open group; p < 0.01). Freedom from reoperation was 97.5% (closed group) vs 96.5% (open group). At follow-up, New York Heart Association functional class was similar between groups, and 91% in the closed group and 84% in the open group were free from moderate or severe mitral regurgitation (p = 0.05). Closed group patients had a longer line of leaflet coaptation (9.1 + or - 2.7 mm) vs the open group (7.1 + or - 1.9 mm; p < 0.01). CONCLUSIONS: Patients with closed semirigid annuloplasty rings demonstrated significantly longer lines of leaflet coaptation and tendency toward better echocardiographic midterm results than patients with open bands and may, therefore, benefit from improved repair durability.

Quality of mitral valve repair: median sternotomy versus port-access approach.

OBJECTIVES: We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means of the port-access and median sternotomy approaches. METHODS: Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwent surgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group had better preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Other preoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques. RESULTS: Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that most patients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extended for up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was 97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) in the port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11). CONCLUSIONS: In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with the conventional median sternotomy approach.

Revascularization of left anterior descending artery with drug-eluting stents: comparison with minimally invasive direct coronary artery bypass surgery.

BACKGROUND: The proximal left anterior descending artery (LAD) is a challenging area for percutaneous interventions; therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the proximal LAD. This study compares mid-term results of LAD revascularization using drug-eluting stents (Cypher) with minimally invasive direct coronary artery bypass grafting (MIDCAB). METHODS: From May 2002 to December 2003, 376 consecutive patients underwent myocardial revascularization of the LAD, 272 by Cypher and 104 by MIDCAB. After matching for age, sex, and extent of coronary artery disease, two groups of 83 patients each were used to compare the two revascularization modalities. The groups were similar; however, ejection fraction of less than 0.35 was more prevalent in the MIDCAB group and prior percutaneous coronary intervention in the Cypher group. RESULTS: Thirty-day mortality was 1.1% in the MIDCAB and 0% in the Cypher group. Mean follow-up was 22.5 months. Two late cardiac deaths occurred in the MIDCAB group and one in the Cypher group (p = NS). Angina returned in 35% of the Cypher group and in 8.4% of the MIDCAB group (p < 0.001). There were 14 (16.8%) reinterventions in the Cypher compared with three (3.6%) in the surgical group (p = 0.005). Cox proportional hazard model showed that assignment to the Cypher group was the only independent predictor of reangina (hazard ratio [HR], 6.17, 95% confidence interval [CI], 2.46 to 15.4). Treatment with Cypher was also an independent predictor of reintervention (HR 8.26, 95% CI, 1.68 to 40). CONCLUSIONS: Despite improved results of percutaneous interventions with Cypher to the LAD, mid-term clinical outcome of patients treated with MIDCAB was better.

Drug-eluting stents versus coronary artery bypass grafting in patients with diabetes mellitus.

BACKGROUND: Reduction of restenosis and reinterventions was recently reported with percutaneous interventions (PCI) with drug-eluting stents (Cypher). This study compares results of Cypher (Cordis, Miami Lakes, FL) stenting and surgical revascularization in diabetic patients. METHODS: From January 2002 to January 2005, 518 consecutive diabetic patients underwent myocardial revascularization; 176 by PCI incorporating Cyphers and 342 treated surgically. Single-vessel patients in the surgical group were treated with the left internal thoracic artery (ITA) and most multivessel patients were treated with two ITAs. After matching for age, sex, right system revascularization, and extent of coronary disease, two groups (86 patients each) were used to compare the two revascularization modalities. RESULTS: Both groups were similar; however, left main, poor ejection fraction, total occlusion, and bifurcation lesions were more prevalent in the surgical group, and in-stent restenosis in the PCI group. The mean number of coronary vessels treated was higher in the surgical group (2.05 vs 1.6, p < 0.001). Mean follow-up was 18 months. Overall mortality (early and late) was 2.3% and 3.5% in the Cypher and surgical groups, respectively (p = 0.65). Angina returned in 39.5% of the Cypher group and 15.1% of the surgical group, p < 0.001. There were 25 reinterventions in the Cypher group compared with five in the surgical group (p = 0.010). The Cox proportional hazard model revealed assignment to the Cypher group to be the only independent predictor of reangina (odds ratio [OR] 3.26, 95% confidence interval [CI] 1.63 to 6.53) and reintervention (OR 4.17, 95% CI 1.92 to 20.83). CONCLUSIONS: Despite improved results of PCI with Cyphers, midterm clinical outcome of diabetic patients treated surgically is better.

Drug-eluting stents versus arterial myocardial revascularization in patients with diabetes mellitus.

OBJECTIVE: The introduction of drug-eluting stents significantly reduced restenosis and reinterventions in patients undergoing percutaneous coronary interventions. This study compares results of Cypher stenting with those of surgical arterial revascularization in patients with diabetes mellitus. METHODS: From May 2002 through May 2005, 523 consecutive diabetic patients underwent myocardial revascularization: 244 underwent percutaneous coronary interventions incorporating drug-eluting stents, and 279 were treated surgically. All single-vessel patients in the surgical group were treated with the left internal thoracic artery, and most multivessel patients were treated with 2 internal thoracic arteries. After propensity score matching, 2 groups (93 patients each) were used to compare the 2 revascularization modalities. RESULTS: The number of coronary vessels treated per patient was higher in the surgical group (2.72 vs 1.75, P < .001). Follow-up ranged between 6 and 42 months (mean, 19 months). Overall mortality (early and late) was 3.2% in the surgical group and 2.2% in the Cypher group (P = .65). Two-year angina-free survival and reintervention-free survival (Kaplan-Meier) of the surgical group were 88% and 95%, respectively, compared with 47.8% (P = .001) and 83.6% (P = .01), respectively, in the percutaneous coronary intervention group. Cox proportional hazards modeling revealed assignment to the Cypher group to be the only predictor of reintervention (odds ratio, 3.86; 95% confidence interval, 1.25-11.9). Assignment to the Cypher group (hazard ratio, 5.92; 95% confidence interval, 2.96-11.87) and insulin treatment (hazard ratio, 2.06; 95% confidence interval, 1.06-4.02) were independent predictors of angina recurrence. CONCLUSIONS: The midterm clinical outcome of diabetic patients who underwent surgical arterial revascularization is better than that of patients undergoing percutaneous coronary intervention treated with drug-eluting stents.

Comparison between multivessel stenting with drug eluting to the LAD and bilateral internal thoracic artery grafting.

BACKGROUND: Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting. METHODS: From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revascularization, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revascularization modalities. RESULTS: The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015). CONCLUSIONS: Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.

Non-invasive measurement of cardiac output by whole-body bio-impedance during dobutamine stress echocardiography: clinical implications in patients with left ventricular dysfunction and ischaemia.

OBJECTIVES: To compare non-invasive determination of cardiac index (CI) by whole body electrical bioimpedance using the NICaS apparatus and Doppler echocardiography, and the role of cardiac power index (Cpi) and total peripheral resistance index (TPRi) calculation during dobutamine stress echocardiography (DSE). SUBJECTS AND METHODS: We enrolled 60 consecutive patients undergoing DSE. Patients were prospectively divided into 3 groups: Group 1 (n = 20): normal DSE (control). Group 2 (n = 20): EF<40% without significant ischaemia. Group 3 (n = 20): patients with significant ischaemia on DSE. Measurements of CI were performed at the end of each stage of DSE by both echocardiographic left ventricular outflow track flow and the NICaS apparatus, using whole-body bio-impedance. MAP was measured simultaneously and TPRi and Cpi were calculated. RESULTS: The correlation between non-invasive CI as determined by NICaS and echocardiography was 0.81, although Echocardiographic readings of CI were higher during administration of higher doses of dobutamine. Lower EF correlated with lower Cpi, especially stress induced Cpi. Hence, patients with reduced EF (group 2) had a blunted increase in Cpi during stress. Patients with ischaemia (group 3) had a blunted increase in Cpi as well as a decrease in Cpi and increase in TPRi during the last stages of DSE. CONCLUSION: Measurement of CI by NICaS correlated well with Doppler derived CI. The calculation of Cpi and TPRi changes during dobutamine stress may provide important clinical information.

Drug-eluting stents versus bilateral internal thoracic grafting for multivessel coronary disease.

BACKGROUND: Reduction of restenosis and reinterventions was recently reported with percutaneous interventions (PCI), including drug-eluting stents (Cypher; Cordis, Miami Lakes, FL). This study compares results of multivessel Cypher stenting with those of bilateral internal thoracic artery (BITA) grafting. METHODS: From January 2002 to June 2004, 768 consecutive patients underwent multivessel myocardial revascularization; 138 by PCI including Cyphers and 630 by BITA. After matching for age, sex, ejection fraction, extent of coronary disease, and congestive heart failure, two groups (113 patients each) were used to compare the two revascularization modalities. RESULTS: Both groups were similar; however, left main and intraaortic balloon were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.87 vs 2.22, p < 0.001). Follow-up ranged between 6 and 34 months. Thirty-day mortality was 0.9% in the BITA and zero in the PCI group (p = 0.32). There were no late deaths in the BITA and three (2.7%) in the Cypher group (p = 0.08). Angina returned in 28.3% of the Cypher and 12.4% of the BITA group, p = 0.003. A Cox proportional hazard model revealed assignment to the Cypher group to be the only predictor of angina recurrence (odds ratio 2.78, 95% confidence interval 1.46-2.56). There were 16 (14.2%) reinterventions in the Cypher group compared with six (5.3%) in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA was 96% compared with 86.6% in the Cypher group (p = 0.005, log-rank test). CONCLUSIONS: Despite improved results of PCI with Cyphers, midterm clinical outcome of multivessel patients treated with BITA is still better.