Long-term outcomes of coronary artery bypass grafting patients supported preoperatively with an intra-aortic balloon pump.

OBJECTIVE: Most studies describing the outcome of coronary artery bypass grafting patients supported preoperatively with an intra-aortic balloon pump (IABP) have reported early results. The purpose of our study was to evaluate the early and long-term results. METHODS: Of 2658 isolated coronary artery bypass grafting procedures performed from 1996 to 2001, 215 were supported preoperatively with an IABP. The indications for IABP insertion were cardiogenic shock in 18 (8.4%), acute evolving myocardial infarction in 38 (17.7%), clinical instability in 84 (39.1%), and critical coronary lesions in 75 (34.9%). RESULTS: Operative mortality was 12.6%. The mortality of the cardiogenic shock patients was greater (22.2%; P=.174). Logistic regression analysis showed patient age (odds ratio, 1.057; 95% confidence interval, 1.010-1.108) and cardiopulmonary bypass (CPB) time (odds ratio, 1.020; 95% confidence interval, 1.008-1.031) were associated with increased operative mortality. An increased number of bypass grafts had a protective effect (odds ratio, 0.241; 95% confidence interval, 0.113-0.515). The actual early mortality was lower than the logistic EuroSCORE calculated mortality (12.6% vs 32.8%, P<.0001). The mean follow-up was 8±4 years. The Kaplan-Meier 10-year survival was 49%. The Cox adjusted overall (early and late) survival and major adverse cardiac events-free survival of the different IABP subgroups was similar. Cox analyses showed peripheral vascular disease, off-pump coronary artery bypass surgery, age, CPB time, female gender, and fewer bypass grafts were associated with decreased survival. CONCLUSIONS: In patients supported preoperatively with an IABP, better early and long-term results were strongly related to younger age, a shorter CPB time, and a greater number of bypass grafts. Avoiding the use of CPB (off pump) in these emergency cases is not recommended.

Hemodynamic performance and outcome of percutaneous versus surgical stentless bioprostheses for aortic stenosis with anticipated patient-prosthesis mismatch.

OBJECTIVES: We aimed to compare the performance and midterm survival of transcutaneous aortic valve replacement (TAVR) and surgically implanted stentless aortic valve replacement (SAVR) for severe aortic stenosis in patients anticipated to have patient-prosthesis mismatch (PPM). METHODS: A retrospective analysis was performed of 86 and 49 consecutive TAVR and SAVR patients with severe aortic stenosis and calculated minimal effective orifice area larger than the best projected effective orifice area. Cox hazard analyses were used to assess the effect of TAVR versus SAVR on outcome. RESULTS: The peak and mean transprosthetic gradient at discharge were lower (P < .001 for both) in the TAVR group. Mild or greater aortic regurgitation was more frequent in the TAVR group (61% vs 7%; P < .0001). At 3 months of follow-up, the mean gradient in the TAVR group was similar to that of the SAVR group but the prevalence of aortic regurgitation was still higher. The unadjusted 3-year survival rate was superior in the SAVR versus TAVR group (91.6% ± 4% vs 67.0% ± 7%; P = .01). Adjustments for both age and comorbidity resulted in loss of the difference in mortality between the 2 groups. CONCLUSIONS: In patients with anticipated PPM, TAVR offers an immediate lower incidence of PPM than SAVR but a greater prevalence of aortic regurgitation. The differences in transaortic gradients became nonsignificant 3 months postoperatively. The question of whether TAVR is a suitable substitute for SAVR in patients with anticipated PPM, in particular, those who are older and sicker, warrants additional investigation.

Long-term clinical and echocardiographic follow-up of the freestyle stentless aortic bioprosthesis: the Tel Aviv Medical Center experience.

BACKGROUND: Stentless aortic bioprostheses were designed to provide improved hemodynamic performance and potentially better survival. OBJECTIVES: To report the outcomes of patients after aortic valve replacement with the Freestyle stentless bioprosthesis at the Tel Aviv Medical Center followed for < or = 15 years. METHODS AND RESULTS: Between 1997 and 2011, 268 patients underwent primary aortic valve replacement with a Freestyle bioprosthesis, 211 (79%) of them in the sub-coronary position. Mean age, Charlson comorbidity index and Euro-score were 71.0 +/- 9.2 years, 4.2 +/- 1.5 and 10.2 +/- 11 respectively, and 156 (58%) were male. Peak and mean trans-aortic gradient decreased significantly (75.0 +/- 29.1 vs. 22.8 +/- 9.6 mmHg, P < 0.0001; and 43.4 +/- 17.2 vs. 12.1 +/- 5.4 mmHg, P < 0.0001 respectively) during 3 months of follow-up. Mean overall follow-up was 4.9 +/- 3.1 years and was complete in all patients. In-hospital mortality was 4.1% (n=11) but differed significantly between the first 100 patients operated before 2006 and the last 168 patients operated after January 2006 (8 vs. 3 patients, 8.0% vs. 1.8%, P = 0.01). Overall, 5 and 10 year survival rates were 85 +/- 2.5% and 57.2 +/- 5.7%, respectively. Five year survival was markedly improved in patients operated after January 2006 compared to those operated in the early years of the experience (92.3 +/- 2.3% vs. 76.0 +/- 4.4%, P = 0.0009). All the 21 octogenarians operated after January 2006 survived surgery, with excellent 5 year survival (85.1 +/- 7.9%). Six patients required reoperation during follow-up: structural valve deterioration in five and endocarditis in one. CONCLUSIONS: Aortic valve replacement with the Freestyle bioprosthesis provides good long-term hemodynamic and clinical outcomes, even in octogenarians. Valve calcification is the major (and rare) mode of valve deterioration leading to reoperation in these patients.

Should bilateral internal thoracic artery grafting be used in elderly patients undergoing coronary artery bypass grafting?

BACKGROUND: Although bilateral internal thoracic artery grafting is associated with improved survival, the use of this technique in the elderly is controversial because of their increased surgical risk and shorter life expectancy. The purpose of this study was to evaluate the effect of age on outcome of patients undergoing bilateral internal thoracic artery grafting. METHODS AND RESULTS: Between 1996 and 2001, 1714 consecutive patients underwent skeletonized bilateral internal thoracic artery grafting, of whom 748 were ≤65 years of age, 688 were between 65 and 75 years of age, and 278 were ≥75 years of age. Operative mortality of the 3 age groups (1.2%, 4.1%, and 5.8%, respectively) was lower than the logistic EuroSCORE predicted mortality (3.9%, 6.5%, and 9.3%, respectively; P<0.001). There were no significant differences among the groups in occurrence of sternal infection (1.3%, 2.6%, and 1.4%, respectively; P=0.171). Mean follow-up was 11.5 years. Kaplan-Meier 10-year survival for patients ≤65, 65 to 75, and >75 years of age was 85%, 65%, and 40%, respectively (P<0.001). These rates were better than the corresponding predicted Charlson Comorbidity Index survival rates (68%, 37%, and 20%, respectively; P<0.001 for all age groups), approaching survival of the sex- and age-matched general population (90%, 70%, and 41%, respectively). Age ≤65 years (hazard ratio, 0.232; 95% confidence interval, 0.188-0.288) and age 65 to 75 years (hazard ratio, 0.499; 95% confidence interval, 0.414-0.602) were independent predictors of improved survival (Cox model). CONCLUSIONS: Bilateral internal thoracic artery grafting should be considered in patients >65 years of age because of the significant survival benefit obtained with this surgical technique with no additional risk of sternal wound infection related to age.

Expandable external support device to improve Saphenous Vein Graft Patency after CABG.

OBJECTIVES: Low patency rates of saphenous vein grafts remain a major predicament in surgical revascularization. We examined a novel expandable external support device designed to mitigate causative factors for early and late graft failure. METHODS: For this study, fourteen adult sheep underwent cardiac revascularization using two vein grafts for each; one to the LAD and the other to the obtuse marginal artery. One graft was supported with the device while the other served as a control. Target vessel was alternated between consecutive cases. The animals underwent immediate and late angiography and were then sacrificed for histopathologic evaluation. RESULTS: Of the fourteen animals studied, three died peri-operatively (unrelated to device implanted), and ten survived the follow-up period. Among surviving animals, three grafts were thrombosed and one was occluded, all in the control group (p = 0.043). Quantitative angiographic evaluation revealed no difference between groups in immediate level of graft uniformity, with a coefficient-of-variance (CV%) of 7.39 in control versus 5.07 in the supported grafts, p = 0.082. At 12 weeks, there was a significant non-uniformity in the control grafts versus the supported grafts (CV = 22.12 versus 3.01, p < 0.002). In histopathologic evaluation, mean intimal area of the supported grafts was significantly lower than in the control grafts (11.2 mm^2 versus 23.1 mm^2 p < 0.02). CONCLUSIONS: The expandable SVG external support system was found to be efficacious in reducing SVG's non-uniform dilatation and neointimal formation in an animal model early after CABG. This novel technology may have the potential to improve SVG patency rates after surgical myocardial revascularization.

Long-term outcomes of patients with diabetes receiving bilateral internal thoracic artery grafts.

OBJECTIVES: Bilateral internal thoracic artery (BITA) grafting in patients with diabetes are controversial because of increased risk of sternal infection. On the other hand, patients with diabetes may benefit from BITA grafts because of the associated improved survival. This study evaluated factors affecting early and long-term outcomes for better selection of patients with diabetes for BITA grafts. METHODS: Between 1996 and 2006, 69 patients with insulin-treated diabetes and 732 with orally treated diabetes received isolated skeletonized BITA grafts. Of these patients, 338 were younger than 65 years, 322 were between 65 and 74 years old, and 141 were 75 years or older. RESULTS: Operative mortality was lower than logistic EuroSCORE-calculated mortality (2.9% vs 7%, P < .001). Predictors of increased mortality were critical preoperative state (P < .001) and age (P = .008). There were 30 cases of sternal infection (3.7%); predictors were reoperation (P < .001), peripheral vascular disease (P = .009), obesity (P = .012), chronic lung disease (P = .009), and female sex (P = .020). Mean follow-up was 8.4 ± 4 years. Kaplan-Meier 10-year survivals were 75%, 59%, and 39% for patients younger than 65, 65 to 74, and at least 75 years, respectively (P < .001). They were better than corresponding Charlson comorbidity index-predicted survivals (36%, 10%, and 3%, respectively; P < .001). Predictors of decreased survival were age (P < .001), congestive heart failure (P < .001), and peripheral vascular disease (P < .001). Off-pump surgery was independently associated with better long-term survival (P = .003). CONCLUSIONS: BITA grafts are safe in patients with diabetes. Favorable short- and long-term outcomes outweigh increased sternal infection risk.

Video-assisted thymectomy with contralateral surveillance camera: a means to minimize the risk of contralateral phrenic nerve injury.

OBJECTIVE: Thymectomy for thymoma has traditionally been performed through midsternotomy that provides excellent exposure for a complete and safe resection. Minimally invasive alternatives have not been extensively evaluated for this disease process because data regarding the long-term oncologic effectiveness of these techniques remain to be established. Furthermore, video-assisted surgery as a unilateral approach may compromise the extension of the resection and could cause irreversible damage to the phrenic nerve of the opposite side. We evaluated the clinical feasibility and safety of a bilateral concomitant video-assisted approach with contralateral surveillance camera in patients undergoing thymectomy for thymoma. METHODS: Four patients (3 females, 1 male) with thymoma causing myasthenia gravis (MG) were operated thoracoscopically at our institute under general anesthesia with double-lumen endotracheal intubation. The patients were placed in a supine position, and a 5-mm 30-degree lens thoracoscope was introduced into the left pleural space. Two other 10-mm working channels were applied. En bloc thymectomy was then performed, including mediastinal and pericardial fat pads, other tissue, and pleura from the level of the thoracic inlet to the diaphragm. A second 5-mm thoracoscope was inserted into the right hemithorax, and it was kept inside during the entire procedure to allow lateral surveillance of the extension and safety of the resection. Carbon dioxide insufflation and valved ports were used. RESULTS: The duration of the operation was 90 ± 72 minutes. Complete resection was achieved in all patients without any nerve injury. There were no perioperative adverse events. Gradual remission from extremity and ocular weakness was achieved after recovery. CONCLUSIONS: The ultimate surgical goal of thymectomy is to completely remove the gland and anterior mediastinal tissue without nerve injury. Bilateral concomitant video-assisted thoracic thymectomy with a contralateral surveillance camera was found feasible and safe. Given the capability of our technique to perform a complete and extensive thymectomy associated with less invasiveness and beneficial effects, there seems to be a role for minimally invasive thymectomy in the treatment of thymoma.

Surgical myocardial revascularization versus percutaneous coronary intervention with drug-eluting stents in octogenarian patients.

OBJECTIVE: Our goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization. METHODS: We retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006. RESULTS: Of the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis. CONCLUSION: Octogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.

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.

Open heart reoperations after coronary artery bypass grafting: the role of preoperative imaging with multidetector computed tomography.

BACKGROUND: Injury to patent grafts or cardiac chambers may occur during reoperation after coronary artery bypass grafting. Preoperative spatial localization of bypass grafts with computed tomography may improve the safety of these procedures. OBJECTIVES: To characterize patients who undergo CT before repeat operations after previous coronary artery bypass grafting, and evaluate its benefit in terms of surgical outcome. METHODS: We compared 28 patients who underwent cardiac gated CT angiography before reoperation (CT group) to 45 redo patients who were not evaluated with CT (no-CT group). RESULTS: The two groups were similar in most preoperative and operative characteristics. The CT group, however, included more patients with patent saphenous vein grafts and fewer with emergency operations, acute myocardial infarction and need for intraaortic balloon pump support. During mid-sternotomy, there was no injury to grafts in the CT group, while there were two patent grafts and three right ventricular injuries in the no-CT group. There was no significant difference in perioperative mortality (3.6% vs. 8.9%). The overall complication rate in the CT group was 21.4% compared to 42.2% in the no-CT group (P = 0.07). The only independent predictors of postoperative complications were diabetes mellitus, preoperative stroke and preoperative acute MI. CONCLUSIONS: The patency and proximity of patent grafts to the sternum are well demonstrated by multidetector CT and may provide the surgeon with an important roadmap to avoid potential graft injury. A statistical trend towards reduced complications rate was demonstrated among patients who underwent CT angiography before their repeat cardiac operation. Larger series are required to demonstrate a statistically validated complication-free survival benefit of preoperative CT before repeat cardiac surgery.

Loss of systemic endothelial function post-PCI.

Loss of endothelial function (LEF) post-PCI may contribute to both acute and long-term complications. A protective effect of BNP on endothelium was suggested previously. Flow-mediated vasodilation (FMD) of the brachial artery, as well as plasma levels of endothelin, BNP, Pro BNP and corin were measured before and following routine PCI. 49 patients with normal baseline endothelial function were recruited. 30 patients developed LEF and were randomized to i.v. nesiritide (the commercially available recombinant form of human BNP) or saline infusion for 3 h. Patients who developed LEF post-PCI had reduced baseline plasma corin levels and their BNP/ProBNP ratio was reduced after the procedure. Nesiritide infusion significantly improved FMD both immediately (Nesiritide versus saline: 2.87+/-0.78% versus 0.51+/-0.25%, P=0.007) and 24 h after the treatment (2.52+/-0.69% versus 0.72+/-0.32%, P=0.025). The elevated plasma ET-1 was reduced by Nesiritide (0.38+/-0.11 fmol/ml 24 h post-PCI versus 0.16+/-0.02 fmol/ml 24 h post BNP, P=0.047), but remained unchanged in saline group (0.39+/-0.21 fmol/ml versus 0.42+/-0.23 fmol/ml, P=0.749). Systemic LEF post-PCI is a frequent event. It may be related to impaired cleavage of ProBNP to BNP. Short-term i.v. nesiritide improves systemic LEF post-PCI.

Cardioplegic ischemia or reperfusion: which is a main trigger for tumor necrosis factor production?

BACKGROUND: Tumor necrosis factor alpha (TNF-alpha) is a key cytokine in the pathogenesis of ischemia-reperfusion injury (I/R) that also possesses negative inotropic and direct cardiotoxic effects. We investigated whether myocardial ischemia and/or reperfusion is the trigger for TNF-alpha synthesis and whether TNF-alpha release is time dependent. METHODS: Isolated rat hearts undergoing 30 min of coronary perfusion with modified Krebs-Henseleit solution followed by cardioplegic arrest for 60 min of global cardioplegic normothermic ischemia (GCI) and 30 min of reperfusion using a modified Langendorff model. Myocardial TNF-mRNA expression and TNF-alpha protein levels in effluent from the coronary sinus were measured at baseline and then after 15, 30, and 60 min of GCI and after 10 and 30 min of reperfusion. RESULTS: GCI induced myocardial TNF-alpha mRNA expression and elevation protein TNF-alpha levels in a time-dependent manner after 30 min of ischemia from 78+/-17 pg/ml to 915+/-287 pg/ml after 60 min (p<0.0015). Reperfusion did not cause time-dependent increase of TNF-alpha synthesis and release but was accompanied by progressive decrease of left ventricular (LV) function. There was a correlation between TNF-alpha protein levels and depression of LV function immediately after GCI but not with TNF-alpha protein levels at 30 min of reperfusion. CONCLUSION: This study demonstrated that myocardial ischemia rather than reperfusion is the main trigger for time-dependent TNF-alpha synthesis. Depression of LV function during reperfusion correlated significantly only with TNF-alpha levels at the end of GCI.

Angiographic evidence for reduced graft patency due to competitive flow in composite arterial T-grafts.

OBJECTIVE: Composite arterial grafting causes splitting of internal thoracic artery flow to various myocardial regions. The amount of flow supplying each region depends on the severity of coronary stenosis. Competitive flow in the native coronary artery can cause occlusion or severe narrowing of the internal thoracic artery supplying this coronary vessel. METHODS: Two hundred three consecutive postoperative coronary angiographies of 163 patients who underwent bilateral internal thoracic artery grafting using the composite-T-graft technique were analyzed. Angiographies were done in symptomatic patients or in patients with positive thallium scan between 2 and 102 months after surgery and were compared with preoperative angiograms. RESULTS: In 123 patients, both internal thoracic arteries were patent. The remaining 40 control patients had at least 1 nonfunctioning internal thoracic artery. A lower stenosis rate in the left anterior and circumflex arteries was associated with higher occlusion rate of the left internal thoracic artery (P < .005) and the right internal thoracic artery (P < .005), respectively. In 19 angiograms of 18 patients, graft failure could be related to competitive flow. This included 7 patients with disease of the left main artery and a preoperative stenosis degree ranging between 50% and 80%, 8 patients with moderate stenosis (70% or less) of the circumflex artery, and 3 with moderate stenosis of the left anterior descending artery. Three of the patients with disease of the left main artery, 2 of the patients with competitive flow in the circumflex artery, and all patients in the subgroup with left anterior descending arterial disease underwent percutaneous or surgical reintervention. CONCLUSION: The composite T-graft technique of bilateral internal thoracic artery grafting should be reserved for patients with severe (70% or more) left anterior descending and circumflex arterial stenosis.

The potential advantage of "no-touch" aortic technique in off-pump complete arterial revascularization.

OBJECTIVES: Off-pump coronary artery bypass grafting (OPCAB) and complete arterial revascularization without proximal anastomosis to the aorta may decrease neurological events after open-heart surgery. Few reports exist regarding the combination of OPCAB and complete arterial revascularization exploring the theoretical advantage of avoiding manipulation of the aorta. We review our results in 110 patients who underwent multiple grafts off-pump complete arterial revascularization. METHODS: 110 patients underwent multiple grafts OPCAB complete arterial revascularization, and were compared to 216 patients who underwent traditional multiple grafts on pump CABG. Preoperative renal failure was 12.7% (n=14) as compared to 5.1%, (n=11, p=0.01) in the control group and 33.6% (n=37) of the patients were 75 years or older as compared to 19.0% (n=41, p=0.003) in the control group. RESULTS: The mean number of grafts per patient undergoing multiple OPCAB complete arterial revascularization was 2.3, as compared to 3.11 in the control group (p<0.001). The mortality rate was 2.73% as compared to 1.85% (NS) in the control group. The incidence of CVA was 0% as compared to 2.31% (p=0.17) in the control group. CONCLUSIONS: Complete arterial OPCAB revascularization without manipulation of the aorta in high-risk patients can be performed with short-term similar results to conventional CABG and very low neurological complications.

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.

Higher levels of serum cytokines and myocardial tissue markers during on-pump versus off-pump coronary artery bypass surgery.

Increased Troponin I levels and pro-inflammatory cytokines have been reported in most patients undergoing cardiac surgery, ascribed to the type and extent of surgery, reperfusion injury, and the method of myocardial protection. We investigated their levels in patients undergoing on-pump (CCAB) or off-pump (OPCAB) coronary artery bypass surgery and whether these correlated with the extent of myocardial injury. One hundred twenty patients were prospectively randomized to undergo OPCAB (n = 60) or CCAB (n = 60). Hemodynamic and respiratory data, as well as serum CK-MB mass fraction, Troponin I, and interleukin (IL)-6, IL-8, and IL-10 levels, were collected perioperatively. Demographic, hemodynamic, and respiratory parameters were similar between the two groups. Troponin I was significantly lower in the OPCAB than in the CCAB group, either at the end of ischemia, end of surgery, 6-hour and 24-hour postoperatively (4 +/- 3, 5 +/- 3, 7 +/- 5, and 8 +/- 3 microg/L, vs. 19 +/- 18, 27 +/- 19, 28 +/- 13.5, and 33 +/- 8.5 microg/L, respectively, p < 0.05). Serum cytokine levels in the OPCAB patients were lower compared to the CCAB group at the end of surgery (32 +/- 35, 25 +/- 30, and 40 +/- 30 pg/ml for IL-6, IL-8, and IL-10 vs. 230 +/- 30, 140 +/- 70, and 125 +/- 50 pg/ml, respectively, p < 0.05). Plasma IL-6 levels correlated with the Troponin I levels at the end of surgery in both groups (r = 0.45, p = 0.01). Thus, OPCAB surgery is associated with reduced levels of Troponin I and activation of cytokines, compared to those in the CCAB group. High levels of these factors could correlate with myocardial damage during coronary artery bypass surgery. This finding warrants further laboratory and clinical confirmation in the future.