Internal thoracic artery graft failure and recurrence of symptoms following single-vessel coronary artery bypass graft surgery.

OBJECTIVES: Coronary events and disease recurrence following coronary artery bypass (CABG) surgery could derive from either failure in the internal thoracic artery (ITA) graft, failure in other conduits or progressive disease in the coronaries. We aim to estimate the contribution of ITA graft failure to the recurrence of symptoms after CABG surgery. METHODS: Within the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry, we identified patients who had coronary artery bypass grafting from 1997 to 2020 with a single-vessel ITA graft bypass. Deaths, postoperative incidence of coronary angiography and the presence of a failed graft at the time of the angiography were recorded. RESULTS: The study population consisted of 1939 patients with a mean follow-up time (SD) of 17.2 (5.6) years. The cumulative incidence (95% CI) at 20 years for a first clinically-driven postoperative angiography was 38.6% (36.2-41.1). A failed ITA graft was reported in 16.4% of the angiographies. CONCLUSIONS: A substantial part of recurrent symptoms of coronary artery disease do not seem to be related to ITA failure. Disease progression in the native coronary vessels may instead be the main driver of symptom recurrence.

Symptomatic late saphenous vein graft failure in coronary artery bypass surgery.

OBJECTIVES: Coronary artery bypass grafting for advanced coronary artery disease is a well-established procedure with excellent long-term results. The issue of saphenous vein graft (SVG) performance and its relation to clinical symptoms and thereby the potential for improvement by using superior grafts are still not fully understood. We aim to estimate the contribution of late SVG failure to the long-term outcome. METHODS: A study population operated between 1997 and 2020, with an internal thoracic artery with a single distal anastomosis and 1, 2 or 3 distal SVG anastomoses, was isolated from the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry. Data regarding postoperative clinically driven coronary angiography and status of bypass grafts were collected. RESULTS: The study population consisted of 44 951 patients. Clinically driven angiography occurred in 10.1% (9.5-10.8), 7.9% (7.6-8.3) and 7.1% (6.7-7.5), respectively, of patients within 3 years and 23.6% (22.6-24.5), 20.0% (19.5-20.6) and 17.5% (16.9-18.2), respectively, of patients within 10 years after surgery. Excluding the first 3 postoperative years, no failed SVGs were found in >75%, 60% and 45%, respectively, of cases when an angiography was performed in the first 10 years after surgery. CONCLUSIONS: The results suggest that the risk of symptomatic graft failure due to vein graft disease during the first 10 years after surgery is in the range of 1-2% for every grafted coronary vessel and provide an estimate for the upper limit of the improvements in results that could be achieved by replacing SVGs with superior grafts.

Commando procedure in a patient with double-valve endocarditis after transcatheter aortic valve implantation.

The indication for transcatheter aortic valve implantation (TAVI) is continuously expanding with a simultaneous increase in number of TAVI associated prosthetic valve endocarditis (TAVI-PVE). Evidence for management of TAVI-PVE is lacking but the need for surgical management of complex TAVI-PVE is expected to increase. The Commando procedure, a technically challenging surgery for treatment of complex endocarditis, has never been described in a patient with TAVI-PVE. An 80-year-old female with TAVI-PVE, native mitral valve endocarditis and an abscess in the intervalvular fibrous body was admitted to our clinic. She successfully underwent the Commando procedure with implantation of biological mitral and aortic valve prostheses and reconstruction of the intervalvular fibrous body. We demonstrate that the Commando procedure is a feasible surgical alternative in patients with TAVI-PVE and that it can be considered in patients with high surgical risk.

No-touch saphenous vein grafts in coronary artery surgery (SWEDEGRAFT): Rationale and design of a multicenter, prospective, registry-based randomized clinical trial.

The SWEDEGRAFT study (ClinicalTrials.gov Identifier: NCT03501303) tests the hypothesis that saphenous vein grafts (SVGs) harvested with the "no-touch" technique improves patency of coronary artery bypass grafts compared with the conventional open skeletonized technique. This article describes the rationale and design of the randomized trial and baseline characteristics of the population enrolled during the first 9 months of enrollment. The SWEDEGRAFT study is a prospective, binational multicenter, open-label, registry-based trial in patients undergoing first isolated nonemergent coronary artery bypass grafting (CABG), randomized 1:1 to no-touch or conventional open skeletonized vein harvesting technique, with a planned enrollment of 900 patients. The primary end point is the proportion of patients with graft failure defined as SVGs occluded or stenosed >50% on coronary computed tomography angiography at 2 years after CABG, earlier clinically driven coronary angiography demonstrating an occluded or stenosed >50% vein graft, or death within 2 years. High-quality health registries and coronary computed tomography angiography are used to assess the primary end point. The secondary end points include wound healing in the vein graft sites and the composite outcome of major adverse cardiac events during the first 2 years based on registry data. Demographics of the first 200 patients enrolled in the trial and other CABG patients operated in Sweden during the same time period are comparable when the exclusion criteria are taken into consideration. RCT# NCT03501303.

Long-term outcome after coronary endarterectomy adjunct to coronary artery bypass grafting.

OBJECTIVES: Coronary endarterectomy (CE) in coronary artery bypass grafting (CABG) is occasionally required to achieve revascularization in diffusely diseased vessels. Its beneficial effect has been questioned because of an increased risk of perioperative mortality and morbidity; however, its influence on the long-term outcome remains uncertain. The purpose of the study was to evaluate the impact of adjunct CE on the incidence of a first postoperative angiogram and the need for repeat intervention and on late deaths after CABG. METHODS: Two propensity-matched cohorts of patients undergoing CABG with CE (537 patients) and without adjunct CE (no CE) (537 patients) in Sweden over the period 2000-2015 were used to compare long-term outcomes. Mortality rates, postoperative incidence of coronary angiography and the need for reintervention were determined using the Kaplan-Meier method. RESULTS: The mean follow-up time (standard deviation) was 9.9 (4.6) years for CE and 10.0 (4.6) years for no CE. Overall survival, clinically driven angiography and coronary reintervention during follow-up (95% confidence interval) at 10 years were 65.8% (60.8-70.3), 28.2% (23.8-34.3) and 11.6% (8.7-15.3), respectively, for CE and 70.7% (65.9-74.9), 21.7% (17.8-26.3) and 12.7% (9.7-16.6), respectively, for no CE. There was a significant difference in the use of postoperative angiography between the 2 groups (P = 0.02). CONCLUSIONS: Although patients are subjected to an increased risk of repeat angiography, CE seems to be an acceptable treatment alternative in patients who have diffuse coronary artery disease that cannot be treated effectively by CABG alone.

Re-exploration for bleeding associated with increased incidence of the need for reintervention after coronary artery bypass graft surgery.

OBJECTIVES: Re-exploration for bleeding after cardiac surgery increases the risk of other severe postoperative complications and early mortality. Patients re-explored for bleeding after coronary artery bypass grafting are potentially subject to threats to graft patency. Our goal was to assess the effects of re-exploration for bleeding regarding the incidence of coronary angiographies, the need for coronary reintervention and mortality during long-term follow-up. METHODS: Within the SWEDEHEART registry, all isolated coronary artery bypass operations with a single internal mammary artery and saphenous vein graft in patients aged 40-80 between the years 2005 and 2015 were identified. Incidences of coronary angiography and the subsequent need for coronary reintervention were recorded, and multivariable adjusted hazard ratios (HRs) were calculated. RESULTS: The study cohort consisted of 27 957 patients, and the mean follow-up time was 6.5 ± 3.1 years. The incidence of re-exploration for bleeding was 3.8% (n = 1071). The cumulative incidence [95% confidence interval (CI)] of a clinically occurring coronary angiography within 1 year after surgery was 7.8% (6.3-9.7) in re-explored and 4.8% (4.6-5.1) in non-re-explored patients, and the adjusted HR was 1.64 (1.31-2.06), (P < 0.001). The cumulative incidence of the need for coronary reintervention within 1 year (95% CI) was 4.9% (3.7-6.4) in re-explored and 2.6% (2.4-2.8) in non-re-explored patients, and the adjusted HR was 1.91 (1.43-2.56). No difference in incidence or hazard ratio was observed beyond the first year. Mortality rate was increased within but not beyond 90 days after surgery. CONCLUSIONS: Re-exploration for bleeding is associated with an increased risk for the need of repeat coronary reintervention during the first year after coronary artery bypass surgery.

Long-term clinical outcomes after coronary artery bypass grafting with pedicled saphenous vein grafts.

BACKGROUND: Coronary artery bypass grafting (CABG) using saphenous vein grafts (SVG) is vitiated by poor long-term patency of the vein grafts. Pedicled SVG harvested with the "no-touch" (NT) technique have demonstrated improved patency and could confer better outcomes. We aim to compare long-term results after CABG where NT or conventional technique was used for vein graft harvesting in a hypothesis-generating registry-based study. METHODS: Two propensity score matched cohorts (1349 patients) undergoing CABG with veins harvested with NT (NTT) or conventional (CT) technique in Sweden over the period 2005-2015 were used to compare long-term outcomes. Mortality, postoperative incidence of coronary angiography and need for reintervention was recorded and multivariable hazard ratios adjusted for risk factors were calculated. RESULTS: The mean follow-up time (SD) was 6.8 (3.3) years for NTT and 6.6 (3.2) years for CT. The adjusted hazard ratios for death, first angiography and need for reintervention for NTT patients were (95% CI) 0.97 (0.80-1.19), 0.76 (0.63-0.93), 0.91 (0.78-1.05), and 0.91 (0.71-1.17), respectively. Failed grafts were found in 43.2% of NTT patients and 53.6% of CT patients at angiography. CONCLUSIONS: In this study NT grafting was associated with a lower risk for repeat angiography, however no difference could be observed for mortality and need for reintervention. The earlier reported improvements in patency of NT veins could possibly be reflected in an improved clinical outcome during the first 10 years after surgery.

Graft failure and recurrence of symptoms after coronary artery bypass grafting.

OBJECTIVES: Saphenous vein grafts (SVGs) most often used in coronary artery bypass grafting (CABG) are subject to graft disease and have poor long-term patency, however the clinical implication of this is not completely known. We aim to assess the influence of graft failure on the postoperative recurrence of coronary artery disease (CAD) symptoms in relation to the contribution from progression of atherosclerosis in the native coronary vessels. DESIGN: Within the SWEDEHEART registry we identified 46,663 CABG cases between 2001 and 2015 with patient age 40-80 years where single internal mammary artery (IMA) anastomosis (IMA), single IMA with one (1SVG) or multiple SVG anastomoses (2+ SVG) had been performed. Clinical characteristics as well as mortality and postoperative incidence of coronary angiography were recorded and multivariable adjusted hazard ratios were calculated. Indications for the angiographies and occurrence of graft failure were also registered. RESULTS: The adjusted hazard ratio for death was similar for the three groups. The adjusted hazard ratio for being submitted to angiography as compared to 2+ SVG was (95% CI) 1.24 (1.06-1.46) for IMA and 1.21 (1.15-1.28) for 1SVG. Failed grafts were found at the first postoperative angiography with preceding CAD symptoms in 21.4% of patients in the IMA group, 41.6% in the 1SVG group and 61.1% in the 2+ SVG group. CONCLUSIONS: A substantial amount of angiographies occur in patients without any graft failure and a large part of postoperative recurrence of CAD symptoms and are likely attributed to IMA failure or progression of atherosclerosis in the native coronary arteries.

Proteomic Biomarkers for Incident Aortic Stenosis Requiring Valvular Replacement.

BACKGROUND: Aortic valve stenosis (AS) is the most common indication for cardiac valve surgery; untreated AS is linked to high mortality. The etiological background of AS is unknown. Previous human studies were typically based on case-control studies. Biomarkers identified in prospective studies could lead to novel mechanistic insights. METHODS: Within a large population survey with blood samples obtained at baseline, 334 patients were identified who later underwent surgery for AS (median age [interquartile range], 59.9 [10.4] years at survey and 68.3 [12.7] at surgery; 48% female). For each case, 2 matched referents were allocated. Plasma was analyzed with the multiplex proximity extension assay for screening of 92 cardiovascular candidate proteins. Conditional logistic regression models were used to assess associations between each protein and AS, with correction for multiple testing. A separate set of 106 additional cases with 212 matched referents was used in a validation study. RESULTS: Six proteins (growth differentiation factor 15, galectin-4, von Willebrand factor, interleukin 17 receptor A, transferrin receptor protein 1, and proprotein convertase subtilisin/kexin type 9) were associated with case status in the discovery cohort; odds ratios ranged from 1.25 to 1.37 per SD increase in the protein signal. Adjusting the multivariable models for classical cardiovascular risk factors at baseline yielded similar results. Subanalyses of case-referent triplets (n=133) who showed no visible coronary artery disease at the time of surgery in the index person supported associations between AS and growth differentiation factor 15 (odds ratio, 1.40; 95% confidence interval, 1.10-1.78) and galectin-4 (odds ratio, 1.27; 95% confidence interval, 1.02-1.59), but these associations were attenuated after excluding individuals who donated blood samples within 5 years before surgery. In triplets (n=201), which included index individuals with concurrent coronary artery disease at the time of surgery, all 6 proteins were robustly associated with case status in all sensitivity analyses. In the validation study, the association of all but 1 (interleukin 17 receptor A) of these proteins were replicated in patients with AS with concurrent coronary artery disease but not in patients with AS without coronary artery disease. CONCLUSIONS: We provide evidence that 5 proteins were altered years before AS surgery and that the associations seem to be driven by concurrent atherosclerotic disease.

No improvements in long-term outcome after coronary artery bypass grafting with arterial grafts as a second conduit: a Swedish nationwide registry study.

OBJECTIVES: Coronary artery bypass grafting using saphenous vein grafts (SVGs) in addition to the left internal mammary artery (IMA) graft is vitiated by poor long-term patency of the vein grafts. Hypothetically, the increased use of arterial grafts could confer even better outcomes. Our goal was to evaluate results after coronary artery bypass grafting in Sweden, where arterial grafts were used as a second conduit. METHODS: Within the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry, we identified patients who had coronary artery bypass grafting from 2001 to 2015 using the IMA and the SVG, the radial artery (RA) or the additional IMA [bilateral IMA (BIMA)] as a second conduit. Deaths, postoperative incidence of coronary angiography and need for reintervention were recorded, and multivariable adjusted hazard ratios were calculated for different types of grafts. RESULTS: The study population comprised 46 343 cases of IMA + SVG, 1036 cases of IMA + RA and 862 cases of BIMA. The mean follow-up time (SD) was 9.3 (4.2) years for IMA + SVG, 10.7 (4.1) years for IMA + RA grafts and 5.5 (5.0) years for the BIMA graft. The adjusted hazard ratio for death was (95% confidence interval) 1.01 (0.89-1.14) for IMA + RA and 0.87 (0.72-1.06) for BIMA grafts compared with IMA + SVG. The adjusted hazard ratio for the first angiographic examination was (95% confidence interval) 0.96 (0.84-1.10) for IMA + RA and 1.13 (0.95-1.35) for BIMA grafts. The adjusted hazard ratio for the need for reintervention was (95% confidence interval) 0.91 (0.75-1.09) for IMA + RA and 1.26 (1.00-1.58) for BIMA grafts. CONCLUSIONS: Patients who had arterial grafts as second conduits did not demonstrate a better outcome in any of the studied end-points. Radial artery grafts seem to be preferable to BIMA grafts as an alternative to an SVG.

Death in low-risk cardiac surgery: Stockholm experience.

In cardiac surgery, perioperative death in low-risk patients is uncommon, but does occur. Reports on the incidence, cause and circumstances of death in this population are rare. We analyzed the early mortality and cause of death in patients with an additive EuroSCORE≤3 who underwent cardiac surgery between 2001 and August 2009 in Stockholm. We also investigated if death could be considered preventable, and in that case, if it was due to a technical or a system error. Among 3924 low-risk patients, 15 died within 30 days of surgery, and early mortality was 0.38%. Cause of death was mostly cardiac related (11 of 15). Death occurred after hospital discharge in three patients, and was classified as non-preventable in 13 patients. In the remaining two patients, the circumstances leading to death were categorized as due to a system error. A systematic and structured analysis of the circumstances resulting in death in low-risk patients, in addition to traditional morbidity and mortality conferences, have the potential to identify problems and offer improvements in the quality of care.