Assessment of Myocardial Viability in Ischemic Cardiomyopathy With Reduced Left Ventricular Function Undergoing Coronary Artery Bypass Grafting.

BACKGROUND: We aim to provide a comprehensive review of the current state of knowledge of myocardial viability assessment in patients undergoing coronary artery bypass grafting (CABG), with a focus on the clinical markers of viability for each imaging modality. We also compare mortality between patients with viable myocardium and those without viability who undergo CABG. METHODS: A systematic database search with meta-analysis was conducted of comparative original articles (both observations and randomized controlled studies) of patients undergoing CABG with either viable or nonviable myocardium, in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to 2022. Imaging modalities included were dobutamine stress echocardiography (DSE), cardiac magnetic resonance (CMR), single-photon emission computed tomography (SPECT), and positron emission tomography (PET). RESULTS: A total of 17 studies incorporating a total of 2317 patients were included. Across all imaging modalities, the relative risk of death post-CABG was reduced in patients with versus without viability (random-effects model: odds ratio: 0.42; 95% confidence interval: 0.29-0.61; p < 0.001). Imaging for myocardial viability has significant clinical implications as it can affect the accuracy of the diagnosis, guide treatment decisions, and predict patient outcomes. Generally, based on local availability and expertise, either SPECT or DSE should be considered as the first step in evaluating viability, while PET or CMR would provide further evaluation of transmurality, perfusion metabolism, and extent of scar tissue. CONCLUSION: The assessment of myocardial viability is an essential component of preoperative evaluation in patients with ischemic heart disease undergoing surgical revascularization. Careful patient selection and individualized assessment of viability remain paramount.

Empagliflozin to prevent post-operative atrial fibrillation in patients undergoing coronary artery bypass graft surgery: Rationale and design of the EMPOAF trial.

BACKGROUND: Postoperative atrial fibrillation (POAF) is one of the most common types of acute AF and can complicate the treatment course of approximately one third of patients undergoing cardiac surgery. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are among the newest antidiabetic drugs which can be therapeutic options for preventing POAF by different mechanisms. METHODS: Empagliflozin to Prevent POAF (EMPOAF) is an interventional, investigator-initiated, double-blind, placebo-controlled, multicenter, randomized controlled trial which will be conducted in two referral teaching cardiology hospitals in Tehran. Four-hundred ninety-two adult patients who are scheduled for elective isolated coronary artery bypass graft (CABG) surgery will be randomly assigned to one of the groups of intervention (empagliflozin 10 mg daily) or placebo starting at least 3 days before surgery until discharge. Key exclusion criteria are a history of diabetes mellitus, AF, ketoacidosis, or recurrent urinary tract infections along with severe renal or hepatic impairment, unstable hemodynamics, and patients receiving SGLT2 inhibitors for another indication. The primary outcome will be the incidence of POAF. Key secondary endpoints will be the composite rate of life-threatening arrhythmias, postoperative acute kidney injury, hospitalization length, in-hospital mortality, stroke, and systemic embolization. Key safety endpoints will be the rate of life-threatening and/or genitourinary tract infections, hypoglycemia, and ketoacidosis. CONCLUSIONS: EMPOAF will prospectively evaluate whether empagliflozin 10 mg daily can reduce the rate of POAF in patients undergoing elective CABG. Enrolment into this study has started by November 2023 and is expected to be ended before the end of 2025.

An updated meta-analysis of optimal medical therapy with or without invasive therapy in patients with stable coronary artery disease.

BACKGROUND: The efficacy of optimal medical therapy (OMT) with or without revascularization therapy in patients with stable coronary artery disease (SCAD) remains controversial. We performed a meta-analysis of randomized controlled trials (RCTs) that compared OMT with or without revascularization therapy for SCAD patients. METHODS: Studies were searched in PubMed, EMBASE, and the Cochrane Central Register of Clinical Trials from January 1, 2005, to December 30, 2023. The main efficacy outcome was a composite of all-cause death, myocadiac infarction, revascularization, and cerebrovascular accident. Results were pooled using random effects model and fixed effects model and are presented as odd ratios (ORs) with 95% confidence intervals (CI). RESULTS: Ten studies involving 12,790 participants were included. The arm of OMT with revascularization compared with OMT alone was associated with decreased risks for MACCE (OR 0.55 [95% CI 0.38-0.80], I²=93%, P = 0.002), CV death (OR 0.84 [95% CI 0.73-0.97], I²=36%, P = 0.02), revascularization (OR 0.32 [95% CI 0.20-0.50], I²=92%, P < 0.001), and MI (OR 0.85 [95% CI 0.76-0.96], I²=45%, P = 0.007). While there was no significant difference between OMT with revascularization and OMT alone in the odds of all-cause death (OR 0.94 [95% CI 0.84-1.05], I²=0%, P = 0.30). CONCLUSIONS: The current updated meta-analysis of 10 RCTs shows that in patients with SCAD, OMT with revascularization would reduce the risk for MACCE, cardiovascular death, and MI. However, the invasive strategy does not decrease the risks for all-cause mortality when comparing with OMT alone.

Association of blood glucose change with postoperative delirium after coronary artery bypass grafting in patients with diabetes mellitus: a study of the MIMIC-IV database.

Aim: Study results on blood glucose and the risk of delirium in patients receiving cardiac surgery are inconsistent, and there is also a gap in how to manage blood glucose after coronary artery bypass grafting (CABG). This study focused on patients with diabetes mellitus (DM) undergoing CABG and explored the associations of different blood glucose-related indexes and blood glucose change trajectory with postoperative delirium (POD), with the aim of providing some information for the management of blood glucose in this population. Methods: Data of patients with DM undergoing CABG were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database in this retrospective cohort study. The blood glucose-related indexes included baseline blood glucose, mean blood glucose (MBG), mean absolute glucose (MAG), mean amplitude of glycemic excursions (MAGE), glycemic lability index (GLI), and largest amplitude of glycemic excursions (LAGE). The MBG trajectory was classified using the latent growth mixture modeling (LGMM) method. Univariate and multivariate logistic regression analyses were utilized to screen covariates and explore the associations of blood glucose-related indexes and MBG trajectory with POD. These relationships were also assessed in subgroups of age, gender, race, estimated glomerular filtration rate (eGFR), international normalized ratio (INR), sepsis, mechanical ventilation use, and vasopressor use. In addition, the potential interaction effect between blood glucose and hepatorenal function on POD was investigated. The evaluation indexes were odds ratios (ORs), relative excess risk due to interaction (RERI), attributable proportion of interaction (AP), and 95% confidence intervals (CIs). Results: Among the eligible 1,951 patients, 180 had POD. After adjusting for covariates, higher levels of MBG (OR = 3.703, 95% CI: 1.743-7.870), MAG >0.77 mmol/L/h (OR = 1.754, 95% CI: 1.235-2.490), and GLI >2.6 (mmol/L)2/h/per se (OR = 1.458, 95% CI: 1.033-2.058) were associated with higher odds of POD. The positive associations of MBG, MAG, and GLI with POD were observed in patients aged <65 years old, male patients, White patients, those with eGFR <60 and INR <1.5, patients with sepsis, and those who received mechanical ventilation and vasopressors (all p < 0.05). Patients with class 3 (OR = 3.465, 95% CI: 1.122-10.696) and class 4 (OR = 3.864, 95% CI: 2.083-7.170) MBG trajectory seemed to have higher odds of POD, compared to those with a class 1 MBG trajectory. Moreover, MAG (RERI = 0.71, 95% CI: 0.14-1.27, AP = 0.71, 95% CI: 0.12-1.19) and GLI (RERI = 0.78, 95% CI: 0.19-1.39, AP = 0.69, 95% CI: 0.16-1.12) both had a potential synergistic effect with INR on POD. Conclusion: Focusing on levels of MBG, MAG, GLI, and MBG trajectory may be more beneficial to assess the potential risk of POD than the blood glucose level upon ICU admission in patients with DM undergoing CABG.

Comparison of Intercostal and Subxiphoid Left Pleural Drain After Coronary Artery Bypass Grafting (CABG) Surgery: A Systematic Review and Meta-Analysis.

Coronary artery bypass grafting (CABG), a prevalent surgery for coronary artery disease, often involves left internal mammary artery harvesting, necessitating left pleural drain insertion. This can lead to pain, discomfort, and respiratory issues. This analysis compares outcomes between subxiphoid and intercostal left pleural drain insertion. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, this systematic review and meta-analysis involved searches in MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected based on primary outcomes (postoperative ventilator support duration and pain score) and secondary outcomes (percentage predicted vital capacity (VC), forced VC (FVC), and partial pressure of oxygen (PO2) in arterial blood gas (ABG) analysis). Statistical analysis used a random effect model, pooled risk ratio, and I2 heterogeneity. Nine studies (seven randomized and two nonrandomized) with 412 patients met the inclusion criteria. Pooled analysis indicated reduced ventilation time and postoperative pain with the subxiphoid drain compared to the intercostal drain. Spirometry parameters showed improved VC, FVC, and PO2 in ABG analysis. This meta-analysis suggests that subxiphoid pleural drain insertion in CABG patients is associated with shorter ventilation times, lower pain scores, and improved pulmonary function compared to intercostal drain placement.

Sex-specific troponin and creatine kinase thresholds after coronary bypass surgery.

BACKGROUND: The impact of sex-differences on the release of cardiac biomarkers after coronary artery bypass grafting (CABG) remains unknown. The aim of our study was to (a) investigate the impact of sex-differences in cardiac biomarker release after CABG and (b) determine sex-specific thresholds for high-sensitivity troponin (hs-cTn) and creatine kinase-MB (CK-MB) associated with 30-day major adverse cardiovascular event (MACE) and mortality. METHODS: A consecutive cohort of 3687 patients (female: n= 643 (17.4%); male: 3044 (82.6%) undergoing CABG from 2008-2021 in two tertiary university centers with serial postoperative cTn and CK-MB measurement was analyzed. The composite primary outcome was MACE at 30 days. Secondary endpoints were 30-day mortality and five-year mortality and MACE. Sex-specific thresholds for cTn and CK-MB were determined. RESULTS: Lower levels of cTn were found in women after CABG (69.18 vs. 77.57 xURL; p<0.001). Optimal threshold value for cTn was calculated at 94.36 times the URL for female and 206.07 times the URL for male patients to predict 30-day MACE. Female patients missed by a general threshold had increased risk for MACE or death within 30 days (cTn: MACE: OR 3.78 CI: 1.03-13.08; p=0.035; death: OR 4.98; CI: 1.20.-20.61; p=0.027; CK-MB: MACE: OR 10.04; CI: 2.07-48.75; p<0.001; death: OR 13.59; CI: 2.66-69.47; p=0.002). CONCLUSIONS: We provide evidence for sex-specific differences in the outcome and biomarker release after CABG. Sex-specific cut-offs are necessary for the diagnosis of perioperative myocardial injury to improve outcomes of women after CABG.

Impact of preoperative intra-aortic balloon pump on outcomes in coronary artery bypass grafting for unprotected left-main coronary artery disease.

Background: Preoperative intra-aortic balloon pump (IABP) before coronary artery bypass grafting (CABG) could improve operative outcomes by augmenting the diastolic coronary blood flow. Data on preoperative IABP use in patients with left-main coronary artery (LMCA) disease are limited. This study aimed to characterize patients who received preoperative IABP before CABG for LMCA and evaluate its effect on postoperative outcomes. Methods: This multicenter retrospective cohort study that included consecutive 914 patients who underwent CABG for unprotected LMCA disease from January 2015 to December 2019 in 14 tertiary referral centers. Patients were grouped according to the preoperative IABP insertion into patients with IABP (n=101) and without IABP (n=813). Propensity score matching adjusting for preoperative variables, with 1:1 match and a caliber of 0.03 identified 80 matched pairs. The primary outcomes used in propensity score matching were cardiac mortality and major adverse cardiac and cerebrovascular events (MACCE). Results: IABP was commonly inserted in patients with previous myocardial infarction (MI), chronic kidney disease, peripheral arterial disease, and congestive heart failure. IABP patients had higher EuroSCORE [ES >8%: 95 (11.86%) vs. 40 (39.60%), P<0.001] and SYNTAX {29 [interquartile range (IQR) 25-35] vs. 33 (IQR 26-36); P=0.02} scores. Preoperative cardiogenic shock and arrhythmia were more prevalent in patients with IABP, while acute coronary syndrome was more prevalent in patients without IABP. After matching, there was no difference in vasoactive inotropic score between groups [3.5 (IQR 1-7.5) vs. 6 (IQR 1-13.5), P=0.06], and lactate levels were nonsignificantly higher in patients with IABP [2.4 (IQR 1.4-4.5) vs. 3.1 (IQR 1.05-7.75), P=0.05]. There were no differences between groups in acute kidney injury [20 (25%) vs. 26 (32.5%), P=0.34], cerebrovascular accidents [3 (3.75%) vs. 4 (5%), P>0.99], heart failure [5 (6.25%) vs. 7 (8.75%), P=0.75], MI [7 (8.75%) vs. 8 (10%), P>0.99], major adverse cardiac and cerebrovascular events [10 (12.5%) vs. 17 (21.25%), P=0.21], and cardiac mortality [6 (7.50%) vs. 14 (17.50%), P=0.09]. Patients who received IABP had longer ventilation times [8.5 (IQR 6-23) vs. 15.5 (IQR 5-50.5) h, P=0.03] and intensive care unit (ICU) stays [3 (IQR 2-5) vs. 4 (IQR 2-7.5) days, P=0.01]. Conclusions: Preoperative IABP in patients with LMCA might not be associated with reduced cardiac mortality or hospital complications. IABP could increase the duration of mechanical ventilation and ICU stay, and its use should be individualized for each patient.

Cardiac computed tomography-derived coronary artery volume to myocardial mass in patients with severe coronary artery disease.

BACKGROUND: Coronary artery lumen volume (V) to myocardial mass (M) ratio (V/M) can show the mismatch between epicardial coronary arteries and the underlying myocardium. METHODS: The V, M and V/M were obtained from the coronary computed tomography angiography (CCTA) of patients in the FAST-TRACK CABG study, the first-in-human trial of coronary artery bypass grafting (CABG) guided solely by CCTA and fractional flow reserve derived from CCTA (FFRCT) in patients with complex coronary artery disease (CAD). The correlations between V/M ratios and baseline characteristics were determined and compared with those from the ADVANCE registry, an unselected cohort of historical controls with chronic CAD. RESULTS: The V/M ratio was obtained in 106 of the 114 pre-CABG CCTAs. Mean age was 65.6 years and 87% of them were male. The anatomical SYNTAX score from CCTA was significantly higher than the functional SYNTAX score derived using FFRCT [43.1 (15.2) vs 41.1 (16.5), p â€‹< â€‹0.001]. Mean V, M, and V/M were 2204 â€‹mm3, 137 â€‹g, and 16.5 â€‹mm3/g, respectively. There were weak negative correlations between V and anatomical and functional SYNTAX scores (Pearson's r â€‹= â€‹-0.26 and -0.34). V and V/M had a strong correlation (r â€‹= â€‹0.82). The V/M ratio in the current study was significantly lower than that in the ADVANCE registry (median 16.1 vs. 24.8 [1st quartile 20.1]). CONCLUSION: Systematically smaller V/M ratios were found in this population with severe CAD requiring CABG compared to an unselected cohort with chronic CAD. The V/M ratio could provide additional non-invasive assessment of CAD especially when combined with FFRCT.

Pre-operative anaemia-does it influence post-operative outcomes after isolated coronary artery bypass grafting?

Introduction: Preoperative anaemia is prevalent in a number of patients undergoing coronary artery bypass grafting. Studies provide conflicting results due to several reasons including variation in the threshold of haematocrit used to define anaemia. We aimed to assess the independent effect of preoperative anaemia on outcomes in patients undergoing off pump coronary artery bypass grafting (OPCAB). Methods: In this retrospective study, patients with a hemoglobin level less than 11g/dl (haematocrit <33%) were considered to have moderate-to-severe anaemia as per the recommendations of the World Health Organization. Association between haematocrit <33% and mortality as well as adverse post-operative outcomes was assessed. Multivariable logistic regression (MLR) was carried out to assess the independent effect of haematocrit<33% on 30-day mortality and other outcomes. Results: The study included 4957 consecutive patients undergoing isolated OPCAB surgery between 2015 and 2020. Out of 4957, 635 (12.8%) had haematocrit <33% and 4322 (81.2%) had haematocrit ≥33%. Patients with haematocrit < 33% had a 30-day mortality of 13 (2%) compared to 38 (0.9%) in patients without anaemia and had a greater requirement for blood transfusion (p<0.0001). It was also associated with an increased incidence of renal failure (p<0.0001), tracheostomy (p=.0.012) and risk of re-intubation (p=0.006). On multiple linear regression (MLR), haematocrit < 33% was not an independent predictor of 30-day mortality odds ratio (OR) 1.47, 95% confidence interval (CI) 0.745-2.917; p=0.26. It was however an important independent risk factor for blood transfusion (OR 1.80, 95% CI 1.29-2.50, p<0.001) and renal failure (OR 3.06, 95% CI 1.338-7.012, p=0.008). The receiver operating characteristic (ROC)-area under the curve (AUC) was 0.63 suggesting moderate discriminatory value of haematocrit < 33% for 30-day mortality. Conclusion: Haematocrit < 33% is an important risk factor for adverse outcomes following isolated, primary, elective OPCAB. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-024-01746-1.

Predominant Use of Bilateral Internal Mammary Arteries in Off-Pump Coronary Artery Bypass Surgery.

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has been shown to provide long-term clinical benefits over single internal mammary artery (SIMA) grafting. Nevertheless, the perceived technical complexity of the procedure and concerns about potential early postoperative complications, particularly, sternal wound infections, have led to a utilization rate of BIMA grafting of less than 5% in the United States. We systematically compared early (30-day) postoperative outcomes between the BIMA and SIMA cohorts in patients with similar baseline characteristics. A retrospective single-center study was conducted on matched patients, using stabilized inverse probability treatment weighting to mitigate bias between the 2 study cohorts. From 546 patients who underwent off-pump CABG initially identified, we examined 328 B.M. and 213 SIMA grafts from the matched samples. Despite using 60.4% BIMA grafts, we observed similar rates of 30-day overall and cardiac mortality between the BIMA and SIMA groups. The rates of 30-day postoperative complications, including superficial and deep sternal wound infections, stroke, sepsis, acute kidney injury, and cardiac arrest, were similar between the 2 groups. The rates of 30-day overall and cardiac readmission were also similar. In addition, the median length of hospital stays, intensive care unit stay, and ventilation times were similar between the 2 groups. In conclusion, our data suggest that a BIMA utilization rate of 60.4% in off-pump CABG procedures is achievable without causing any significant increment in early postoperative complications, including deep sternal wound infection.

New approach to the mitral valve through the left anterior minithoracotomy for combined valve and coronary surgical procedures.

Objective: We have developed a new technique for accessing the mitral valve through the left anterior minithoracotomy. This approach has been used in patients requiring both mitral valve surgery and coronary artery bypass grafting. Methods: From October 2020 to September 2022, we performed 24 concomitant mitral valve procedures and coronary artery bypass grafting through the left anterior minithoracotomy. The average age of the patients was 65.5 years, and the mean left ventricular ejection fraction was 44.5%. Computed tomography angiography was routinely performed preoperatively. The surgical technique included a left anterior minithoracotomy in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic crossclamping using a transthoracic clamp through the additional port in the left second intercostal space, the administration of cold blood cardioplegia, a right atrial transseptal approach to the mitral valve, and special surgical exposure maneuvers. These maneuvers were designed to displace the heart into the left pleural space by pulling the inferior vena cava tape and the ascending aorta tape to the left. Conventional mitral valve surgical techniques were used. The mitral valve repair or replacement was performed after the distal anastomoses to the right and circumflex coronary system were completed. Subsequently, after the mitral valve procedure, coronary anastomosis to the left anterior descending artery was performed. Results: The mitral valve was effectively visualized, and a planned procedure was successfully completed in all patients. There was no need for conversion to a sternotomy. mitral valve repair was performed in 22 patients (91.7%), and mitral valve replacement was performed in 2 patients (8.3%). Conventional surgical instruments were used in 10 cases (41%), and long-shafted instruments were used in 14 cases (59%). A knot-pusher was required in 9 cases (37.5%). A computed tomography distance from the skin level to the mitral valve posterior annulus of more than 14 cm was identified as a technical difficulty marker, necessitating the use of long-shafted instruments. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomoses was 2.54 ± 0.7 (1; 4). Total operation time was 341 ± 41 (285; 420) minutes, cardiopulmonary bypass time was 231 ± 38 (172; 316) minutes, and the crossclamp time was 127 ± 23 (80; 169) minutes. Patients had a mean intensive care unit stay of 1.87 ± 0.69 (1; 4) days, and their total hospital stay averaged 6.54 ± 1.86 (4; 10) days. There were no reoperations due to bleeding, no occurrences of strokes, and no other major complications. There were no instances of hospital mortality or mortality within 30 days after the procedures. Conclusions: Mitral valve repair or replacement through the left anterior thoracotomy and transseptal approach is a valuable and effective technique that can be used for concomitant procedures performed through a single minithoracotomy incision in selected patients.

Synergistic Effect of Transmyocardial Revascularization and Platelet-Rich Plasma on Improving Cardiac Function After Coronary Artery Bypass Grafting.

Background Coronary artery disease (CAD) is a global health burden, contributing to mortality and morbidity. A proportion of patients with CAD suffer from diffuse CAD, where conventional revascularization techniques such as percutaneous coronary intervention and coronary artery bypass grafting (CABG) may be insufficient to adequately restore myocardial perfusion. Transmyocardial revascularization (TMR) uses a laser to create microscopic channels in the myocardium, inducing inflammation, angiogenesis, and neovascularization to improve perfusion to ischemic regions. Platelet-rich plasma (PRP) is an autologous concentrate of platelets that contains a myriad of growth factors and bioactive proteins, which have been shown to promote tissue regeneration and wound healing. The combination of TMR and PRP therapies has been proposed to synergistically enhance myocardial revascularization and functional recovery in patients with advanced CAD undergoing surgical revascularization. Methods This study evaluated the efficacy of combining TMR and PRP with CABG in improving cardiac function in diffuse CAD patients. Fifty-two patients were randomized to CABG alone (n = 16), CABG+TMR (n = 17), CABG+PRP (n = 10), and CABG+TMR+PRP (n = 9). TMR was performed using a holmium:YAG laser to create 10 channels in the inferolateral left ventricular wall. PRP was prepared from autologous whole blood and injected into the myocardium adjacent to the TMR channels. Cardiac function was assessed using speckle-tracking echocardiography preoperatively, postoperatively, and at one-year follow-up. Adverse events, including post-operative atrial fibrillation, acute kidney injury, and readmissions, were also recorded. Statistical analyses were performed to compare outcomes between the treatment groups. Results The CABG+TMR+PRP group showed significantly improved global longitudinal strain (GLS) at one year compared to CABG alone (mean GLS -15.96 vs -12.09, p = 0.02). Post-operative left ventricular ejection fraction trended higher in the TMR+PRP group (57.78%) vs other groups, but not significantly. Post-operative atrial fibrillation was higher in the TMR+PRP group (67% vs 25%, p = 0.04), potentially reflecting increased inflammation. No significant differences were observed in other adverse events. Conclusions The results of this study suggest a synergistic benefit of combining TMR and PRP therapies as an adjunct to CABG in patients with diffuse CAD. The significant improvement in GLS at one year in the TMR+PRP group compared to CABG alone indicates enhanced myocardial remodeling and functional recovery, which may translate to improved long-term outcomes. The higher incidence of postoperative atrial fibrillation in the TMR+PRP group warrants further investigation but may reflect the heightened inflammatory response necessary for angiogenesis and tissue regeneration. Prospective, randomized controlled trials with larger sample sizes and longer follow-up periods are needed to validate these findings and optimize treatment protocols. Nonetheless, concomitant TMR+PRP therapy represents a promising approach to augmenting myocardial revascularization and recovery in patients with advanced CAD undergoing surgical revascularization.

Intraoperative Methadone Use Is Associated With Reduced Postoperative Pain and More Rapid Opioid Weaning After Coronary Artery Bypass Grafting.

OBJECTIVE: To explore the association between intraoperative methadone use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG) surgery. DESIGN: Retrospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: Patients undergoing isolated CABG over a 5-year period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, comorbidities, and intraoperative anesthetic medications were recorded. Primary study outcomes were average and maximum pain scores and morphine milligram equivalent consumption on the first 2 postoperative days (PODs). Linear mixed-effects regression models were used to examine the effect of intraoperative methadone use on study outcomes. Among 1,338 patients, 78.6% received intraoperative methadone (0.2 mg/kg). Patients who did not receive methadone had higher average (estimated [Est], 0.48; 95% confidence interval [CI], 0.22-0.73; p < 0.001) and maximum postoperative (Est, 0.49; 95% CI, 0.23-0.75; p < 0.001) pain scores over PODs 0 to 2. For postoperative opioid consumption, there was a significant intraoperative methadone use-time interaction effect on postoperative opioid use (odds ratio [OR], 2.21; 95% CI, 1.74-2.80; p < 0.001). Across PODs 0 to 2, patients who received intraoperative methadone had a faster decline in postoperative opioid use than those who did not receive intraoperative methadone. Patients who did not receive intraoperative methadone were extubated slightly faster (OR, 0.82; 95% CI, 0.72-0.93; p < 0.01). CONCLUSIONS: Our data suggest that the use of intraoperative methadone is safe, reduces postoperative pain, and expedites weaning from postoperative opioids after CABG surgery.

Short-Term Clinical Results of Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Procedure.

Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of the isolated left anterior descending (LAD) artery or as a multi-vessel (MV) procedure for the diagonal branch (RD) or the left circumflex coronary artery (LCX) region. Methods: From 2021 to 2022, 91 patients underwent MIDCAB or multi-vessel MIDCAB procedures in our heart center. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending artery via the left minithoracotomy approach in all patients. Results: Of the patients, a total of 86.8% were male. Eighty percent of the patients had two- or three-vessel coronary artery disease. The mean age was 65.1 ± 10.1 years. The mean operation time was 2.6 ± 0.8 h. The 30-day mortality was 0. The mean required packed red blood cells (pRBC) was 0.4 ± 1.2 unit. The mean intensive care unit stay (ICU) was 1.5 ± 1.6 days. The mean follow-up time was 1.5 ± 0.5 years. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2.2%. The Kaplan-Meier survival rate was 98.8% at 1 and 2 years. Conclusions: The postoperative complication rate of our MIDCAB cohort is low, and the short-term survival is favorable. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible.

Evaluation of the effectiveness of curcumin and piperine co-supplementation on inflammatory factors, cardiac biomarkers, atrial fibrillation, and clinical outcomes after coronary artery bypass graft surgery.

BACKGROUND: Coronary artery bypass graft (CABG) is one of the preferred treatments for patients with heart problems, especially in individuals with other comorbidities and when multiple arteries are narrowed. This study aimed to assess the effects of administrating curcumin-piperine on patients who underwent CABG surgery. METHODS: This was a randomized, double-blind, placebo-controlled clinical trial, in which 80 eligible adults who underwent CABG surgery, were randomized into 4 groups. Patients received 3 tablets daily for 5 days after the surgery, which contained curcumin-piperine (each tablet contained 500 mg curcumin +5 mg piperine) or a placebo (each tablet contained 505 mg maltodextrin). Group A received 3 placebo tablets, group B received 2 placebos and one curcumin-piperine tablet, group C received 1 placebo and 2 curcumin-piperine tablets, and group D received 3 curcumin-piperine tablets. Before and after the intervention, C-reactive protein (CRP), total antioxidant capacity (TAC), cardiometabolic factors, clinical outcomes, and 28-day mortality were evaluated. RESULTS: Between-group analysis showed that CRP significantly decreased (P = 0.028), and TAC significantly increased (P = 0.033) after the intervention (Post hoc analysis showed that for CRP, the difference was between group B and D, and for TAC was between group C and D). Between-group analysis also showed that creatine kinase mono-phosphate (CK-MB) marginally reduced (P = 0.077); however, changes for troponin I (P = 0.692), lactate dehydrogenase (LDH) (P = 0.668), ejection fraction (P = 0.340), and arterial fibrillation (P = 0.99) were not significant. Blood urea nitrogen (P = 0.820) and serum creatinine (P = 0.244) did not show notable changes between groups. CONCLUSION: Supplementation with curcumin-piperine had a promising effect on serum CRP and TAC. It also had a favorable impact on CK-MB among patients who underwent CABG surgery. TRIAL REGISTRATION: IRCT20201129049534N4, available on https://en.irct.ir/trial/56930.

Perfusion Measures and Outcomes (PERForm) registry: First annual report.

BACKGROUND: The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology. METHODS: This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported. RESULTS: A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%). CONCLUSION: Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain.

Bangladeshi Atherosclerosis Biobank and Hub: The BANGABANDHU Study.

Background: Genetic factors contribute significantly to the risk of ischaemic heart disease (IHD), which is the leading cause of mortality in Bangladesh. The BANGABANDHU (Bangladeshi Atherosclerosis Biobank AND Hub) study will allow a hypothesis-free genome-wide association study (GWAS) to identify genetic risk factors associated with ischaemic heart disease patients undergoing coronary artery bypass graft (CABG) surgery in Bangladesh. Methods:  This is a multi-centre population-based case-control study aimed to evaluate 1500 (Fifteen Hundred) adult (≥18 years of age) people divided into 2 study groups: Case/Proband (750 IHD patients undergoing CABG surgery) and Control (750 healthy people). Spouses or family members are preferred as healthy control subjects due to their shared geographic location and similar environmental exposure. Results: This will be the first largest DNA repository of CABG patients in Bangladesh, and identifying novel gene loci among CABG patients might help to discover novel therapeutic targets for Bangladeshi IHD patients. Further, identifying and comparing novel gene loci among CABG patients with other ancestry might help devise national guidelines for treating coronary artery disease. Conclusion: Promising current study results will encourage Bangladeshi researchers and pharmaceutical companies to conduct further studies into the genetic basis of Bangladeshi complex coronary artery disease, which might identify novel genes for therapeutic targets for Bangladeshi patients and strengthen the healthcare standards in Bangladesh.

Incidental Finding of Transthyretin Cardiac Amyloidosis During Coronary Artery Bypass Grafting.

Transthyretin cardiac amyloidosis (ATTR-CA) is a condition characterized by extracellular deposition of misfolded transthyretin proteins in the myocardium and has been historically difficult to diagnose due to diverse clinical manifestations and nonspecific, variable electrocardiogram (ECG) and echocardiogram findings. Advancements in noninvasive cardiac imaging have led to significant increases in diagnoses of ATTR-CA. Once thought to be a rare condition, there is growing evidence to suggest that ATTR-CA is more prevalent than previously understood, prompting the need for early diagnosis and intervention. We outline the case of a 78-year-old male who presented to the emergency department with chest discomfort, shortness of breath, dizziness, and diaphoresis. He was found to have severe coronary artery disease (CAD) and intermittent complete heart block. Cardiac dysfunction was unable to be resolved by percutaneous coronary intervention (PCI) and thus the patient was referred for coronary artery bypass grafting (CABG). Intraoperatively, the patient's heart was found to be abnormally thickened and fibrosed. Biopsy of the cardiac tissue and evaluation using technetium-99m pyrophosphate scintigraphy, single-photon emission computed tomography, and liquid chromatography-tandem mass spectrometry revealed ATTR-CA. There is a need for fast and low-cost screening tools to allow for early identification of the disease. Diagnostic clues for cardiac amyloidosis include the presence of carpal tunnel syndrome, lumbar spinal stenosis, atrial fibrillation, treatment-resistant heart failure with preserved ejection fraction, and a thickened left ventricular wall. Given the presence of these red flag symptoms, clinicians should have a heightened index of suspicion for ATTR cardiac amyloidosis in elderly patients even when presenting in acute settings.

The Effects of Osteopathic Manipulative Treatment (OMT) on Postoperative Length of Stay: A Meta-Analysis.

Osteopathic manipulative treatment (OMT) is a therapy used by osteopathic physicians in various medical settings. Postoperatively, OMT can be utilized to optimize the body's function and recovery. This meta-analysis examines the efficacy of OMT in reducing the length of postoperative hospital stays. Given the significant implications of prolonged hospitalization for both patients and healthcare resources, research strategies to safely shorten this period are crucial. This meta-analysis examined five select studies that measured the length of hospital stay in postoperative patients who received OMT compared with postoperative patients who did not. A random effects model was applied in our statistical analysis to account for heterogeneity due to variations in surgical procedures, hospitals, and patient populations. Individually, three studies reported statistically significant reductions in hospital stay for OMT patients, while two did not. This meta-analysis, comprising five studies and 519 patients, found a mean difference of -2.37 days in favor of OMT; however, this finding did not reach a statistical significance (P = 0.06). The substantial heterogeneity observed (heterogeneity tau2 = 6.75, chi2 = 34.6, df = 4, P < 0.00001, I2 = 88%) suggests that clinical dissimilarities among the five studies may have resulted in our inconclusive findings. While OMT shows promise in postoperative care, further research with standardized protocols and more homogenous patient populations is needed to assess its true impact.