SUVmean ratios of liver/muscle and lung/muscle from 13N-NH3 PET perfusion outperformed traditional myocardial viability parameters in predicting survival after CABG.

PURPOSE: Myocardial viability evaluation in predicting survival after coronary artery bypass graft (CABG) remains debatable. Thus, this study aimed to investigate the role of 13N-NH3/18F-FDG PET myocardial viability scan in predicting treatment outcomes and survival. METHODS: 90 patients with CABG and pre-surgical PET-based myocardial viability scan were retrospectively reviewed. Perfusion-metabolism features, myocardium motion parameters, and patient characteristics were recorded. Additionally, the SUVmean of blood pool, lung, liver, spleen, and muscle were measured and the SUVmean ratios were calculated. Factors associated with treatment outcomes and survival were analyzed by Logistic and Cox regressions. Nomogram models were subsequently established to predict ejection fraction (EF) improvement and survival outcomes. RESULTS: The mean EF of these 90 patients was 38.1 ± 9.5% and 46.0 ± 9.2% before and after CABG surgery, and 35 patients (38.9%) achieved EF improvement ≥ 10%. EF measurements by PET and echocardiogram showed a reasonable linear correlation (R = 0.752). Sex, pre-surgical EF, mismatch of the left ventricle, total perfusion deficit (TPD), and peak ejection rate (PER) were independent predictive factors of EF improvements. Surgery waiting time, valve damage, and SUVmean ratio of Liver/Muscle were independently predictive of event-free survival (EFS), while valve damage, together with SUVmean ratio of either Liver/Muscle or Lung/Muscle, were independently predictive of overall survival (OS). CONCLUSION: Although traditional cardiac parameters from PET-based myocardial viability can effectively predict EF improvements after CABG, SUVmean ratios of liver/muscle and lung/muscle from 13N-NH3 PET perfusion outperformed these parameters in predicting survival.

Off-pump CABG surgery in left main coronary artery disease: a single-center prospective registry.

Background and objective: The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Patients with left main multi-vessel coronary artery disease (LM CAD) have concerns regarding incomplete revascularization and reduced survival with off-pump (OPCAB) when compared with on-pump (ONCAB) coronary bypass surgery. To evaluate outcomes among high-risk LM CAD patients undergoing OPCAB, we performed a registry-based prospective study. Methods: We performed 4868 coronary artery bypass graft (CABG) surgeries from Jan 2013 to Jun 2019 with 4662 (95.8%) OPCAB. In OPCAB cohort, we had 1323 patients (28.4%) with significant LM (> 50%) triple vessel CAD. Data regarding clinical features, extent of CAD, operative details, in-hospital outcomes, and 3-year follow-up were obtained. Descriptive statistics are reported. Results: The study cohort (n = 1323) was aged 63 ± 9 years with men 88.4%. Tobacco use was in 328 (24.8%), diabetes 598 (45.2%), previous myocardial infarction 463 (35.0%), previous coronary intervention 40 (3.0%), and congestive heart failure in 54 (4.1%). All patients had LM (100.0%) with triple vessel disease in 99.4% (LAD, left anterior descending 100.0%; LCX, left circumflex 99.4%; RCA, right coronary artery 78.7%). Vessels bypassed/patient were 2.7 ± 0.4 with 3.2 ± 0.7 total grafts and 2.1 ± 0.8 venous grafts. In total, 1278 (96.5%) patients received left internal mammary artery (LIMA), 63(4.7%) bilateral internal mammary artery (BIMA), and 74 (5.6%) radial artery grafts. There was no patient with conversion from OPCAB to ONCAB. In-hospital major adverse cardiovascular events (MACE: all-cause deaths, myocardial infarction, and stroke) were in 21 (1.6%). At 3-year follow-up (n = 1041), MACE rates were in 84 (8.1%) and cardiovascular deaths in 28 (2.7%). Conclusions: This study shows that off-pump CABG surgery is safe in patients with LM CAD. There is low in-hospital mortality and MACE and 3-year outcomes are similar to the published data of LM CAD patients who undergo on-pump CABG. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01526-3.

Novel technique of left atrial appendage occlusion-a pilot study.

A clot in the left atrial appendage (LAA) is an important cause of cardio-embolic stroke. Concomitant occlusion of the LAA during cardiac surgery is found to have reduced postoperative stroke. A study was designed to observe the results of LAA occlusion in 17 patients undergoing coronary artery bypass graft surgery (CABG) and aortic valve replacement (AVR). The LAA was occluded epicardially with a SIRONIX 60-mm linear noncutting stapler (Healthium Medtech Pvt limited, Peenya, Bengaluru). The effectiveness of occlusion was confirmed by trans-esophageal echocardiography and at 2 years of follow-up with trans-thoracic echocardiography. There was no re-canalization of the LAA, and the patients remained in sinus rhythm. Concomitant LAA occlusion with a linear stapler during cardiac surgery is a safe, feasible, and reproducible option.

Additional improvement in regional myocardial ischemia after intracardiac injection of bone marrow cells during CABG surgery.

Background: Post-procedure residual ischemia is associated with worse prognosis in patients with coronary artery diasease (CAD). Objective: We evaluated whether autologous bone marrow-derived cells (BMC) contribute to additional reduction in regional stress-induced myocardial ischemia (SIMI) in patients undergoing incomplete coronary artery bypass graft surgery (CABG). Methods: In a double-blind, randomized, placebo-controlled trial, we enrolled 143 patients (82% men, 58 ± 11 years) with stable CAD and not candidates for complete CABG. They received 100 million BMC (n = 77) or placebo (n = 66) injected into ischemic non-revascularized segments during CABG. The primary outcome was improvement on SIMI quantified as the area at risk in injected segments assessed by cardiovascular magnetic resonance (CMR) 1, 6, and 12 months after CABG. Results: The reduction in global SIMI after CABG was comparable (p = 0.491) in both groups indicating sustained beneficial effects of the surgical procedure over 12 month period. In contrast, we observed additional improvement in regional SIMI in BMC treated group (p = 0.047). Baseline regional SIMI values were comparable [18.5 (16.2-21.0) vs. 18.5 (16.5-20.7)] and reached the lowest values at 1 month [9.74 (8.25; 11.49) vs. 12.69 (10.84; 14.85)] for BMC and placebo groups, respectively. The ischemia's improvement from baseline represented a 50% difference in regional SIMI in favor of the BMC transplanted group at 30 days. We found no differences in clinical and LVEF% between groups during the 12 month follow-up period. The 1 month rate of major adverse cerebral and cardiovascular events (MACCE) (p = 0.34) and all-cause mortality (p = 0.08) did not differ between groups 1 month post intervention. Conclusion: We provided evidence that BMC leads to additional reduction in regional SIMI in chronic ischemic patients when injected in segments not subjected to direct surgical revascularization. This adjuvant therapy deserves further assessment in patients with advanced CAD especially in those with microcirculation dysfunction. Clinical trial registration: https://clinicaltrials.gov/, identifier NCT01727063.

Effect of recombinant human brain natriuretic peptide on acute kidney injury after coronary artery bypass grafting: a retrospective comparative cohort study.

Background: Acute kidney injury (AKI) is a common complication of coronary artery bypass grafting (CABG) that results in worse prognosis. Studies have shown that recombinant human brain natriuretic peptide (rh-BNP) reduces renal injury. However, its treatment effects for AKI in patients underwent cardiac surgery are unclear. This study sought to explore the efficacy of rh-BNP in patients with AKI after bypass surgery. Methods: This study included patients with AKI diagnosed within 4 days after CABG during the period January 2016 to December 2020. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The clinical characteristics and outcomes were collected. Patients were divided into BNP and non-BNP groups according to whether rh-BNP was injected intravenously after the operation. Multivariable logistic regression was adjusted the confounding effects between clinical characteristics and rh-BNP. Propensity score matching (PSM) was used to perform a sensitivity analysis. Results: A total of 395 patients, including 56 and 339 patients in the BNP and non-BNP groups, respectively, were included in this study. The decreasing trend of postoperative serum creatinine levels (P<0.001) and postoperative urine volume (P=0.001) within 4 days of surgery were independent associated with rh-BNP. From PSM, 175 patients, including 44 and 131 patients in the BNP and non-BNP groups, respectively, were included in this study. The decreasing trend of postoperative serum creatinine levels in the BNP group was significantly stronger than that in the non-BNP group (0.04±0.28 vs. -0.16±0.36, P=0.001). The postoperative urine volume within 4 days of surgery of the BNP group was higher than that of the non-BNP group (11.3±2.8 vs. 9.11±2.66, P<0.001). The cumulative dosage of diuretics after the procedure did not differ between the BNP and non-BNP groups {60 [40, 80] vs. 60 [40, 120], P=0.852}. Conclusions: Rh-BNP can reduce creatinine levels and increases postoperative urine volume to improve renal function in patients.

Prophylactic levosimendan in patients with low ejection fraction undergoing coronary artery bypass grafting: A pooled analysis of two multicentre randomised controlled trials.

OBJECTIVES: To assess the effect of preoperative levosimendan on mortality at day 90 in patients with left ventricular ejection fraction (LVEF) ≤ 40%, and to investigate a possible differential effect between patients undergoing isolated coronary artery bypass grafting (CABG) versus CABG combined with valve replacement surgery. DESIGN: Pooled analysis of two multicentre randomised controlled trials (RCT) investigating prophylactic levosimendan versus placebo prior to CABG surgery on mortality at day 90 in patients with LVEF ≤ 40%. A meta-analysis of all RCT investigating the same issue was also conducted. RESULTS: A cohort of 1084 patients (809 isolated CABG, and 275 combined surgery) resulted from the merging of LEVO-CTS and LICORN databases. Seventy-two patients were dead at day 90. The mortality at day 90 was not different between levosimendan and placebo (Hazard Ratio (HR): 0.73, 95% CI: 0.41-1.28, p = 0.27). However, there was a significant interaction between the type of surgery and the study drug (p = 0.004). We observed a decrease in mortality at day 90 in the isolated CABG subgroup (HR: 0.39, 95% CI: 0.19-0.82, p = 0.013), but not in the combined surgery subgroup (HR: 1.73, 95% CI: 0.77-3.92, p = 0.19). The meta-analysis of 6 RCT involving 1441 patients confirmed the differential effect on mortality at day 30 between the 2 subgroups. CONCLUSIONS: Preoperative levosimendan did not reduce mortality in a mixed surgical population with LV dysfunction. However, the subgroup of patients undergoing isolated CABG had a reduction in mortality at day 90, whereas there was no significant effect in combined surgery patients. This finding requires confirmation with a specific prospective trial.

Vitamin C May Improve Left Ventricular Ejection Fraction: A Meta-Analysis.

Background: Vitamin C deprivation can lead to fatigue, dyspnea, oedema and chest pain, which are also symptoms of heart failure (HF). In animal studies vitamin C has improved contractility and mechanical efficiency of the heart. Compared with healthy people, patients with HF have lower vitamin C levels, which are not explained by differences in dietary intake levels, and more severe HF seems to be associated with lower plasma vitamin C levels. This meta-analysis looks at the effect of vitamin C on left ventricular ejection fraction (LVEF). Methods: We searched for trials reporting the effects of vitamin C on LVEF. We assessed the quality of the trials, and pooled selected trials using the inverse variance, fixed effect options. We used meta-regression to examine the association between the effect of vitamin C on LVEF level and the baseline LVEF level. Results: We identified 15 trials, three of which were excluded from our meta-analysis. In six cardiac trials with 246 patients, vitamin C increased LVEF on average by 12.0% (95% CI 8.1-15.9%; P < 0.001). In six non-cardiac trials including 177 participants, vitamin C increased LVEF on average by 5.3% (95% CI 2.0-8.5%; P = 0.001). In meta-regression analysis we found that the effect of vitamin C was larger in trials with the lowest baseline LVEF levels with P = 0.001 for the test of slope. The meta-regression line crossed the null effect level at a baseline LVEF level close to 70%, with progressively greater benefit from vitamin C with lower LVEF levels. Some of the included trials had methodological limitations. In a sensitivity analysis including only the four most methodologically sound cardiac trials, the effect of vitamin C was not substantially changed. Conclusions: In this meta-analysis, vitamin C increased LVEF in both cardiac and non-cardiac patients, with a strong negative association between the size of the vitamin C effect and the baseline LVEF. Further research on vitamin C and HF should be carried out, particularly in patients who have low LVEF together with low vitamin C intake or low plasma levels. Different dosages and different routes of administration should be compared.

Computational Evaluation of Venous Graft Geometries in Coronary Artery Bypass Surgery.

Cardiothoracic surgeons are faced with a choice of different revascularization techniques and diameters for saphenous vein grafts (SVG) in coronary artery bypass graft surgery . Using computational simulations, we virtually investigate the effect of SVG geometry on hemodynamics of both venous grafts and the target coronary arteries. We generated patient-specific 3-dimensional anatomic models of coronary artery bypass graft surgery patients and quantified mechanical stimuli. We performed virtual surgery on 3 patient-specific models by modifying the geometry vein grafts to reflect single, Y, and sequential surgical configurations with SVG diameters ranging from 2 mm to 5 mm. Our study demonstrates that the coronary artery runoffs are relatively insensitive to the choice of SVG revascularization geometry. We observe a 10% increase in runoff when the SVG diameter is changed from 2 mm to 5 mm. The wall shear stress of SVG increases dramatically when the diameter drops, following an inverse power scaling with diameter. For a fixed diameter, the average wall shear stress on the vein graft varies in ascending order as single, Y, and sequential graft in the patient cohort. The runoff to the target coronary arteries changes marginally due to the choice of graft configuration or diameter. The shear stress on the vein graft depends on both flow rate and diameter and follows an inverse power scaling consistent with a Poiseuille flow assumption. Given the similarity in runoff with different surgical configurations, choices of SVG geometries can be informed by propensity for graft failure using shear stress evaluations.

The Relationship Between Body Mass Index and In-Hospital Mortality in Patients Following Coronary Artery Bypass Grafting Surgery.

Background: The association between Body Mass Index (BMI) and clinical outcomes following coronary artery bypass grafting (CABG) remains controversial. Our objective was to investigate the real-world relationship between BMI and in-hospital clinical course and mortality, in patients who underwent CABG. Methods: A sampled cohort of patients who underwent CABG between October 2015 and December 2016 was identified in the National Inpatient Sample (NIS) database. Outcomes of interest included in-hospital mortality, peri-procedural complications and length of stay. Patients were divided into 6 BMI (kg/m2) subgroups; (1) under-weight ≤19, (2) normal-weight 20-25, (3) over-weight 26-30, (4) obese I 31-35, (5) obese II 36-39, and (6) extremely obese ≥40. Multivariable logistic regression model was used to identify predictors of in-hospital mortality. Linear regression model was used to identify predictors of length of stay (LOS). Results: An estimated total of 48,710 hospitalizations for CABG across the U.S. were analyzed. The crude data showed a U-shaped relationship between BMI and study population outcomes with higher mortality and longer LOS in patients with BMI ≤ 19 kg/m2 and in patients with BMI ≥40 kg/m2 compared to patients with BMI 20-39 kg/m2. In the multivariable regression model, BMI subgroups of ≤19 kg/m2 and ≥40 kg/m2 were found to be independent predictors of mortality. Conclusions: A complex, U-shaped relationship between BMI and mortality was documented, confirming the "obesity paradox" in the real-world setting, in patients hospitalized for CABG.

Homocysteine alters vasoreactivity of human internal mammary artery by affecting the KCa channel family.

BACKGROUND: Hyperhomocysteinemia is an independent risk factor for atherosclerotic heart disease. We previously demonstrated that disruption of calcium-activated potassium (KCa) channel activity is involved in homocysteine-induced dilatory dysfunction of porcine coronary arteries. Recently we reported that the KCa channel family, including large-, intermediate-, and small-conductance KCa (BKCa, IKCa, and SKCa) subtypes, are abundantly expressed in human internal mammary artery (IMA). In this study, we further investigated whether homocysteine affects the expression and functionality of the KCa channel family in this commonly used graft for coronary artery bypass surgery (CABG). METHODS: Residual IMA segments obtained from patients undergoing CABG were studied in a myograph for the role of KCa subtypes in both vasorelaxation and vasoconstriction. The expression and distribution of KCa subtypes were detected by Western blot and immunohistochemistry. RESULTS: Both the BKCa channel activator NS1619 and the IKCa/SKCa channel activator NS309 evoked significant IMA relaxation. Homocysteine exposure suppressed NS1619-induced relaxation whereas showed no influence on NS309-induced response. Blockade of BKCa but not IKCa and SKCa subtypes significantly suppressed acetylcholine-induced relaxation and enhanced U46619-induced contraction. Homocysteine compromised the vasodilating activity of the BKCa subtype in IMA, associated with a lowered protein level of the BKCa ß1-subunit. Homocysteine potentiated the role of IKCa and SKCa subtypes in mediating endothelium-dependent relaxation without affecting the expression of these channels. CONCLUSIONS: Homocysteine reduces the expression of BKCa ß1-subunit and compromises the vasodilating activity of BKCa channels in IMA. Unlike BKCa, IKCa and SKCa subtypes are unessential for IMA vasoregulation, whereas the loss of BKCa functionality in hyperhomocysteinemia enhances the role of IKCa and SKCa subtypes in mediating endothelial dilator function. Targeting BKCa channels may form a strategy to improve the postoperative graft performance in CABG patients with hyperhomocysteinemia who receive IMA grafting.

IL-8 and CRP moderate the effects of preoperative psychological interventions on postoperative long-term outcomes 6 months after CABG surgery - The randomized controlled PSY-HEART trial.

INTRODUCTION: Inflammation has been related to several somatic and psychological disorders and may moderate effects of psychological interventions. In the PSY-HEART trial patients benefitted from preoperative psychological interventions before undergoing coronary artery bypass graft surgery (CABG) and, if necessary, concomitant valvular surgery, compared to standard medical care. In this study we examined whether patients' baseline inflammatory status moderated the intervention effects. MATERIAL AND METHODS: In a prospective three-arm randomized clinical trial with 6-months follow-up, 124 patients scheduled for CABG surgery alone or concomitant with valvular surgery were randomized to (i) standard medical care only (SMC) or two preoperative psychological interventions: (ii) CBT-based optimizing expectations (EXPECT) and an (iii) an active control group focusing on emotional support (SUPPORT). Available baseline CRP- (n = 79), IL-6- (n = 78), IL-8- (n = 78) and TNF-alpha-(n = 80) parameters were considered as potential moderators (CRP as a categorical and continuous moderator). Linear mixed model analyses were calculated to test whether baseline inflammatory levels moderated intervention effects on disability, mental and physical quality of life at 6 months after surgery. RESULTS: IL-8 moderated intervention effects on patients' disability and categorical CRP moderated intervention effects on mental quality of life. Follow-up tests indicated that EXPECT (and in part SUPPORT) led to lower postoperative disability and higher mental quality of life compared to SMC in patients with low baseline inflammatory markers. EXPECT indicated higher mental quality of life compared to SUPPORT in the high CRP subgroup. Patients in the SMC group had higher mental quality of life in the high CRP subgroup compared to the low CRP subgroup. CONCLUSION: Especially for patients with a lower inflammatory baseline status preoperative psychological interventions might be helpful to optimize long-term CABG surgery outcomes.

Sitagliptin for the prevention and treatment of perioperative hyperglycaemia in patients with type 2 diabetes undergoing cardiac surgery: A randomized controlled trial.

AIM: To assess whether treatment with sitagliptin, starting before surgery and continued during the hospital stay, can prevent and reduce the severity of perioperative hyperglycaemia in patients with type 2 diabetes undergoing coronary artery bypass graft (CABG) surgery. MATERIALS AND METHODS: We conducted a double-blinded, placebo-controlled trial in adults with type 2 diabetes randomly assigned to receive sitagliptin or matching placebo starting 1 day prior to surgery and continued during the hospital stay. The primary outcome was difference in the proportion of patients with postoperative hyperglycaemia (blood glucose [BG] > 10 mmol/L [>180 mg/dL]) in the intensive care unit (ICU). Secondary endpoints included differences in mean daily BG in the ICU and after transition to regular wards, hypoglycaemia, hospital complications, length of stay and need of insulin therapy. RESULTS: We included 182 participants randomized to receive sitagliptin or placebo (91 per group, age 64 ± 9 years, HbA1c 7.6% ± 1.5% and diabetes duration 10 ± 9 years). There were no differences in the number of patients with postoperative BG greater than 10 mmol/L, mean daily BG in the ICU or after transition to regular wards, hypoglycaemia, hospital complications or length of stay. There were no differences in insulin requirements in the ICU; however, sitagliptin therapy was associated with lower mean daily insulin requirements (21.1 ± 18.4 vs. 32.5 ± 26.3 units, P = .007) after transition to a regular ward compared with placebo. CONCLUSION: The administration of sitagliptin prior to surgery and during the hospital stay did not prevent perioperative hyperglycaemia or complications after CABG. Sitagliptin therapy was associated with lower mean daily insulin requirements after transition to regular wards.

On-pump versus off-pump coronary artery bypass surgery for multi-vessel coronary revascularization.

BACKGROUND: This study aims to compare the operative and postoperative results of on-pump (ONCAB) and off-pump (OPCAB) coronary artery bypass surgery (CABG) for multi-vessel coronary revascularization (≥4 anastomoses). METHODS: From May 2018 to August 2019, a total of 120 patients (22.5% women, mean age 61.5±8.4 years) received either ONCAB (Group 1, n=60) or OPCAB (Group 2, n=60) for multi-vessel coronary artery disease (CAD). Preoperative left ventricular (LV) ejection fraction (EF) was 53.1%±8.4%. Median EuroSCORE II was 1.59 (interquartile range, 1.01-2.54). The median number of performed coronary anastomoses was 4 (interquartile range, 4-5), with equal distribution in both groups (P=0.4). All procedures were performed by highly experienced surgeons. The primary endpoints were overall survival at 30 days and freedom from severe adverse events (SAE), which included myocardial infarction (MI), coronary artery re-operation, and re-thoracotomy, caused by bleeding and stroke. RESULTS: The overall survival in both groups was 100% with no intraoperative OPCAB-to-on-pump conversion. The median procedure time was 169 min (interquartile range, 150-179 min) for Group 1 and 183 min (interquartile range, 169-205 min) for Group 2 (P<0.001). The overall freedom from SAE numbered 93.3% (98.3% vs. 88.3%, P=0.030). Postoperative MI rate was 2.5% (n=3) with no significant difference for either group (0 vs. 5.0%, P=0.100). One MI patient underwent a re-operation, and two other patients received a conservative treatment. A total of 2.5% (n=3) of patients underwent a re-thoracotomy on account of bleeding (0 vs. 5.0%, P=0.100); no anastomosis-related bleeding was detected. Blood transfusion was applied in 31.7% of patients (38.3% vs. 25.0%, P=0.090). A total of 1.7% of patients (1.7% vs. 1.7%, P=0.800) developed a stroke. Ventilation time, intensive care unit stay, and hospital stay were similar in both groups. CONCLUSIONS: ONCAB showed superior freedom from SAE and shorter procedure times when compared to OPCAB for multi-vessel coronary artery revascularization.

Computational fluid dynamic study of different incision length of coronary artery bypass grafting in a native coronary stenosis model.

BACKGROUND: The objective of this study was to evaluate hemodynamic patterns in end-side coronary artery bypass grafting with different anastomosis length by computational fluid dynamic study in the native coronary stenosis model. METHODS: The fluid dynamic computations were carried out using ANSYS CFX. Incision length was set to be 2, 4, 6, 8, 10 mm. The angle between the two blood vessels corresponded to the length of the incision. Native vessels were set to be 90% stenosis. The radius of both native and graft vessels was set to be 2 mm. The inlet boundary condition was set by the sample of the transient time flow which was measured intraoperatively. RESULTS: The energy efficiency was higher and energy loss was lower when the anastomosis length was longer until 8 mm. However, energy efficiency was lowest and energy loss was highest in the 10-mm model. In the 10-mm incision model, the streamline showed the scanty bypass flow in the bottom. Vortex showed that only 10-mm model showed the vortex just distal to the stenosis in the native inlet, and more vortex in native outlet than other length models. The oscillatory shear index (OSI) was higher in the outlet top in all models. And only 10-mm model showed high oscillatory index just distal to the stenosis. CONCLUSIONS: In the end-side anastomosis, an anastomosis length of 8 mm was the ideal length with less flow complexity, low OSI, and less energy loss and high energy efficiency in the native 90% stenosis model.

Impact of coronary angiography early after CABG for suspected postoperative myocardial ischemia.

BACKGROUND: The incidence of perioperative myocardial infarction is reported to 2-8%. The aim of the study (retrospectively registered) was to evaluate whether control coronary angiography after surgery is useful in case of suspected postoperative myocardial ischemia. METHODS: All patients who demonstrated signs of myocardial ischemia post CABG and underwent coronary angiography from 6/2008 to 06/2015 were retrospectively analyzed. Myocardial ischemia post CABG was defined as an increase of CK/CK-MB, occasionally associated with arrhythmias or low output syndrome. RESULTS: Overall, 108 patients (age 66 ± 9 years) demonstrated signs of myocardial ischemia post CABG and underwent coronary angiography corresponding to an incidence of 2.2%. Of them, 70 patients (65%) demonstrated graft pathologies. A therapeutic consequence was drawn in 62 Patients (57%), which consisted of redo surgery in 10 patients (9%) and PCI with stent placement in 52 patients (48%). Of the remaining 46 patients, 29 patients showed intact bypass grafts (27%), whereas 17 patients had minor pathologies (16%). Demographic data including the extent of the coronary artery disease, urgency of operation, comorbidities, EuroScore, surgical technique, postoperative lab tests and transfusion requirements were comparable among the groups. Redo surgery patients had prior PCI in 33% of patients, which was much higher than in the other groups. Patients with reintervention had a 30d-mortality rate of 13%, conservatively treated patients only 2.2%. Mortality was highest after redo surgery with 25%. CONCLUSIONS: Postoperative coronary angiography is a useful tool with a significant therapeutic value. Pathological findings mandate further revascularization therapy in roughly half of the patients. PCI is a safe choice in the majority of patients, redo surgery is much less indicated.

The Role of Serial NT-ProBNP Level in Prognosis and Follow-Up Treatment of Acute Heart Failure after Coronary Artery Bypass Graft Surgery.

BACKGROUND: After coronary artery bypass graft (CABG) surgery, heart failure is still major problem. The valuable marker for it is needed. AIM: Evaluating the role of serial NT-proBNP level in prognosis and follow-up treatment of acute heart failure after CABG surgery. METHODS: The prospective, analytic study evaluated 107 patients undergoing CABG surgery at Ho Chi Minh Heart Institute from October 2012 to June 2014. Collecting data was done at pre- and post-operative days with measuring NT-proBNP levels on the day before operation, 2 hours after surgery, every next 24 h until the 5th day, and in case of acute heart failure occurred after surgery. RESULTS: On the first postoperative day (POD1), the NT-proBNP level demonstrated significant value for AHF with the cut-off point = 817.8 pg/mL and AUC = 0.806. On the second and third postoperative day, the AUC value of NT- was 0.753 and 0.751. It was statistically significant in acute heart failure group almost at POD 1 and POD 2 when analyzed by the doses of dobutamine, noradrenaline, and adrenaline (both low doses and normal doses). CONCLUSION: Serial measurement of NT-proBNP level provides useful prognostic and follow-up treatment information in acute heart failure after CABG surgery.

Lessons learned from Radial Artery Database International ALliance (RADIAL).

Coronary artery bypass graft (CABG) surgery was first performed in the 1960s. As the surgery has evolved, there has been a growing interest in the use of multiple arterial grafts in CABG. Since the re-introduction of the radial artery (RA) to clinical use as a bypass conduit in the 1990s, there have been several randomized controlled trials (RCTs) which have compared saphenous vein graft (SVG) conduits to RA use in CABG. While most trials have shown improved patency of the RA, none of them have been able to demonstrate a survival benefit using the arterial conduit. In this review, we examine the existing RCTs on the subject. We then look at our solution to the decades-old inquiry regarding the RA compared with the SVG. The Radial Artery Database International ALliance (RADIAL) project is an individual patient-level meta-analysis developed to adequately power a study to assess if the RA has superior clinical outcomes compared with the SVG. We describe the process by which this investigation was conducted and the collaboration necessary to achieve success.

Physiologic assessment of moderate coronary lesions: a step towards complete revascularization in coronary artery bypass grafting.

BACKGROUND: An accurate diagnostic assessment of coronary artery disease is crucial for patients undergoing coronary artery bypass grafting (CABG). Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) to guide complete revascularization have not been adequately studied in patients prior to CABG. We compared an anatomic to a physiologic assessment of moderate coronary lesions (40-70% stenosis) in patients referred for CABG. METHODS: We retrospectively reviewed 109 medical records of patients who underwent CABG at Tulane Medical Center from 2014 to 2016. Patients were divided into an FFR/iFR-guided and an angiography-guided group. Clinical characteristics, procedural outcomes, and clinical outcomes for the two groups were compared over an 18-month follow-up period. RESULTS: There were significantly higher rates of three-vessel anastomoses (85.7% vs. 74.7%, P<0.05) and venous grafting (85.7% vs. 76.8%, P<0.05) in the FFR/iFR group. The FFR/iFR group had a lower rate of grafts placed to the left anterior descending artery (LAD) distribution than the angiography group (7.1% vs. 29.5%, P<0.05). The FFR/iFR group had a higher rate of grafts placed to the left circumflex (LCx) artery distribution than the angiography group (28.6% vs. 9.5%, P<0.05). We observed a trend toward reduction in major adverse cardiac events (MACEs) (7.1% vs. 11.6%, P=0.369) and angina (0.0% vs. 6.3%, P=0.429) in the FFR/iFR group compared to the angiography group over 18 months. CONCLUSIONS: Physiologic assessment of coronary lesions can effectively guide complete revascularization in patients undergoing CABG. Moreover, FFR/iFR-guided CABG was associated with significantly higher rates of three-vessel anastomoses, venous grafting, and graft distribution to the circumflex system.

The effect of a peer support intervention on early recovery outcomes in men recovering from coronary bypass surgery: A randomized controlled trial.

BACKGROUND AND AIM: Examine the effect of a professionally-guided telephone peer support intervention on recovery outcomes including depression, perceived social support, and health services utilization after coronary artery bypass graft surgery (CABG). METHODS: A randomized controlled trial was conducted with post-coronary artery bypass graft surgery men ( N=185) who were randomized before hospital discharge. The intervention arm received telephone-based peer support through weekly telephone calls from a peer volunteer over six weeks, initiated within 3-4 days of discharge. RESULTS: Although a significant difference was detected in pre-intervention depression scores at discharge, there were no differences between groups in changes in depression scores at six weeks ( p=0.08), 12 weeks (0.49) or over time ( p=0.51); and no significant differences in perceived social support scores over time ( p=0.94). At 12 weeks, the intervention group had significantly lower incidence of health services utilization (family physician ( p=0.02) and emergency room ( p=0.04)). CONCLUSIONS: Healthcare providers need to continue to investigate novel interventions to enhance social support and reduce depression in cardiac patients.

The role of video-assisted thoracoscopic surgery for management of symptomatic pleural effusion after coronary artery bypass surgery: a best evidence topic report.

A best evidence topic in thoracic surgery was written addressing whether video-assisted thoracoscopic surgery (VATS) talc pleurodesis could be justified in patients with pleural effusion (PE) after coronary artery bypass graft (CABG) surgery and no-responded to repeated thoracentesis. Ten papers were identified to answer the question. Of these, two were case-series study including ≥4 patients, 7 retrospective analytical studies, and one observational study but no randomized controlled trial (RCTs) was included in the analysis. The score of the level of evidence was low; only one study presented a level of evidence of 2, 7 studies a level of 3b; and two studies a level of evidence of 4. The incidence of symptomatic post-CABG PE ranged from 2% to 9.7%. Management strategies included medical management, thoracentesis, and/or surgical drainage. Most of the authors treated early and late PE with thoracentesis or chest drainage, while VATS with pleurodesis was reserved only for selected patients with persistent effusion after repeating thoracentesis and/or chest drainage. All studies but one do not include follow-up, thus rendering it difficult to define the real role of thoracentesis or chest drainage as definitive treatments for effusion, given the incomplete data regarding how many patients' effusions recur. Conversely, with follow up reported, no case of recurrence was found after VATS procedure. In patients who underwent delayed VATS, it was common to identify the formation of tenacious peel that trapped the lung. In three cases conversion to thoracotomy was required to decorticate the inflammatory peel that covered the pleura and did not allow the lung re-expansion. However, only five papers showed that VATS for management of post-CABG PEs is safe and efficacious and its use could help to prevent trapped lung through the resection of adhesions and loculations sometimes associated with multiple previous thoracentesis or chest drainage. As the low grade of evidence from the present analysis, future randomized controlled studies are wanted to define the real effectiveness of VATS in this field.