A Fibrin-Thrombin Based In Vitro Perfusion System to Study Flow-Related Prosthetic Heart Valves Thrombosis.

Prosthetic heart valve (PHV) replacement has increased the survival rate and quality of life for heart valve-diseased patients. However, PHV thrombosis remains a critical problem associated with these procedures. To better understand the PHV flow-related thrombosis problem, appropriate experimental models need to be developed. In this study, we present an in vitro fibrin clot model that mimics clot accumulation in PHVs under relevant hydrodynamic conditions while allowing real-time imaging. We created 3D-printed mechanical aortic valve models that were inserted into a transparent glass aorta model and connected to a system that simulates human aortic flow pulse and pressures. Thrombin was gradually injected into a circulating fibrinogen solution to induce fibrin clot formation, and clot accumulation was quantified via image analysis. The results of valves positioned in a normal versus a tilted configuration showed that clot accumulation correlated with the local flow features and was mainly present in areas of low shear and high residence time, where recirculating flows are dominant, as supported by computational fluid dynamic simulations. Overall, our work suggests that the developed method may provide data on flow-related clot accumulation in PHVs and may contribute to exploring new approaches and valve designs to reduce valve thrombosis.

Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia.

BACKGROUND: Reducing the need for blood transfusion among patients undergoing cardiac surgery FLA reduce postoperative complications and mortality. Our study aimed to assess the effects of administering preoperative i.v. ferric carboxymaltose on postoperative red cell transfusion requirements in patients without anaemia undergoing on-pump cardiac surgery. METHODS: This double-blind, randomised, placebo-controlled trial was conducted between October 2016 and November 2019, with a follow-up period of up to 6 weeks after surgery. Patients without anaemia who underwent on-pump cardiac surgery were included as participants and administered i.v. iron in the form of ferric carboxymaltose or placebo once, 24-72 h before surgery. The primary outcome was the number of red cell units transfused during the first four postoperative days, and the secondary outcome measures were blood haemoglobin concentrations at 4 days and 6 weeks after surgery. RESULTS: The 200 patients included were randomly assigned to the ferric carboxymaltose (n=102) and placebo (n=98) groups. By postoperative Day 4, a significantly lower mean number of red cell units were transfused in the ferric carboxymaltose than in the placebo group, 0.3 (0.8) vs 1.6 (4.4), respectively; P=0.007. The mean haemoglobin concentrations on postoperative Day 4 were 9.7 (1) g dl-1 and 9.3 (1) g dl-1, respectively (P=0.03). Corresponding values at 6 weeks after surgery were 12.6 (1.4) g dl-1 and 11.8 (1.5) g dl-1, respectively (P=0.012). CONCLUSIONS: In patients without anaemia undergoing on-pump cardiac surgery, treatment with a single dose of 1000 mg ferric carboxymaltose i.v. 1-3 days before surgery significantly reduced the need for red cell transfusions and increased the postoperative haemoglobin concentration. CLINICAL TRIAL REGISTRATION: NCT02939794.

High sensitivity troponin-I threshold to predict perioperative myocardial infarction.

BACKGROUND: High-sensitivity Troponin I (hs-cTnI) has largely replaced conventional troponin assays in an effort to improve detection of myocardial infarction. However, the mean displacement of hs-cTnI following coronary artery bypass graft (CABG) and the optimal threshold to detect perioperative myocardial infarction (MI) is unclear. Our objective is to describe mean hs-cTnI values at 6-12 h post-CABG and to determine the highest specificity while maintaining 100% sensitivity hs-cTnI cut-off values for diagnosis of perioperative or type-5 MI. METHODS: Between 2016 and 2018, 374 patients underwent non-emergent, isolated CABG. Pre-operative and 6 h post-operative hs-cTnI values were recorded as well as ECG, echocardiographic and angiographic data. RESULTS: Of 374 patients, 151 (40.3%) had normal and 224 (59.7%) had elevated preoperative hs-cTnI. Patients with normal preoperative hs-cTnI had a mean 6 h hs-cTnI of 9193 ng/l or 270X the upper normal value. Eleven patients (7.3%) presented with post-operative MI with a mean 6 h hs-cTnI of 50,218 ng/l or 1477X the upper normal value. Patients with elevated preoperative hs-cTnI had a mean 6 h hs-cTnI of 9449 ng/l or 292X the upper normal value. Eleven patients (4.9%) who presented with post-operative MI had a mean 6 h hs-cTnI of 26,823 ng/l or 789X the upper normal value. CONCLUSIONS: We suggest hs-cTnI threshold of 80-fold in patients with normal pre-operative hs-cTnI and 2.7-fold in patients with elevated pre-operative hs-cTnI. These results have important implications for perioperative care and for surgical trial reporting.

Outcomes of Extracorporeal Membrane Oxygenation (ECMO) for COVID-19 Patients: A Multi-Institutional Analysis.

BACKGROUND: In March 2020, COVID-19 was announced as a global pandemic. The first COVID-19 patient was connected to an ECMO device in Israel during that time. Since then, over 200 patients have required ECMO support due to COVID-19 infection. The present study is a multi-institutional analysis of all COVID-19 patients requiring veno-venous (VV) ECMO in Israel. The aim was to characterize and compare the survivors and deceased patients as well as establish risk factors for mortality. METHODS: This retrospective multi-institutional study was conducted from March 2020 to March 2021 in eleven of twelve ECMO centers operating in Israel. All COVID-19 patients on VV ECMO support were included in the cohort. The patients were analyzed based on their comorbidities, procedural data, adverse event on ECMO, and outcomes. Univariate and multivariate analyses were used to compare the deceased and the surviving patients. RESULTS: The study included 197 patients, of which 150 (76%) were males, and the mean age was 50.7 ± 12 years. Overall mortality was 106 (54%). Compared with the deceased subjects, survivors were significantly younger (48 ± 11 vs. 53 ± 12 years), suffered less from ischemic heart disease (IHD) (3% vs. 12%), and were ventilated for a significantly shorter period (≤4 days) prior to cannulation (77% vs. 63%). Patients in the deceased group experienced more kidney failure and sepsis. Rates of other complications were comparable between groups. CONCLUSIONS: Based on this study, we conclude that early cannulation (≤4 days) of younger patients (≤55 years) may improve overall survival and that a history of IHD might indicate a reduced prognosis.

Transcatheter Closure of a Iatrogenic Gerbode Type Ventricular Septal Defect Post Surgical Septal Myectomy With Mitral and Aortic Valve Replacement.

Jatrogenic communication between left ventricle and right atrium, known as Gerbode type ventricular septal defect (GVSD) may be observed after different surgical interventions. We present a case of iatrogenic GVSD following complex cardiac surgery including septal myectomy combined with mitral and aortic valve replacement, which was successfully closed percutanously by Occlutech septal occluder.

Sutureless repair of subacute left ventricular free wall rupture.

Left ventricular free wall rupture (LVFWR) is one of the most lethal heart conditions where mortality rates reach 40% intraoperatively and 80% in hospital. A few days after the acute event, the rupture becomes subacute, and surgery is indicated to repair the frail myocardium. Despite the lack of strong evidence to support the efficacy of sutureless repair of subacute LVFWR in the literature, this technique has recently been gaining popularity with acceptable success rates. In this article, we present two techniques to repair the subacute LVFWR without using sutures: the direct glued-hemostatic patch technique and the glued pericardial patch technique. In both techniques, the healthy myocardium surrounding the infarcted zone is recruited, together with hemostatic materials, to seal the rupture. Moreover, we describe the clinical presentation of the acute and subacute LVFWR, peri-operative management, together with intra-operative tips and the advantages and disadvantages of each material used in these operations.

Effects of the harvesting technique and external stenting on progression of vein graft disease 2 years after coronary artery bypass.

OBJECTIVES: In a post hoc analysis of the VEST III trial, we investigated the effect of the harvesting technique on saphenous vein graft (SVG) patency and disease progression after coronary artery bypass grafting. METHODS: Angiographic outcomes were assessed in 183 patients undergoing open (126 patients, 252 SVG) or endoscopic harvesting (57 patients, 114 SVG). Overall SVG patency was assessed by computed tomography angiography at 6 months and by coronary angiography at 2 years. Fitzgibbon patency (FP I, II and III) and intimal hyperplasia (IH) in a patient subset were assessed by coronary angiography and intravascular ultrasound, respectively, at 2 years. RESULTS: Baseline characteristics were similar between patients who underwent open and those who underwent endoscopic harvesting. Open compared with endoscopic harvesting was associated with higher overall SVG patency rates at 6 months (92.9% vs 80.4%, P = 0.04) and 2 years (90.8% vs 73.9%, P = 0.01), improved FP I, II and III rates (65.2% vs 49.2%; 25.3% vs 45.9%, and 9.5% vs 4.9%, respectively; odds ratio 2.81, P = 0.09) and reduced IH area (-31.8%; P = 0.04) and thickness (-28.9%; P = 0.04). External stenting was associated with improved FP I, II and III rates (odds ratio 2.84, P = 0.01), reduced IH area (-19.5%; P < 0.001) and thickness (-25.0%; P < 0.001) in the open-harvest group and reduced IH area (-12.7%; P = 0.01) and thickness (-9.5%; P = 0.21) in the endoscopic-harvest group. CONCLUSIONS: A post-hoc analysis of the VEST III trial showed that open harvesting is associated with improved overall SVG patency and reduced IH. External stenting reduces SVG disease progression, particularly with open harvesting.

Midterm Results of Isolated Tricuspid Valve Replacement-Implications for Clinical Decision Making.

BACKGROUND: Isolated tricuspid valve replacement (TVR) is considered high-risk surgery. We investigated our outcomes of TVR with the aim of identifying variables that may influence morbidity and mortality of isolated TVR compared with combined TVR and left-sided valve surgery. METHODS: Retrospective analysis of patients undergoing TVR surgery. The primary endpoint was long-term mortality. The association of postoperative outcomes with isolated compared with combined replacement was analyzed. The association between type of surgery and mortality over time was evaluated using Cox proportional hazards regression models to estimate the hazard ratio. RESULTS: Overall, 70 patients underwent TVR. Mean age was 61 ± 12 years and 74% (52 of 70) were women. About two thirds (61%) of the study population had a diagnosis of rheumatic heart disease and 8% (6 of 70) had previous infectious endocarditis. Atrial fibrillation was prevalent (86%, 60 of 70). Comorbidities were similar between groups. Tricuspid valve replacement combined with left-sided valvular surgery was performed in 37 patients (53%), and isolated replacement in 33 patients (47%). Previous cardiac surgery was common (40 patients, 57%). One-month survival rate was 94.3% (66 of 70). During a median follow-up period of 3.6 years, 12 patients (17%) died. The cumulative 5-year survival tended to be lower among patients with isolated TVR compared with patients having combined surgery. CONCLUSIONS: We showed that TVR can be performed with good outcomes. Isolated TVR did not increase morbidity and mortality when patients are referred for surgery early, including after previous sternotomy. This finding should perhaps lead to a more aggressive approach toward patients requiring isolated replacement.

Defining and understanding the "extra-corporeal membrane oxygenation gap" in the veno-venous configuration: Timing and causes of death.

In-hospital mortality of adult veno-venous extracorporeal membrane oxygenation (V-V ECMO) patients remains invariably high. However, little is known regarding timing and causes of in-hospital death, either on-ECMO or after weaning. The current review aims to investigate the timing and causes of death of adult patients during hospital admittance for V-V ECMO, and to define the V-V ECMO gap, which is represented by the patients that are successfully weaned of ECMO but still die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-V ECMO patients from January 2006 to December 2020 were screened. Studies that did not report on at least on-ECMO mortality and discharge rate were excluded from analysis as they could not provide the required information regarding the proposed V-V ECMO-gap. Mortality rates on-ECMO and after weaning, as well as weaning and discharge rates, were analyzed as primary outcomes. Secondary outcomes were the causes of death and complications. Initially, 35 studies were finally included in this review. Merely 24 of these studies (comprising 975 patients) reported on prespecified V-V ECMO outcomes (on-ECMO mortality and discharge rate). Mortality on V-V ECMO support was 27.8% (95% confidence interval (CI) 22.5%-33.2%), whereas mortality after successful weaning was 12.7% (95% CI 8.8%-16.6%, defining the V-V ECMO gap). 72.2% of patients (95% CI 66.8%-77.5%) were weaned successfully from support and 56.8% (95% CI 49.9%-63.8%) of patients were discharged from hospital. The most common causes of death on ECMO were multiple organ failure, bleeding, and sepsis. Most common causes of death after weaning were multiorgan failure and sepsis. Although the majority of patients are weaned successfully from V-V ECMO support, a significant proportion of subjects still die during hospital stay, defining the V-V ECMO gap. Overall, timing and causes of death are poorly reported in current literature. Future studies on V-V ECMO should describe morbidity and mortality outcomes in more detail in relation to the timing of the events, to improve patient management, due to enhanced understanding of the clinical course.

Animal Study of a Novel Device for Clampless Proximal Anastomosis in Coronary Bypass Surgery.

PURPOSE: Limitations of existing techniques for clampless proximal anastomosis (CPA) in coronary artery bypass grafting include air emboli and excessive bleeding. This study evaluated the safety and performance of a new device for performing CPA. DESCRIPTION: The device includes a temporary adjustable sealing element that is connected by a catheter to a handle that controls its opening and closure. An aortic punch is mounted on the catheter and activated by a detachable handle. EVALUATION: Six adult female swine underwent partial coronary artery bypass grafting that included construction of a CPA using autologous arterial or venous conduits. During anastomosis construction, good sealing was achieved in all cases, and a blower was not needed in 4 of 6 animals. In the first 2 cases, the blower was intermittently used in 14 % of the entire anastomosis construction time. A mean flow rate of 140.0 ± 52.9 mL/min was measured for the arterial grafts and 666.7 ± 230.9 mL/min for the venous grafts. CONCLUSIONS: The VIOLA device (Vascular Graft Solutions, Tel Aviv, Israel) is safe and associated with good hemostasis and minimal use of a blower during CPA construction in a swine model.

Understanding the "extracorporeal membrane oxygenation gap" in veno-arterial configuration for adult patients: Timing and causes of death.

Timing and causes of hospital mortality in adult patients undergoing veno-arterial extracorporeal membrane oxygenation (V-A ECMO) have been poorly described. Aim of the current review was to investigate the timing and causes of death of adult patients supported with V-A ECMO and subsequently define the "V-A ECMO gap," which represents the patients who are successfully weaned of ECMO but eventually die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-A ECMO patients from January 1993 to December 2020 were screened. The studies included in this review were studies that reported more than 10 adult, human patients, and no mechanical circulatory support other than V-A ECMO. Information extracted from each study included mainly mortality and causes of death on ECMO and after weaning. Complications and discharge rates were also extracted. Sixty studies with 9181 patients were included for analysis in this systematic review. Overall mortality was 38.0% (95% confidence intervals [CIs] 34.2%-41.9%) during V-A ECMO support (reported by 60 studies) and 15.3% (95% CI 11.1%-19.5%, reported by 57 studies) after weaning. Finally, 44.0% of patients (95% CI 39.8-52.2) were discharged from hospital (reported by 60 studies). Most common causes of death on ECMO were multiple organ failure, followed by cardiac failure and neurological causes. More than one-third of V-A ECMO patients die during ECMO support. Additionally, many of successfully weaned patients still decease during hospital stay, defining the "V-A ECMO gap." Underreporting and lack of uniformity in reporting of important parameters remains problematic in ECMO research. Future studies should uniformly define timing and causes of death in V-A ECMO patients to better understand the effectiveness and complications of this support.

Heart Team/Guidelines Discordance Is Associated With Increased Mortality: Data From a National Survey of Revascularization in Patients With Complex Coronary Artery Disease.

BACKGROUND: Practice guidelines emphasize the role of the SYNTAX score (SS; Synergy Between PCI With TAXUS and Cardiac Surgery) in choosing between percutaneous coronary intervention and coronary artery bypass graft surgery in cases of complex coronary artery disease. There is paucity of data on the implementation of these recommendations in daily practice, and on the consequences of guideline discordant revascularization. METHODS: This was a retrospective analysis of a prospective national survey of consecutive real world patients undergoing coronary revascularization for complex coronary artery disease according to decisions of local heart team at each center. SS was calculated at a dedicated CoreLab, and patients were classified as heart team/guidelines agreement/discordant. RESULTS: Nine hundred seventy-nine patients (571 percutaneous coronary intervention and 408 coronary artery bypass graft) were included. Mean age was 65 years and the mean SS was 22. Heart team/guidelines discordance occurred in 170 (17.3%) patients. Independent predictors of heart team/guidelines discordance were age, admission to a center with no cardiac surgery service, SS, and previous percutaneous coronary intervention/myocardial infarction. A multivariate model based on these characteristics had a C statistic of 0.83. Thirty-day outcomes were similar in the agreement/discordance groups, however, heart team/guidelines discordance was associated with a significant increase in 3 year mortality (17.6% versus 8.4%; hazard ratio, 2.05; P=0.002) after multivariate adjustment. CONCLUSIONS: Heart team/guidelines discordance is not infrequent in real world patients with complex coronary artery disease undergoing revascularization. This is more likely to occur in elderly patients, those with more complex coronary disease (as determined by the SS), and those treated at centers with no cardiac surgery service. These patients have a higher risk for mid-term mortality.

Effect of Prolonged Hypothermic Cardiopulmonary Bypass, Heparin, and Protamine on Platelet: A Small-Group Study.

Cardiopulmonary bypass (CPB) is associated with platelet dysfunction (PD), an important cause of postoperative bleeding. The etiology of PD is not completely understood. We mapped the platelets' function during CPB to determine the etiology of PD. Platelets activation, measured by procaspase activating compound-1 and P-selectin expression (CD62P), after activation by adenosine diphosphate and thrombin receptor activator peptide, were decreased by protamine. Changes during CPB were insignificant. Platelet-leukocyte aggregation was increased by CPB but not by protamine. Platelet apoptosis marker, annexin V, was increased by protamine. Changes during CPB were insignificant. Our findings demonstrate that protamine given after CPB plays a central role in PD and count decrease.

"Risk factors for ventilator-associated pneumonia following cardiac surgery: case-control study".

BACKGROUND: Ventilator-associated pneumonia (VAP) following cardiac surgery is a preventable complication associated with adverse outcomes. AIMS: We aimed to assess risk factors and outcomes of VAP following cardiac surgery. METHODS: A matched 1:3 case:control study, including adult patients undergoing cardiac surgery through sternotomy between Sep-2014 to Mar-2017 was conducted in a tertiary-care hospital in Israel. Cases included all patients developing VAP within 30 days after surgery, defined using consensus criteria. Controls were matched for age, gender and surgery type. Operative data were collected prospectively, other data were collected retrospectively. Cox regression was used for adjusted analysis of matched data. FINDINGS: Out of 946 operated patients, we identified 57 patients with VAP after cardiac surgery (17.7 episodes per 1000 ventilator-days) matched to 149 controls. Significant independent risk factors for VAP included congestive heart failure (OR 2.357 95%CI 1.052-5.281), Chest re-exploration in ICU (OR 10.213 95%CI: 2.235-46.678), preoperative glucose levels (OR 1.1010 per 1 mg/dl increase 95%CI: 1.004-1.019) intraoperative red blood cell transfusions (OR 1.542 per 1 unit 95%CI: 1.109-2.094) and pulmonary hypertension (OR 2.261 95%CI 1.048-6.554). VAP was most commonly caused by Gram-negative pathogens. VAP was associated with higher mortality, longer length of stay, longer need for ventilator support and longer stay in ICU setting. CONCLUSIONS: Postoperative VAP in cardiac surgery patients is associated with severe clinical outcomes. We identified risk factors that can aid in preventive measures implementation for high risk patients.

Automated 4-dimensional regional myocardial strain evaluation using cardiac computed tomography.

Evaluation of myocardial regional function is generally performed by visual "eyeballing" which is highly subjective. A robust quantifiable parameter of regional function is required to provide an objective, repeatable and comparable measure of myocardial performance. We aimed to evaluate the clinical utility of novel regional myocardial strain software from cardiac computed tomography (CT) datasets. 93 consecutive patients who had undergone retrospectively gated cardiac CT were evaluated by the software, which utilizes a finite element based tracking algorithm through the cardiac cycle. Circumferential (CS), longitudinal (LS) and radial (RS) strains were calculated for each of 16 myocardial segments and compared to a visual assessment, carried out by an experienced cardiologist on cine movies of standard "echo" views derived from the CT data. A subset of 37 cases was compared to speckle strain by echocardiography. The automated software performed successfully in 93/106 cases, with minimal human interaction. Peak CS, LS and RS all differentiated well between normal, hypokinetic and akinetic segments. Peak strains for akinetic segments were generally post-systolic, peaking at 50 ± 17% of the RR interval compared to 43 ± 9% for normokinetic segments. Using ROC analysis to test the ability to differentiate between normal and abnormal segments, the area under the curve was 0.84 ± 0.01 for CS, 0.80 ± 0.02 for RS and 0.68 ± 0.02 for LS. There was a moderate agreement with speckle strain. Automated 4D regional strain analysis of CT datasets shows a good correspondence to visual analysis and successfully differentiates between normal and abnormal segments, thus providing an objective quantifiable map of myocardial regional function.

Retraction mechanics of Finochietto-style self-retaining thoracic retractors.

OBJECTIVES: Analyze the mechanics of Finochietto-style retractors, including the responses of thoracic tissues during thoracotomy, with an emphasis on tissue trauma and means for its reduction. METHODS: Mechanical analyses of the retractor were performed, including analysis of deformation under load and kinematics of the crank mechanism. Thoracotomies in a porcine model were performed in anesthetized animals (7) and fresh cadavers (17) using an instrumented retractor. RESULTS: Mechanical analyses revealed that arm motion is a non-linear function of handle rotation, that deformation of the retractor under load concentrates force at one edge of the retractor blade, and that the retractor behaves like a spring, deforming under the load of retraction and continuing to force open the incision long after crank rotation stops. Experimental thoracotomies included retractions ranging from 50 to 112 mm over 30 to 370 s, generating maximum forces of 118 to 470 N (12-50 kgf). Tissue ruptures occurred in 12 of the 24 retractions. These ruptures all occurred at retraction distances wider than 30 mm and at forces greater than 122.5 N. Significant tissue ruptures were observed for nearly all retractions at higher retraction rates (exceeding ½ rotation of the crank per 10 s). CONCLUSIONS: The Finochietto-style retractor can generate large forces and some aspects of its design increase the probability of tissue trauma.

Extracorporeal Membrane Oxygenation (ECMO)-A Lifesaving Technology. Review and Single-center Experience.

OBJECTIVE: Extracorporeal membrane oxygenation is used to bypass the cardiopulmonary system in a severe heart or/and lung failure, mainly in intractable conditions where all other therapy options fail or are unfeasible. Extracorporeal membrane oxygenation (ECMO) is a well-established therapeutic option in such circumstances for neonatal, pediatric, and adult patients. Managing a patient with ECMO requires dedicated and specific management. The importance and necessity of this essential technology in life-threatening cardio-respiratory rescue prompted Rambam Health Care Campus to implement it and make it available as a service to the population in northern Israel. This article includes a brief review of extracorporeal life support and a report of our single-center experience since the establishment of the service. METHODS: The ECMO unit was established in 2014 under the responsibility of the Cardiac Surgery Department. The ECMO service was initiated by a well-planned program with consideration of all aspects including economics, education and training, the specialist team and equipment needed, strategies for medication, and ethical challenges. RESULTS: Between February 2014 and May 2018, 65 patients were treated with ECMO; 43 patients received veno-arterial ECMO for cardiac support (66%), while 22 received veno-venous ECMO for respiratory support (34%). The in-hospital mortality was 56%. CONCLUSIONS: Extracorporeal membrane oxygenation is an effective therapy that is constantly growing in use and provides a therapy that can replace previous options. To establish such a service requires a planned program and concerted effort. Our single-center experience presented a good learning curve and showed the feasibility as well as the efficacy of the ECMO procedure in life-threatening conditions.

Revascularization Strategies and Survival in Patients With Multivessel Coronary Artery Disease.

BACKGROUND: We sought to assess real-world implementation of the guidelines in patients with multivessel coronary artery disease (CAD) using a prospective national registry in Israel. METHODS: All consecutive patients with left main or 2- to 3-vessel CAD involving the proximal or mid left anterior descending artery were enrolled in a dedicated multicenter registry. Patients were managed at the discretion of the treating team at each hospital and were followed for 30 months. RESULTS: This registry included 1,064 patients, 55% treated with percutaneous coronary intervention (PCI) and 45% with coronary artery bypass surgery (CABG). Multivariate logistic regression analysis showed that chronic renal failure (odds ratio [OR], 2.43; p = 0.001) and prior myocardial infarction (OR, 1.7; p = 0.024) were associated with referral to PCI versus CABG, whereas male gender (OR, 2.27; p < 0.001), prior aspirin treatment (OR, 1.72; p = 0.005), diabetes mellitus (OR, 1.51; p = 0.007), 3-vessel CAD (OR, 3.45; p < 0.001) and SYNTAX score (SS) greater than 32 (OR, 10.0; p < 0.001) were associated with referral to CABG versus PCI. Each point increment in the SS was independently associated with a 9% greater likelihood of referral to CABG (p < 0.001). Survival analysis showed that mortality risk was lower among PCI patients less than 8 months after the procedure, and CABG was associated with a significant survival benefit thereafter. CONCLUSIONS: We found good agreement with current guidelines regarding revascularization strategies in real-world patients with multivessel CAD. The SS was the main independent predictor associated with the choice of revascularization strategy. The time-dependent association between revascularization strategy and long-term survival should be incorporated in the risk assessment of this population.

[TECHNOLOGICAL SOLUTIONS FOR THE IMPROVEMENT OF OUTCOMES IN CARDIAC SURGERY OF OCTOGENARIAN PATIENTS].

INTRODUCTION: The current review addresses present-day technological advances in cardiac surgery performed on octogenarian patients, namely off-pump coronary artery bypass grafting (CABG), proximal anastomosis device, routine use of intraoperative epiaortic ultrasound, transcatheter aortic valve implantation (TAVI), and brain protection during cardiac surgery. Conflict of Interest: Gil Bolotin served as a scientific advisor for Cardiogard Ltd., which is addressed in this review paper.