Coronary bypass surgery for multivessel disease after percutaneous coronary intervention in acute coronary syndromes: why, for whom, how early?

Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of 'complete revascularization' over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI ('hybrid revascularization') is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI. This valuable but poorly studied 'PCI first-CABG later' option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients' clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted. Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians' choices in a case-by-case patient-tailored approach.

Association of Postoperative Atrial Fibrillation Duration after Coronary Artery Bypass Grafting with Poor Postoperative Outcomes.

Background: Postoperative atrial fibrillation (POAF) has long been associated with poor perioperative outcomes after coronary artery bypass grafting (CABG). In this study, we aimed to investigate the effect of prolonged POAF durations on perioperative outcomes of CABG. Methods: This retrospective cohort study examined CABG patients enrolled at Beijing Anzhen Hospital from January 2018 to September 2021. We compared patients with POAF durations ≥ 48 hours to patients with POAF durations < 48 hours. Primary outcomes were in-hospital mortality, stroke, acute respiratory failure (ARF), acute kidney injury (AKI), and significant gastrointestinal bleeding (GIB); secondary outcomes were postoperative length of stay (LOS) and intensive care unit (ICU) duration. Associations between primary outcomes and POAF duration were determined using logistic regression and restricted cubic spline analyses. Differences in baseline characteristics were controlled using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Results: Out of 11,848 CABG patients, 3604 (30.4%) had POAF, while 1131 (31.4%) had it for a duration of ≥ 48 hours. ARF (adjusted odds ratio [OR]: 2.96, 95% confidence interval [CI]: 1.47-6.09), AKI (adjusted OR: 2.37, 95% CI: 1.42-3.99), and significant GIB (adjusted OR: 2.60, 95% CI: 1.38-5.03) were associated with POAF durations ≥ 48 hours; however, neither in-hospital mortality (adjusted OR: 1.60, 95% CI: 0.97-2.65) nor stroke (adjusted OR: 1.28, 95% CI: 0.71-2.34) was. These results remained even following PSM and IPTW analyses. Conclusions: POAF durations longer than 48 hours were independently associated with poorer perioperative recovery from CABG, with respect to the occurrence of ARF, AKI, and GIB, as well as a longer postoperative LOS and ICU duration. However, it was not associated with greater in-hospital mortality or stroke occurrence. All these findings suggest that postoperative monitoring of POAF and positive intervention after detection may be more helpful in optimizing post-CABG patient outcomes.

Sex Differences in Delirium after Coronary Artery Bypass Graft Surgery and Perioperative Neuropsychiatric Conditions: A Secondary Analysis of a Cohort Study.

BACKGROUND: Biological sex influences the risk of depression and cognitive impairment, but its role in relation to postoperative delirium is unclear. This analysis investigates sex differences in delirium risk after coronary artery bypass graft (CABG) surgery and sex-related differences in relation to affective and cognitive symptoms. METHODS: This is a secondary analysis of the Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study, a single-site, observational study of a CABG surgery cohort (n = 149). Preoperative characteristics are stratified by sex, and baseline variables that differ by sex are evaluated to understand whether sex modifies their relationships with delirium. We also evaluate sex differences in one-month depression and cognition. RESULTS: Female sex is associated with several delirium risk factors, including higher risk of preoperative depression and middle cerebral artery (MCA) stenosis. MCA stenosis was statistically associated with delirium only among women (OR 15.6, 95% CI 1.5, 164.4); mild cognitive impairment (MCI) was associated with delirium only in men (OR 4.6, 95% CI 1.2, 17.9). Other sex-based differences failed to reach statistical significance. Depression remained commoner among women 1 month post-CABG. CONCLUSIONS: Women in this CABG cohort were more likely to have depression at baseline and 1 month postoperatively, as well as MCA stenosis and postoperative delirium. Sex might modify the relationship between post-CABG delirium and its risk factors including MCA stenosis and MCI. Cerebrovascular disease deserves study as a potential explanation linking female sex and a range of poor outcomes among women with coronary heart disease.

Sex-based association between high-density lipoprotein cholesterol and adverse outcomes after coronary artery bypass grafting.

BACKGROUND: High-density lipoprotein cholesterol (HDL-C) is shown to be an independent protective factor against coronary artery diseases (CAD). Yet there are limited studies focusing on the association between HDL-C and coronary artery bypass graft (CABG) surgery outcomes. HYPOTHESIS: Low levels of HDL-C are associated with higher incidence of adverse outcomes in patients undergoing CABG. METHODS: This registry-based study included 17,772 patients who underwent elective isolated CABG between 2007 and 2017. Patients were classified into low and desirable HDL-C groups based on their serum HDL-C levels at admission and were followed for one-year post-surgery. The study population included 13,321 patients with low HDL-C and 4,451 with desirable HDL-C. proportional hazard Cox models were performed to evaluate the association between HDL-C levels and incidence of mortality as well as major adverse cardiovascular and cerebrovascular events (MACCE), while adjusting for potential confounders. Moreover, participants were stratified based on sex and the association was also investigated in each subgroup separately. RESULTS: No significant difference was found between the groups regarding incidence of both mortality and MACCE, after adjusting with Inverse Probability Weighting (IPW) [HR (95%CI): 0.84 (0.46-1.53), p-value:0.575 and HR (95% CI): 0.91 (0.56-1.50), p-value:0.733, respectively]. According to the sex-based subgroup analysis, no significant association was observed after adjustment with IPW analysis. However, as we examined the association between the interaction of HDL-C levels, sex and cardiovascular outcomes, we found a significant association (HR;1.19 (95%CI: 1.04-1.45); p = 0.030). CONCLUSION: HDL-C level was not associated with either mortality or MACCE during one year after CABG procedure. Sex-based analysis showed that in males, HDL-C is significantly more protective against these outcomes, compared to females. Further studies are necessary to elucidate the exact mechanisms mediating such association.

Atrial fibrillation incidence after coronary artery bypass graft surgery and percutaneous coronary intervention: the prospective AFAF cohort study.

Objectives. Atrial fibrillation is a common arrhythmia in patients with ischemic heart disease. This study aimed to determine the cumulative incidence of new-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting surgery during 30 days of follow-up. Design. This was a prospective multi-center cohort study on atrial fibrillation incidence following percutaneous coronary intervention or coronary artery bypass grafting for stable angina or non-ST-elevation acute coronary syndrome. Heart rhythm was monitored for 30 days postoperatively by in-hospital telemetry and handheld thumb ECG recordings after discharge were performed. The primary endpoint was the cumulative incidence of atrial fibrillation 30 days after the index procedure. Results. In-hospital atrial fibrillation occurred in 60/123 (49%) coronary artery bypass graft and 0/123 percutaneous coronary intervention patients (p < .001). The cumulative incidence of atrial fibrillation after 30 days was 56% (69/123) of patients undergoing coronary artery bypass grafting and 2% (3/123) of patients undergoing percutaneous coronary intervention (p < .001). CABG was a strong predictor for atrial fibrillation compared to PCI (OR 80.2, 95% CI 18.1-354.9, p < .001). Thromboembolic stroke occurred in-hospital in one coronary artery bypass graft patient unrelated to atrial fibrillation, and at 30 days in two additional patients, one in each group. There was no mortality. Conclusion. New-onset atrial fibrillation during 30 days of follow-up was rare after percutaneous coronary intervention but common after coronary artery bypass grafting. A prolonged uninterrupted heart rhythm monitoring strategy identified additional patients in both groups with new-onset atrial fibrillation after discharge.

Impact of the COVID-19 pandemic on provision of interventional cardiology and cardiac surgery services in Australia: a review of Medicare claims data.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted healthcare service provision worldwide. There is limited information on changes in invasive cardiovascular services during the pandemic, particularly in Australia. AIM: We sought to assess temporal trends on the use of interventional cardiology and cardiac surgery services before and following the COVID-19 pandemic in Australia. METHODS: Medicare Benefits Schedule items data from the Australian Government Services Australia on outpatient and private hospital interventional cardiology procedures (coronary angiogram, percutaneous coronary intervention and transcatheter aortic valve implantation) and cardiac surgery procedures (coronary artery bypass grafting [CABG] and surgical valve replacement, repair and annuloplasty) were analysed from March 2019 to 2021. This was superimposed on monthly COVID-19 case data obtained from the Australian Department of Health and Aged Care epidemiology reports. RESULTS: A sustained reduction in CABG (-10.1%) and surgical valve intervention (-11.1%) was appreciated from March 2019-2020 to March 2020-2021, in the first year of the COVID-19 pandemic. During this period, an overall increase (+25.9%) in the use of transcatheter aortic valve implantation was observed. Following the initial period of mandated isolation in March-April 2020, a reduction in coronary angiography (-29.1%) and percutaneous coronary intervention (-19.5%) was observed in comparison to March-April 2019; however, this was largely attenuated over time. CONCLUSIONS: The COVID-19 pandemic has resulted in reductions in the use of interventional cardiology and cardiac surgery services, with cardiac surgery most affected. However, an increase in uptake of transcatheter aortic valve implantation has been observed during the pandemic. This may have implications for future planning and resource allocation in the aftermath of the pandemic.

Phase Angle as a Reliable Biomarker of Frailty to Predict Postoperative Outcomes in Patients Undergoing Off-Pump Coronary Artery Grafting: A Prospective Observational Study.

OBJECTIVE: To elucidate the association between phase angle (PA) and a composite adverse outcome in patients requiring off-pump coronary artery bypass grafting (OPCAB). DESIGN: A prospective observational study. SETTING: High-volume single center. PARTICIPANTS: A total of 229 adult patients who underwent OPCAB from May 2019 to October 2020. INTERVENTIONS: Each patient underwent bioelectrical impedance analysis, including PA assessment before surgery (PApre), immediately postoperatively (PApost), and 1 day postoperatively (PAPOD1), using an Inbody S10. Frailty index and nutritional assessments also were obtained before surgery. MEASUREMENTS AND MAIN RESULTS: Patient outcomes were assessed using a composite adverse outcome comprising death, myocardial infarction, revascularization, new-onset atrial fibrillation, acute kidney injury, stroke, postoperative pulmonary complications, wound complications, sepsis, reoperation, and/or delirium occurring during hospitalization and over the following year. Patients for whom composite adverse outcomes were reported had lower PApre than those without complications (5.4 ± 0.9 v 6.0 ± 0.9, p < 0.001). The PA was significantly associated with in-hospital and 1-year composite postoperative outcomes. The odds ratios (OR, [95% confidence interval]) for PApre by time were in-hospital complications (0.435 [0.314, 0.604], p < 0.001; 1-year complications: 0.459 [0.330, 0.638], p < 0.001) and PAPOD1 (OR, in-hospital complications: 0.400 [0.277, 0.576], 1-year complications: 0.429 [0.298, 0.619], p < 0.001). The PApre was significantly associated with days alive and out of hospital until 1 year. The cut-off value of PApre for optimal prediction of in-hospital complications was 6.0 (area under the curve: 0.691 [0.623-0.758], p < 0.001). CONCLUSION: Low PA as an indicator of frailty is associated with adverse postoperative outcomes after OPCAB. Low PA may be employed as a noninvasive and practical tool for the prediction of prognosis in patients with coronary artery disease.

Impact of Diabetes in Patients With Acute Myocardial Infarction Undergoing Coronary Artery Bypass Surgery Within 48 Hours.

BACKGROUND: Diabetic patients with coronary artery disease may benefit from elective coronary artery bypass graft (CABG) surgery. It is unknown whether this merit is transferable to patients with acute myocardial infarction (AMI) undergoing surgery. METHOD: A total of 1,427 patients underwent CABG within 48 hours of being diagnosed with AMI at the current institution between 2001 and 2019. Of these patients, 206 (14.4%) had insulin-dependent diabetes mellitus (IDDM) and 148 (10.4%) had non-insulin dependent diabetes mellitus (NIDDM). Retrospective data analysis was performed. RESULTS: Patients with NIDDM showed the highest perioperative risk profile, with a EuroScore II of 11.6 (±10.3) compared with 7.8 (±8.0) in non-diabetic patients and 8.4 (±7.8) in patients with IDDM (p<0.001). Sub-analysis demonstrated a higher proportion of non-ST-elevation myocardial infarction patients in the NIDDM cohort compared with the IDDM cohort (70.9% vs 56.8%; p=0.005). Postoperatively, NIDDM patients had more sepsis (p<0.01) and longer ventilation times (p<0.001) compared with non-DM and IDDM patients (p<0.01). Wound healing complications were rare, but almost twice as high in NIDDM patients compared with non-DM and IDDM patients (4.7% vs 0.9% vs 2.4%, respectively). The 30-day mortality was highest in the NIDDM cohort (18.3% vs 11.3% vs 7.8%; p=0.012). Analysis of survival for up to 15 years revealed a significantly reduced survival of diabetic patients compared with non-diabetic patients, with lowest survival rates in NIDDM patients (p<0.001). CONCLUSIONS: Non-insulin dependent diabetes mellitus patients undergoing CABG within 48 hours of being diagnosed with AMI are at increased risk of short-term and long-term complications. Therefore, this particular group should undergo a careful evaluation concerning the expected risks and benefits of CABG in this setting.

Postoperative Pain Management in Coronary Artery Bypass Grafting: An Integrative Review.

PURPOSE: To identify pharmacological and nonpharmacological interventions adopted for pain relief in the postoperative period of coronary artery bypass graft surgery. DESIGN: Integrative review. METHODS: Studies published in English, Spanish, and Portuguese from January 2010 to December 2019 in Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Literature on Health Science, PubMed, and Web of Science. Two hundred studies were identified and eleven were included. Methodological analysis was performed using the Medical Education Research Study Quality Instrument. FINDINGS: The studies found were organized into three thematic categories: pharmacological interventions (methadone, morphine, lidocaine gel, remifentanil, sufentanil, and nefopam), nonpharmacological interventions (low-level laser therapy, light-emitting diode, Class IV laser, and transcutaneous nerve stimulation) and anesthetic techniques (dexmedetomidine, ultrasound-guided pectoral nerve block, high thoracic epidural analgesia, and perioperative parasternal block with levobupivacaine). CONCLUSIONS: A greater tendency to use drug strategies for postoperative pain relief was identified. The drugs used demonstrated efficacy and safety in the treatment of pain, with the exception of nefopam, which showed little benefit in this population. Nonpharmacological interventions, used as adjuvants to drug treatment, were shown to be safe, effective, and well tolerated by the patients.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.

The Effects of Inspiratory Muscle Training (IMT) on Patients Undergoing Coronary Artery Bypass Graft (CABG) Surgery: A Systematic Review and Meta-Analysis.

Background: To determine the effects of inspiratory muscle training (IMT) alone on inspiratory muscle strength and endurance, pulmonary function, pulmonary complications, and length of hospital stay in patients undergoing coronary artery bypass graft surgery (CABG). Methods: We conducted a literature search across databases (Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily; Ovid Embase; Ovid Cochrane Central Register of Controlled Trials; Ovid Cochrane Database of Systematic Reviews; and Scopus) from inception to December 2021. The eligibility criteria were randomized controlled trials that investigated the effects of IMT versus usual care or sham IMT in patients undergoing CABG. Results: A total of 12 randomized clinical trials with 918 patients were included in the meta-analysis. Postoperative IMT was associated with improved maximal inspiratory pressure (MIP), maximum inspiratory pressure (PImax), and six-minute walking test (6MWT) and with a decrease in length of hospital stay (LOS). For preoperative IMT, there was statistical significance between intervention and MIP, PImax, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), postoperative pulmonary complications (PPCs), and LOS. Pre- and postoperative IMT resulted in improvements in MIP. Conclusions: Isolated IMT in patients who underwent CABG improved their inspiratory muscle strength and endurance, pulmonary function, and 6MWT and helped decrease postoperative pulmonary complications and the length of hospital stay.

Moderate-Intensity Statins Plus Ezetimibe vs. High-Intensity Statins After Coronary Revascularization: A Cohort Study.

PURPOSE: Whether moderate-intensity statins plus ezetimibe could be an alternative to high-intensity statins in patients with atherosclerotic cardiovascular disease is unclear. We compared the risk of adverse cardiovascular events in patients receiving moderate-intensity statins plus ezetimibe vs. high-intensity statins after a coronary revascularization procedure using data from a large cohort study. METHOD: Population-based cohort study using nationwide medical insurance data from Korea. Study participants (n = 20,070) underwent percutaneous coronary intervention or coronary artery bypass graft surgery between January 1, 2015, and December 31, 2016, and received moderate-intensity statins (atorvastatin 10-20 mg or rosuvastatin 5-10 mg) plus ezetimibe (n = 922) or high-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20 mg; n = 19,148). The primary outcome was a composite of cardiovascular mortality, hospitalization for myocardial infarction (MI), hospitalization for stroke, or revascularization. RESULTS: At 12 months, the incidence rates of the primary outcome were 138.0 vs. 154.0 per 1000 person-years in the moderate-intensity stains plus ezetimibe and the high-intensity statins group, respectively. The fully adjusted hazard ratio [HR] for the primary outcome was 1.11 (95% confidence interval [CI] 0.86-1.42; p = 0.43). The multivariable-adjusted HR for a composite of cardiovascular mortality, hospitalization for MI, or hospitalization for stroke was 1.05 (95% CI 0.74-1.47; p = 0.80). During follow-up, the proportion of patients maintaining their initial lipid-lowering therapy was significantly higher in the moderate-intensity statins plus ezetimibe group than in the high-intensity statins group. CONCLUSIONS: Patients undergoing a coronary revascularization procedure who received moderate-intensity statins plus ezetimibe showed similar rates of major adverse cardiovascular events as patients who received high-intensity statins.

7-year outcomes in diabetic patients after coronary artery bypass graft in a developing country.

BACKGROUND: Revascularization in diabetic patients with coronary artery disease remains a challenge in cardiology practice. Although clinical trials have reported the mid-term superiority of coronary artery bypass grafting (CABG) surgery over percutaneous coronary intervention in these patients, little is known about the long-term outcomes of CABG in diabetic patients compared to non-diabetics, particularly in developing countries. METHODS: Between 2007 and 2016, we recruited all patients who underwent isolated CABG in a tertiary care cardiovascular center in a developing country. The patients were followed at 3-6 months and 12 months after surgery, and then annually. The study endpoints were 7-year all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: Of 23,873 patients (17,529 males, mean age 65.67 years) who underwent CABG, 9227 (38.65%) patients were diagnosed with diabetes. After adjustment for potential confounders, patients with diabetes experienced a 31% increase in MACCE seven years after surgery compared to the non-diabetic patients (HR = 1.31, 95% CI: 1.25-1.38, P-value < 0.0001). Meanwhile, diabetes contributes to a 52% increase in the risk of all-cause mortality after CABG (HR = 1.52, 95% CI: 1.42-1.61, P-value < 0.0001). CONCLUSIONS: Our study showed a higher risk of all-cause mortality and MACCE at seven years in diabetic patients undergoing isolated CABG. The outcomes in the studied center in a developing country were comparable to western centers. The high incidence of adverse outcomes in the long term in diabetic patients implies that not only short-term but long-term measures should be taken to improve the CABG outcomes in this challenging patient population.

Time-varying effect of postoperative cholesterol profile on long-term outcomes of isolated coronary artery bypass graft surgery.

BACKGROUND: Controlling cholesterol levels is one of the primary goals of preventing atherosclerotic plaque progression in patients undergoing coronary artery bypass graft (CABG) surgery. This study aimed to investigate the impact of serum cholesterol profile at multiple time points following isolated CABG surgery on long-term patient outcomes. METHOD: This retrospective cohort study was conducted on the admission and follow-up data of isolated CABG patients from the Tehran Heart Center registry between 2009 and 2016. The association of low-density lipoprotein (LDL), high-density lipoprotein (HDL), and their ratio as an atherogenic index with major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality were evaluated using time-varying survival analysis methods. RESULT: A total of 18657 patients were included in this analysis. After adjusting for known confounding factors, no significant difference in all-cause mortality and MACCE was observed at different LDL levels. The incidence of acute coronary syndrome (ACS) in patients with LDL > 100 mg/dl and LDL < 50 mg/dl was significantly higher than in the control group (P-value = 0.004 and 0.04, respectively). The incidence of cerebrovascular accidents (CVA) at LDL > 100 mg/dl was also significantly higher compared to the control group (P -value = 0.033). Lower HDL levels were significantly associated with a higher MACCE (P -value < 0.001), all-cause mortality (P -value < 0.001), ACS (P -value = 0.00), and CVA (P -value = 0.014). The atherogenic index was also directly related to MACCE and all its components (all P-values < 0.001). CONCLUSION: LDL/HDL ratio is suggested as a better marker for secondary prevention goals compared to LDL alone in patients undergoing CABG surgery.

Timing of Blood Transfusions and 30-Day Patient Outcomes After Coronary Artery Bypass Graft Surgery.

OBJECTIVE: Packed red blood cell transfusion during coronary artery bypass graft surgery is known to be associated with adverse outcomes. However, the association of the timing between transfusions in relation to discharge and 30-day postoperative outcomes has not been studied. The study authors investigated the impact of transfusion timing on 30-day surgical outcomes. DESIGN: A retrospective review. SETTING: At a single tertiary-care academic hospital. PARTICIPANTS: A total of 2,481 adult patients underwent primary coronary artery bypass graft surgery between January 2014 and December 2020. MEASUREMENTS AND MAIN RESULTS: The relationship between the timing of packed red blood cell transfusion (intraoperative, postoperative, or both) and 30-day postoperative outcome variables was calculated as an odds ratio. The influence of timing of transfusion on adjusted probability of postoperative complications was plotted against the lowest intraoperative hematocrit. The median age of the population was 67 years (60.0-74.0), body mass index was 28.5 (25.6-32.3) kg/m2, and 497 (20.0%) were female. A total of 1,588 (36%) patients received packed red blood cell transfusions; 182 (7.3%) received intraoperative transfusions, 489 (19.7%) received postoperative transfusions, and 222 (9.0%) received both (intraoperative and postoperative transfusions). Postoperative transfusion was associated with significantly higher odds of readmission (1.83 [1.32-2.54], p = 0.002) and heart failure (1.64 [1.2-2.23], p = 0.008) compared to patients with no transfusions; whereas intraoperative transfusions were not. CONCLUSION: The authors' data suggested that the postoperative timing of transfusion in patients undergoing coronary artery bypass graft surgery may be associated with an increased incidence of 30-day heart failure and readmission. Prospective research is needed to conclusively confirm these findings.

Outcomes Related to Cardiac Enhanced Recovery After Surgery Protocol.

OBJECTIVES: The objective of this study was to assess the quality of pain control and outcomes in patients who underwent coronary artery bypass graft (CABG) over a period of 96 hours preimplementation of a cardiac enhanced recovery after surgery (C-ERAS) protocol compared with postimplementation. DESIGN: Single-center, retrospective cohort study. SETTING: Cleveland Clinic Akron General Hospital. PARTICIPANTS: Patients ≥18 years of age who underwent CABG surgery and received perioperative pain management pre- and post-C-ERAS protocol implementation at admission to Cleveland Clinic Akron General Hospital. INTERVENTIONS: A hospital C-ERAS protocol that included a multimodal analgesia approach to postoperative pain management. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the amount of opioid used measured in morphine milligram equivalents (MME) within 96 hours postoperatively. A total of 146 charts were reviewed, with 133 included (66 pre-C-ERAS and 67 post-C-ERAS). There was a significant reduction in median MMEs 96 hours postoperatively post-C-ERAS (98 [52-135] v 211 [130-290], p < 0.001). Additionally, a significant reduction in median MMEs was observed post-C-ERAS before (65 [43-100] v 129 [95-165], p < 0.001) and after (10 [0-40] v 68 [21-141], p < 0.001) chest tube removal and for the entire prescription at discharge (0 [0-109] v 90 [0-210], p = 0.005). CONCLUSIONS: Implementing a C-ERAS protocol within a CABG surgery patient population reduced the amount of MME.

Optimum heparin dose in off-pump coronary artery bypass grafting: A systematic review and meta-analysis.

INTRODUCTION: Off-pump coronary artery bypass grafting (OPCABG) was introduced many years ago aiming to reduce the known complications of conventional on-pump coronary surgeries. Heparin is required during the procedures, but the available protocols have diverse dosage regimens. The primary objective of this systematic review is to examine the effect of different heparin doses on the outcomes of OPCABG. EVIDENCE ACQUISITION: MEDLINE and EMBASE were searched. Four reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias using Cochrane tool. The primary outcome was the activated clotting time (ACT) at three minutes. The secondary outcomes were proportion of patients requiring blood products and the length of hospital stay. An aggregate data approach was used. EVIDENCE SYNTHESIS: Three single-center randomized studies recruiting 256 patients were included. The studies compared low-dose (1.5-2 mg/kg) and high-dose (3 mg/kg) heparin boluses. The overall mean difference for ACT after three minutes between low- and high-dose heparin is - 126.16 (95% CI: - 142.19, - 110.14). The proportion of patients requiring blood products after surgery [odd ratio 1.27 (95% CI: 0.69, 2.32)] or the overall length of stay [mean difference -0.15 (95% CI: -0.84, 0.53)] did not differ between the heparin doses. CONCLUSIONS: In OPCABG, high-dose compared with low-dose heparin did not affect the utilization of more blood products or increased the overall length of stay. Unsurprisingly, ACT values were higher in the high-dose heparin group. Larger and adequately powered randomized clinical trials are indicated to resolve the uncertainty.

Instantaneous wave free ratio value impact on left internal mammary artery graft patency.

OBJECTIVES: To assess whether instantaneous wave - free ratio (iFR) value is associated with left internal mammary artery (LIMA) graft failure at 12 months follow-up post coronary artery bypass graft (CABG). BACKGROUND: Data suggests bypass to a non-significant left anterior descending artery (LAD) lesion due to visual over-estimation may lead to LIMA graft failure. Implementing iFR may result in better arterial graft patency. METHODS: In iCABG (iFR guided CABG) study patients planned to undergo an isolated CABG procedure was prospectively enrolled and iFR was performed for LAD. Coronary computed tomography angiography was performed at 2 and 12 months follow-up. The primary endpoint of this study was to determine the rate of LIMA graft occlusion or hypoperfusion at 2 and 12-months follow-up. We considered a composite secondary endpoint of Major adverse cardiovascular and cerebrovascular event (MACCE) as a secondary outcome. RESULTS: In total 69 patients were included with no differences regarding age, sex and risk factors. At 2 months, 50 of LIMAs with pre-CABG iFR median 0.855 (0.785 - 0.892) were patent. Hypoperfusion was found in 8 LIMAs (median iFR 0.88 (0.842 - 0.90)). While, 7 LIMAs (median iFR 0.91 (0.88 - 0.96)) were occluded (p = 0.04). At 12 months, when iFR of LAD was >0.85: just 12 (31.6% out of all patent LIMAS) grafts were patent and 24 (100.0% out of all hypoperfused/occluded) grafts were hypoperfused or occluded (p < 0.001). In terms of MACCE, no difference (p = 1.0) was found between all 3 groups divided according to iFR value. CONCLUSIONS: Instantaneous wave - free ratio value above 0.85 in LAD is a powerful tool predicting LIMA graft failure at 1-year follow up period.

Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis.

BACKGROUND: As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD. METHODS: A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries. RESULTS: A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes. CONCLUSIONS: ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.

Multi-Omics Profiling of Human Endothelial Cells from the Coronary Artery and Internal Thoracic Artery Reveals Molecular but Not Functional Heterogeneity.

Major adverse cardiovascular events occurring upon coronary artery bypass graft surgery are typically accompanied by endothelial dysfunction. Total arterial revascularisation, which employs both left and right internal thoracic arteries instead of the saphenous vein to create a bypass, is associated with better mid- and long-term outcomes. We suggested that molecular profiles of human coronary artery endothelial cells (HCAECs) and human internal mammary artery endothelial cells (HITAECs) are coherent in terms of transcriptomic and proteomic signatures, which were then investigated by RNA sequencing and ultra-high performance liquid chromatography-mass spectrometry, respectively. Both HCAECs and HITAECs overexpressed molecules responsible for the synthesis of extracellular matrix (ECM) components, basement membrane assembly, cell-ECM adhesion, organisation of intercellular junctions, and secretion of extracellular vesicles. HCAECs were characterised by higher enrichment with molecular signatures of basement membrane construction, collagen biosynthesis and folding, and formation of intercellular junctions, whilst HITAECs were notable for augmented pro-inflammatory signaling, intensive synthesis of proteins and nitrogen compounds, and enhanced ribosome biogenesis. Despite HCAECs and HITAECs showing a certain degree of molecular heterogeneity, no specific markers at the protein level have been identified. Coherence of differentially expressed molecular categories in HCAECs and HITAECs suggests synergistic interactions between these ECs in a bypass surgery scenario.