Point-of-care testing for tranexamic acid efficacy: a proof-of-concept study in cardiac surgical patients.

BACKGROUND: Low-dose tranexamic acid (TXA) has been recently recommended for cardiopulmonary bypass (CPB) to reduce associated complications. Although point-of-care laboratory tests for TXA concentrations are unavailable, a novel TPA-test on the ClotPro® system can measure TXA-induced inhibition of fibrinolysis. We evaluated the performance of the TPA-test in vitro and in patients undergoing surgery requiring CPB. METHODS: Blood samples were obtained from six volunteers for in vitro evaluation of tissue plasminogen activator (tPA)-triggered fibrinolysis and the effects of TXA. This was followed by an observational study in 20 cardiac surgery patients to assess clinical effects of TXA on the TPA-test. RESULTS: Hyperfibrinolysis induced by tPA was inhibited by TXA ≥2 mg L-1 in a concentration-dependent manner, and was completely inhibited at TXA ≥10 mg L-1. In patients undergoing CPB, antifibrinolytic effect was detectable on TPA-test parameters after a 0.1 g bolus of TXA at the end of CPB, and complete inhibition of fibrinolysis was obtained with TXA ≥0.5 g. The antifibrinolytic effects of 1 g TXA on TPA-test parameters were gradually attenuated over 18 h after surgery. However, the fibrinolytic inhibition continued in four patients with estimated glomerular filtration rate (eGFR) ≤30 ml min-1 1.73 m-2. The eGFR had strong correlations with TPA-test parameters at 18 h after surgery (r=0.86-0.92; P<0.0001). CONCLUSIONS: The TPA-test is sensitive to low concentrations of TXA and serves as a practical monitoring tool for postoperative fibrinolytic activity in cardiac surgery patients. This test might be particularly useful in patients with severe renal impairment.

Resisting arrest: Perioperative confirmation and management of an iatrogenic aortocoronary arteriovenous fistula after coronary artery bypass grafting for redo cardiac surgery.

Although rare, iatrogenic aortocoronary arteriovenous fistulae (ACAVF) occur when a coronary graft is mistakenly anastomosed to an epicardial vein rather than its intended arterial target. Patients may be asymptomatic, demonstrate angina, dyspnea, arrhythmias, syncope, or diminished exercise capacity, and may have wide pulse pressures with evidence of coronary steal. A thorough insight into the disordered anatomy is critical to safely manage a patient for redo cardiac surgery, especially when attempting to arrest the heart. We present a case for redo cardiac surgery of an iatrogenic ACAVF confirmed perioperatively with multiple modalities and its intraoperative management.

Effect of Left Ventricular Hyperenhancement in Magnetic Resonance Imaging on Reverse Remodeling After Mitral Valve Repair for Moderate Ischemic Mitral Regurgitation.

We aimed to investigate cardiac magnetic resonance imaging (MRI)-derived predictors of a lack of left ventricular (LV) reverse remodeling after undersized mitral annuloplasty (uMAP) for moderate ischemic mitral regurgitation (IMR). We retrospectively reviewed 31 patients who underwent uMAP for moderate IMR and cardiac MRI evaluation between 2004 and 2017. Cardiac MRI evaluation included cine MRI LV and right ventricular volumetric measurements and gadolinium-enhanced MRI assessment of myocardial scarring. LV dimensions were assessed preoperatively, postoperatively, and at follow-up using serial transthoracic echocardiography, and the mid-term (median, 49 months) predictors of a lack of LV reverse remodeling were analyzed. At the mid-term follow-up (mean follow-up period: 85 ± 40 months), 15 patients exhibited reverse LV remodeling. The relative reduction in LV dimension at follow-up was negatively correlated with the preoperative number of LV segments with myocardial infarction (MI) (defined as an LV segment with >25% enhancement). The optimal cut-off for predicting a lack of reverse LV remodeling at follow-up was >5 LV segments with MI, with a sensitivity and specificity of 92% and 92%, respectively. This cut-off value also predicted all-cause mortality at follow-up, with a sensitivity and specificity of 88% and 67%, respectively. The presence of >5 LV segments with MI on gadolinium-enhanced MRI might be a useful predictor of lack of reverse LV remodeling and all-cause mortality outcomes after undersized mitral annuloplasty for moderate IMR.

A comparison of the ClotPro system with rotational thromboelastometry in cardiac surgery: a prospective observational study.

Viscoelastic coagulation tests have been increasingly used for hemostasis management in cardiac surgery. The ClotPro system is a novel viscoelastic device based on principles of rotational thromboelastometry. We aimed to compare ClotPro with ROTEM and plasma coagulation assays in cardiopulmonary bypass (CPB) patients. Blood samples were collected from 25 CPB patients at (1) baseline, (2) start of CPB, (3) end of CPB, and (4) end of surgery. The EX-test, IN-test, HI-test, FIB-test parameters on ClotPro were compared with corresponding ROTEM assay (EXTEM, INTEM, HEPTEM, and FIBTEM). Standard plasma coagulation assays and endogenous thrombin generation (TG) were simultaneously evaluated. Pearson correlation analyses showed moderate correlations between clotting times (CTs) (r = 0.63-0.67; p < 0.001, respectively), and strong correlations with maximal clot firmness (MCF) (r = 0.93-0.98; p < 0.001, respectively) between ClotPro and ROTEM. EX-test and IN-test MCF parameters were interchangeable with acceptable percentage errors (EX-test MCF: 7.3%, IN-test MCF: 8.3%), but FIB-test MCF (27.0%) and CT results were not (EX-test CT: 44.7%, IN-test CT: 31.4%). The correlations of PT/INR or peak TG with EX-test CTs were higher than with EXTEM CTs (PT/INR: r = 0.80 and 0.41, peak TG: 0.43 and 0.18, respectively). FIB-test MCF has strong correlation with plasma fibrinogen and factor XIII level (r = 0.84 and 0.66, respectively). ROC analyses showed that ClotPro was capable of emulating well-established ROTEM thresholds (area under curves: 0.83-1.00). ClotPro demonstrated strong correlations in MCF parameters of ROTEM in CPB patients. It may be reasonable to modify ROTEM-based transfusion algorithm pertaining to MCF parameters to establish cut-off values for ClotPro device.

Clinical outcomes of mitral valve repair for degenerative mitral regurgitation in elderly patients.

OBJECTIVES: This study analyzes the safety and outcomes of mitral valve repair for degenerative mitral valve regurgitation in patients 75 years of age or older. METHODS: We retrospectively reviewed the clinical results of 343 patients aged ≥75 years who underwent mitral valve repair for degenerative mitral valve regurgitation as a primary indication between January 1998 and June 2017. RESULTS: The median (interquartile range) age of the patients was 79.4 (76.9, 82.9) years, and 132 (38.5%) patients were women. Concomitant procedures were performed in 123 patients: tricuspid surgery in 68 (19.8%) and a maze procedure or pulmonary vein isolation in 55 (16.0%). Operative mortality was 1.2%. Operative complications included atrial fibrillation in 37.9%, prolonged ventilation in 7.0%, pacemaker implantation in 3.8, renal failure requiring dialysis in 1.5 and stroke in 3 (0.9%). The median follow-up was 7.4 years (interquartile range, 3.5-14.1 years). The cumulative incidence rates of mitral valve reoperation were 2.2%, 3.2% and 3.2% at 1, 5 and 10 years, respectively. Overall survival at 1, 5 and 10 years were 95%, 83% and 51%, respectively. Older age, smoking and over and underweight were associated with increased risk of mortality, while higher left ventricular ejection fraction and hypertension were associated with reduced risk. CONCLUSIONS: Mitral valve repair in elderly patients can be accomplished with low operative mortality and complications. Mitral valve repair in the elderly remains the preferred treatment for degenerative mitral regurgitation.

Staged total arch replacement, followed by fenestrated-branched endovascular aortic repair, for patients with mega aortic syndrome.

OBJECTIVE: The aim of the present study was to review the clinical outcomes of a staged approach using total arch replacement (TAR) with an elephant trunk or a frozen elephant trunk, followed by fenestrated-branched endovascular aortic repair (F-BEVAR) for patients with mega aortic syndrome. METHODS: We reviewed the clinical data and outcomes of 11 consecutive patients (8 men; mean age, 71 ± 7 years) treated by staged TAR and F-BEVAR from January 2014 to December 2018. The F-BEVAR procedures were performed under a prospective, nonrandomized, physician-sponsored investigational device exemption protocol. All patients had had mega aortic syndrome, defined by an ascending aorta, arch, and extent I-II thoracoabdominal aortic aneurysm. The endpoints were 30-day mortality, major adverse events (MAE), patient survival, freedom from reintervention, and freedom from target vessel instability. RESULTS: Of the 11 patients, 6 had developed chronic postdissection aneurysms after previous Stanford A (three A11, two A10, one A9) dissection repair and 5 had had degenerative aneurysms with no suitable landing zone in the aortic arch. The thoracoabdominal aortic aneurysms were classified as extent I in four patients and extent II in seven. One patient had died within 30 days after TAR (9.0%). However, none of the remaining 10 patients who had undergone F-BEVAR had died. First-stage TAR resulted in MAE in three patients (27%), including one spinal cord injury. The mean length of stay was 12 ± 6 days. The mean interval between TAR and F-BEVAR was 245 ± 138 days with no aneurysm rupture during the interval. Second-stage F-BEVAR was associated with MAE in two patients (20%), including spinal cord injury in one patient from spinal hematoma due to placement of a cerebrospinal fluid drain. The mean follow-up period was 14 ± 10 months. At 2 years postoperatively, patient survival, primary patency, secondary patency, and freedom from renal-mesenteric target vessel instability was 80% ± 9%, 94% ± 6%, 100%, and 86% ± 8%, respectively. No aortic-related deaths occurred during the follow-up period. Four patients had required reintervention, all performed using an endovascular approach. CONCLUSIONS: A staged approach to treatment of mega aortic syndrome using TAR and F-BEVAR is a feasible alternative for selected high-risk patients. Larger clinical experience and longer follow-up are needed.

Two-Stage Redo Aortic Arch Repair in a Patient With an Isolated Left Vertebral Artery.

A 47-year-old male presented with an enlarging distal aortic arch false lumen 6 months status post ascending and hemiarch replacement with antegrade endograft insertion for acute type A aortic dissection complicated by lower body malperfusion. Preoperative computed tomographic angiography showed an isolated but dominant left vertebral artery. A 2-stage open surgical repair was performed. First, the left subclavian artery was transposed on the common carotid and vertebral onto the subclavian. At the second stage, a redo total arch reconstruction was done with bypass grafts taken to the innominate and left common carotid arteries. The patient did well postoperatively.

Techniques and outcomes of total aortic arch repair with frozen elephant trunk for DeBakey I dissections.

Total aortic arch replacement (TAR) with frozen elephant trunk (FET) technique (FET) has been increasingly used to treat a variety of aortic pathologies over the past two decades. Because FET can effectively treat the diseased arch and cover the proximal entry tear in the distal arch, it is a valuable option in the treatment of DeBakey I aortic dissections. This report focuses on the techniques and outcomes of TAR with FET for acute/chronic aortic dissection. A review of pooled literature including 27 observational studies showed in-hospital mortality, permanent stroke, and spinal cord injury rates of 8.4%, 5.9% and 2.6% for acute aortic dissections, and 7.5%, 4.0% and 4.6% for chronic aortic dissections, respectively. In most of the studies, complete false lumen thrombosis rate was achieved in 80% of patients at the level of FET for acute and chronic aortic dissections. Mid-term outcomes are equally promising. For chronic aortic dissections, positive remodeling of the non-stented distal aortic segments is less frequent leading to secondary reinterventions within 3 to 5 years. However, most studies have not applied distal abdominal extensions of the repair using fenestrated and branched endografts. In the current endovascular era, TAR + FET should be considered as an alternative to conventional open surgical repair in centers of excellence.

Chronic Type A Aortic Dissection After Transcatheter Aortic Valve Replacement.

An 87-year-old man with a hostile ascending aorta who underwent transfemoral transcatheter aortic valve replacement (TAVR) using a 26-mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA) 2 years earlier presented with chronic type A aortic dissection, which was retrospectively caused by the edge of the pusher of the TAVR implantation system. Redo sternotomy and extraction of the Sapien valve, followed by replacement of the ascending aorta and the aortic valve, were performed successfully. Retrospective image analysis showed the importance of respecting the anatomy of the ascending aorta before considering transfemoral TAVR.

Bilateral internal thoracic artery grafting: in situ or composite?

Bilateral internal thoracic artery (BITA) grafting is considered a superior choice for coronary artery bypass grafting (CABG). While the 10-year outcomes of BITA grafting from the recent Arterial Revascularization Trial (ART) are still pending, numerous observational studies have demonstrated the advantages of BITA grafting. These include better long-term graft patency and freedom from arteriosclerosis, in addition to higher survival rate compared to CABG using only the left internal thoracic artery (ITA). The different BITA configurations are in situ and composite-the choice of optimal grafting configuration is challenging. Patient factors such as coronary anatomy, presence of a diseased ascending aorta and the potential need for a future redo sternotomy will influence the choice of the grafting strategy. In situ BITA grafting is associated with excellent clinical outcomes and has been extensively described in the literature. However, uncertainties remain regarding the ideal in situ configuration and design. Composite BITA grafting is the other option that maximizes right ITA (RITA) utilization. In this configuration, the RITA is able to reach the distal circumflex and right coronary artery branches. This approach decreases the need for a third graft conduit.

Ten-year experience of endocardial linear infarct exclusion technique for ischaemic cardiomyopathy.

OBJECTIVES: To report the mid-term results of our surgical ventricular restoration procedure, called the endocardial linear infarct exclusion technique (ELIET), for ischaemic cardiomyopathy. METHODS: From 2006 to 2015, 43 consecutive patients who underwent surgical ventricular restoration with ELIET for ischaemic cardiomyopathy were retrospectively analysed. RESULTS: The mean age of patients at surgery was 65.3 ± 9.2 years and EuroSCORE II was 13.7 ± 12.0% (median 9.3%). The mean number of distal anastomoses of coronary artery bypass was 2.8 ± 1.5. A concomitant mitral procedure was performed in 58.1% of patients. The hospital mortality rate was 11.6% (5 patients). The ejection fraction was improved from 24.1 ± 9.2% to 31.7 ± 8.2% in 2 weeks after surgery. The end-systolic left ventricular volume index was effectively reduced, irrespective of performing a concomitant mitral procedure (reduction rate, ELIET: 35.6% vs ELIET + mitral: 39.2%). After ELIET, the sphericity index of the left ventricle did not worsen, and the conicity index was significantly improved. The 5-year estimated rates of survival and freedom from cardiac events were 71.3 ± 7.9 and 61.1 ± 8.3%, respectively. A concomitant mitral procedure was significantly associated with cardiac events based on univariate Cox hazard analysis. CONCLUSIONS: This study showed that ELIET can effectively reduce the ventricular volume and create an ellipsoidal left ventricle.

Left main coronary stenosis: surgery still reigns.

PURPOSE OF REVIEW: Coronary artery bypass grafting (CABG) has been regarded as the mainstream treatment for unprotected left main coronary artery (ULMCA) stenosis. However, the results of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, in which percutaneous coronary intervention (PCI) was deemed noninferior to CABG, have raised a question whether the guidelines should be changed. This article provides a critical appraisal of recent randomized control trials (RCTs) on ULMCA stenosis. RECENT FINDINGS: In contrast to EXCEL trial, another large RCT named the Nordic-Baltic-British Left Main Revascularization trial showed that PCI is inferior to CABG in patients treated for ULMCA stenosis. The reason for the discrepancy between these two RCTs may be due to differences in study design. In EXCEL trial, the adoption of new periprocedural myocardial infarction definition, the noninclusion of target vessel revascularization as a primary endpoint component, and the timeline of the study may have helped claim that PCI is noninferior to CABG. SUMMARY: The long-term efficacy of PCI for ULMCA stenosis has not yet been demonstrated. Further studies and follow-up data are needed before the indications for PCI are expanded in this scenario.

Computational fluid dynamics simulation of the right subclavian artery cannulation.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of right subclavian artery cannulation using computational fluid dynamics. METHODS: Patient-specific models of the aortic arch were made with 4 patterns (1: normal aorta, 2: ascending aorta aneurysm, 3: distal arch aneurysm, 4: bovine arch) based on the computed tomography images. Right subclavian artery and ascending aorta cannulation models were created to simulate the physiologic pulsatile flow. Perfusion flow through the arterial cannula was set to 2.50 L/min (50% flow), 3.75 L/min (75% flow), and 5.0 L/min (100%), respectively, and a 3-dimensional movie was made of 1 cardiac cycle to evaluate the blood flow. RESULTS: In both 50% and 75% flow simulation with right subclavian artery cannulation, the blood streamline from the right subclavian artery produced retrograde flow of the brachiocephalic artery and antegrade flow of the right common carotid artery throughout the cardiac cycle in all cases. Right subclavian artery flow deflected ascending aorta flow to the descending aorta. Left-side supra-aortic branches were perfused by blood flow from both the right subclavian artery cannula and the aortic valve. The ascending aortic cannulation model showed that blood flow from the aortic valve reached all 3 supra-aortic vessels in systole. CONCLUSIONS: Right subclavian artery cannulation was cerebroprotective, especially on the right side.

Single-Centre Experience of Off-Pump Multi-Vessel Coronary Artery Bypass Grafting Using Proximal Suture Device.

BACKGROUND: To investigate the results of off-pump coronary artery grafting (OPCAB) with the proximal suture device (PSD) regarding postoperative stroke and graft patency. METHODS: The PSD was used in 376 patients (32.0%), aorta-no-touch OPCAB was performed in 523 patients (45.2%), on-pump beating coronary artery bypass surgery (CABG) (on-beat group) in 125 patients (10.6%) including 51 conversions (conversion rate: 5.4%), and CABG with aortic clamp use (clamp group) in 152 patients. In the PSD group, Enclose II was used in 267 patients (71.0%). RESULTS: The hospital mortality rate was 1.95%. There was no early stroke in the OPCAB group, whereas the early-stroke rate was 0.8% in the on-beat group and 2.6% in the clamp group. The incidences of stroke at one month were: PSD group, 1.6%; no-touch group, 1.1%; on-beat group, 1.6%; and clamp group, 4.6% (p=0.014). The rates of complete revascularisation were higher in the PSD and clamp groups (94.7 and 94.0%, respectively) compared with the no-touch and on-beat groups (81.5 and 84.9%, respectively; p<0.001). The vein graft patency rates were comparable between the PSD and clamp groups. In multiple logistic regression analysis, OPCAB using the PSD did not increase the risk of stroke compared with the no-touch group (adjusted odds ratio [AOR]: 1.40; p=0.594) or on-beat group (AOR: 0.99; p=0.206), but reduced the risk of stroke compared with the clamp group (AOR: 0.19; p=0.005). CONCLUSIONS: Off-pump coronary artery grafting using the PSD was a safe and effective procedure. It led to lower incidences of postoperative stroke and excellent rates of graft patency and complete revascularisation compared with conventional CABG.

Endocardial linear infarct exclusion technique for infarcted lateral wall.

We report a novel method of surgical ventricular restoration for an infarcted lateral wall: the endocardial linear infarct exclusion technique. First, transmural ventriculotomy is performed at the centre of the scar longitudinally along the coronary artery. Second, the inner layer is sutured in a longitudinal direction with 4-0 polypropylene continuous sutures to approximate the border between the normal and infarcted myocardium. Finally, the outer layer is closed with a combination of interrupted buttress and continuous over-and-over sutures with outer felt reinforcement. The advantages of endocardial linear infarct exclusion technique are as follows: the risk of bleeding is low; it is not technically demanding and is reproducible; the coronary artery can be preserved; approximation of the base of the anterior and posterior papillary muscles is possible in the case of ischaemic mitral regurgitation and it can also be applied to the anterior and inferior walls.

Ventricular volume and myocardial viability, evaluated using cardiac magnetic resonance imaging, affect long-term results after surgical ventricular reconstruction.

OBJECTIVES: We aimed to investigate the outcomes of surgical ventricular reconstruction (SVR) for ischaemic cardiomyopathy and to identify ideal candidates for this procedure using cardiac magnetic resonance imaging (MRI) studies. METHODS: We retrospectively examined 50 patients who underwent SVR and were preoperatively evaluated using cardiac MRI from 2004 to 2014. Cine MRI and gadolinium-enhanced MRI were performed to evaluate left ventricular (LV) volume and scarring. The midterm (median, 2.5 years) risk factors of cardiac death or major adverse cardiac events (MACEs) were analysed. Patients were divided into three groups-those with preoperative indexed LV end-systolic volume (LVESVI) of ≤100 ml/m2 (Group 1), those with LVESVI of >100 and ≤130 ml/m2 (Group 2) and those with LVESVI of >130 ml/m2 (Group 3)-and examined. RESULTS: In total, 17 patients exhibited MACEs at follow-up. Kaplan-Meier analysis showed that the 5-year rate of freedom from MACEs was 66%. The Cox hazard model indicated that preoperative LVESVI was the only significant predictor for MACEs (P = 0.006; hazard ratio, 1.02; 95% confidence interval, 1.01-1.04). Moreover, a significant reduction in LVESVI and an increase in LV ejection fraction (LVEF) were observed early after SVR (preoperative versus postoperative: LVESVI, 110 ± 44 vs 68 ± 28 ml/m2, P < 0.001; LVEF, 24.3 ± 10.3 vs 32.0 ± 10.4%, P < 0.001) and at follow-up (LVESVI, 61 ± 28 ml/m2, P < 0.001; LVEF, 36.5 ± 11.5%, P < 0.001). Although no difference was observed between the groups at follow-up, LVEF and LVESVI primarily improved in Group 2. LVEF improvement was significantly greater in Group 2 than in Group 1 (%increase in LVEF: Group 1, 6%; Group 2, 18%; P = 0.008). In patients with a preoperative LVESVI of >130 ml/m2, the number of non-viable segments was a significant risk factor for MACEs. CONCLUSIONS: Patients with preoperative LVESVI ranging from 100 to 130 ml/m2 had fairly better outcomes, and the percentage improvement in LVEF and the percentage reduction in LVESVI were more pronounced in these patients. Hence, accurate preoperative assessments of LV volume and viability testing using cardiac MRI studies are essential for better stratification of the SVR procedure.

Safety and Efficacy of Sequential Left Internal Thoracic Artery Grafting to Left Circumflex Area.

BACKGROUND: This study investigated short-term and long-term results of coronary artery bypass grafting (CABG) with in situ sequential left internal thoracic artery (LITA) grafting to the left circumflex area. METHODS: The study divided 452 patients who underwent CABG with bilateral ITA grafting to the left coronary artery into two groups: 191 in the sequential group and 261 in the individual group. The 147 pairs were matched by the propensity score. RESULTS: In the matched pairs, the rates of off-pump, complete revascularization, and hospital death were comparable between the two groups. Early graft evaluation was performed in 78.6%. There was no occlusion of the sequential LITA graft itself, but 5 complications occurred involving the distal segment of the LITA graft (occlusion, 2; string, 2; and competition, 1), and 3 complications (occlusion, 2; and string, 1) developed in the individual group. Event-free anastomosis rates were 97.8% in the sequential group and 97.4% in the individual group (p = 0.847). Diamond anastomosis of proximal sequential grafting showed a better patency of the distal part of sequential anastomosis compared with a parallel anastomosis of proximal sequential grafting (98.4% vs 90.7%, respectively). The freedom from target lesion revascularization and overall survival at 8 years was 94.6% and 96.3% in the sequential and individual groups, respectively (log-rank p = 0.645) and 80.7% and 77.4% (p = 0.300), respectively. CONCLUSIONS: In situ sequential LITA grafting provides acceptable early graft patency and freedom from repeat revascularization, resulting in excellent survival. This technique is a useful strategy for multivessel revascularization including the left circumflex area.

Impact of Chronic Kidney Disease on Long-Term Outcome of Coronary Artery Bypass Grafting in Patients With Diabetes Mellitus.

BACKGROUND: The aim of this study was to compare the short- and long-term outcomes of CABG in diabetes mellitus (DM) patients according to eGFR. METHODS AND RESULTS: A total of 573 DM patients receiving CABG between 1997 and 2012 were stratified according to preoperative eGFR: normal or mild chronic kidney disease (CKD), eGFR ≥60 ml/min/1.73 m(2); moderate CKD, eGFR 30-60 ml/min/1.73 m(2); severe CKD, eGFR <30 ml/min/1.73 m(2); and severe CKD requiring hemodialysis (HD). Off-pump and bilateral internal thoracic artery (BITA) grafting rates were 83.4 and 62.3%, respectively. Mediastinitis and in-hospital mortality rates were both 1.4%. On logistic regression analysis, preoperative congestive heart failure and CKD severity were independent predictors of postoperative renal failure and major complications. The mean follow-up period was 5.7 years (range, 0-15.5 years). Estimated 5-year survival (92.9±1.6%, 82.8±3.3%, and 47.3±7.0%, respectively, P<0.001) significantly decreased with declining kidney function. On Cox hazard modeling, CKD severity was an independent predictor of major cerebrocardiovascular events (normal/mild: hazard ratio [HR], 1; moderate: HR, 1.35; severe: HR, 1.83; HD: HR, 2.0, P=0.016) and of overall survival (normal/mild: HR, 1; moderate: HR, 1.65; severe: HR, 5.96; HD: HR, 10.93, P<0.001). BITA grafting was a strong protective factor for overall survival (HR, 0.63; P=0.022). CONCLUSIONS: In DM patients, early- and long-term outcomes after CABG are strongly influenced by CKD progression.