Endarterectomy may be an effective additional treatment for three diffuse coronary artery disease complicated with diabetes.

OBJECTIVE: In order to evaluate the clinical efficacy of coronary endarterectomy (CE) and coronary artery bypass grafting (CABG) in patients with diabetes complicated with three diffuse coronary artery stenosis. METHODS: A retrospective analysis was conducted on 460 patients with diabetes mellitus and diffuse three-vessel coronary artery disease who underwent CABG in our department from September 2015 to December 2021. The patients were divided into two groups according to whether they underwent CE: the simple CABG group (group A, n = 254) and the CABG combined CE group (group B, n = 206). The perioperative outcomes, recurrent angina pectoris during 1-year follow-up, and the patency rate of the grafted vessel in coronary CT angiography were compared between the two groups. RESULTS: There was no significant difference in the 30 days mortality rate between the two groups (2.3% vs 2.4%, p < 0.05). Group A had a shorter operation time [(3.55 ± 0.59) h versus (4.35 ± 0.65) h], less bypass grafts [(2.72 ± 0.83) versus (3.65 ± 0.72) vessels/case], a lower incidence of perioperative myocardial infarction (7.1% vs 12.6%), and a lower number of patent graft vessels at 1-year follow-up [(2.15 ± 0.42) versus (2.88 ± 0.68) vessels/case] compared with group B (all p < 0.05). Group A had a higher incidence of recurrent angina during follow-up (14.49% vs 6.47%) (p < 0.05). Although there was no significant difference in the incidence of MACCE events between the two groups, the probability of revascularization was higher in group A. CONCLUSION: Compared with single CABG, combined CE in patients with diabetes mellitus and diffuse three-vessel coronary artery disease can achieve more complete revascularization, reduce the recurrence of angina pectoris and the needing of postoperative revascularization, but the incidence of perioperative myocardial infarction is higher.

Comparative study of coronary artery bypass grafting combined with off-pump mitral valvuloplasty versus coronary artery bypass grafting alone in patients with moderate ischemic mitral regurgitation.

INTRODUCTION: Whether mitral surgery should be performed simultaneously with coronary artery bypass grafting (CABG) in patients with moderate ischemic mitral regurgitation (MIMR) is controversial. This study was performed to introduce a method of off-pump mitral valvuloplasty after off-pump CABG (OPCABG) and compare it with OPCABG alone. METHODS: Eighty-three patients with MIMR underwent OPCABG. Among them, 21 patients (Group A) underwent posterior mitral annuloplasty without cardiopulmonary bypass, and 62 patients (Group B) underwent OPCABG alone. The primary endpoint of follow-up was the mitral regurgitation area. RESULTS: The mean mitral regurgitant area in Group A and B was 6.42 ± 1.02 and 5.49 ± 1.24 cm2 preoperatively (p = .479), 2.93 ± 1.35 and 3.28 ± 1.93 cm2 at 1 week postoperatively (p = .516), 3.06 ± 2.16 and 3.09 ± 1.85 cm2 at 3 months postoperatively (p = .839), and 3.02 ± 1.60 and 3.7 cm2 (median) at 1 year postoperatively (p = .043). There was less regurgitation in Group A at the mid-term. Intragroup comparison showed significant differences between the preoperative and postoperative values in both groups, with no difference in the regurgitant area at each postoperative time point in Group A but a significant difference between 3 months and 1 year postoperatively in Group B (p = .042). Multiple linear regression showed that the mid-term mitral regurgitant area changes were negatively correlated with graft flow and positively correlated with age. CONCLUSION: In patients with MIMR who underwent OPCABG plus off-pump mitral valve annuloplasty, the mitral regurgitant area was smaller and mitral regurgitation recurrence was less frequent at the mid-term follow-up.

Distal end side-to-side anastomosis of sequential coronary bypass for size mismatched saphenous vein grafts and coronary arteries.

INTRODUCTION: The distal end anastomosis is critical to the entire sequential grafts in coronary artery bypass grafting (CABG), but caliber mismatch diminishes the quality of the anastomosis. We aimed to introduce a modified distal end side-to-side (deSTS) anastomosis to handle the size mismatch and compared with classic distal end end-to-side (deETS) anastomosis. METHODS: From January 2014 to December 2018, 185 patients who underwent off-pump CABG with size mismatched sequential vein grafts (≥3.5 mm) and target coronaries (1.0-1.5 mm) at the distal end anastomoses were included. We retrospectively reviewed the data of the patients, perioperative and follow-up outcomes were analyzed. RESULTS: The deSTS group (n = 67) showed higher anastomotic flow (19.8 ± 8.0 vs 14.9±6.8 mL/min; p < 0.001) and lower pulsatility index (2.7 ± 0.8 vs 3.2 ± 1.0; p = 0.001) than the deETS group (n = 118). Higher incidence of in-hospital myocardial infarction (MI) was found in the deETS group but without significant difference (9.0% vs. 15.3%; p = 0.220). Kaplan-Meier analysis illustrated a relatively lower MI and major adverse cardiovascular and cerebrovascular events (MACCE) incidence in the deSTS group, and the deSTS group was associated with a reduction in long-term death, MI and MACCE in the adjusted Cox regression model. In addition, relatively higher graft patency was found in the deSTS group. CONCLUSIONS: The deSTS anastomosis showed superiority in solving size mismatch in sequential CABG, including better intraoperative flow dynamics, ideal long-term graft patency and reduced the incidence of perioperative and follow-up adverse events especially in MI.

A clinical study of genetic testing to guide the dosing of warfarin after heart valve replacement.

OBJECTIVE: To explore the role of genetic testing of VKORC1 and CYP2C9 in determining the dosage of warfarin after aortic valve replacement. METHODS: A total of 172 patients receiving warfarin after aortic valve replacement were divided into a control group (n = 86) and an experimental (n = 86) group based on acceptance of genetic testing. In the experimental group, three loci of VKORC1 and CYP2C9 were tested by polymerase chain reaction-restriction fragment length polymorphism technique, and the initial dose of warfarin was determined based on the genetic testing results and warfarin oral-dose table recommended by U.S. Food and Drug Administration (FDA). In the control group, warfarin (3 mg per night) was used as the initial dose. The international normalized ratio (INR) of each patient was continuously monitored after medication. The percentages of patients meeting the target INR in the two groups at specific time points and at 3-month follow-up after discharge from the hospital were monitored, and the incidence of various adverse events was compared between the groups. RESULTS: Based on the results of genetic testing, 68 patients received 3-4 mg/d (79.1%), 10 patients received 0.5-2 mg/d (11.6%), and eight patients received 5-7 mg/d (9.3%) as the initial dosages of warfarin in the experimental group. The percentages of the patients meeting the target INR on the third and sixth day of postoperative medication were 45.3% and 73.3%, respectively, in the experimental group, and 29.8% and 58.3%, respectively, in the control group. The INR critical values during hospitalization occurred in 2.3% in the experimental group and in 7.1% in the control group, while the percentage of the patients meeting the target INR after 3 months was 86.1% in the experimental group and 83.1% in the control group. CONCLUSION: Genetic testing may guide the selection of the initial dose of warfarin after heart valve replacement to rapidly achieve a stable dose.

Novel Cardioplegia Delivery in Patients with Severe Aortic Regurgitation.

During aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR), repeated delivery of cardioplegia into the coronary ostia using a routine infusion cannula may induce coronary ostial injury. This study aims to introduce a new no-touch delivery method with reduced time and similar or better outcomes. Preliminary results have shown that no-touch cardioplegia delivery method was a simple, safe, and effective approach for cardioplegia infusion during AVR in patients with severe AR.

MiR-140-5p upregulation suppressed ß-glycerophosphate-induced vascular smooth muscle cell calcification via targeting TLR4.

BACKGROUND: The role and function of microRNA (miRNA, miR)-140-5p in the calcification of vascular smooth muscle cells (VSMCs) have been explored in this study. METHODS: The calcium nodules formed in transfected and ß-glycerophosphate (ß-GP)-treated VSMCs were observed using Alizarin Red S staining, and alkaline phosphatase (ALP) activity was determined. VSMC apoptosis was detected with flow cytometry assay. The target gene of miR-140-5p was predicted and confirmed with dual-luciferase reporter assay. Relative expressions of miR-140-5p, toll like receptor 4 (TLR4) and vascular calcification-related proteins (α-smooth muscle actin, α-SMA; Msh Homeobox 2, MSX2; bone morphogenetic protein 2, BMP2; Kruppel-like factor 4, KLF4; Runt-related transcription factor 2, RUNX2) were measured through quantitative real time polymerase chain reaction (qRT-PCR) and western blot. RESULTS: MiR-140-5p upregulation reversed the effects of ß-GP on downregulating miR-140-5p and α-SMA expressions, enhancing ALP activity, calcium nodule formation and cell apoptosis, and upregulating levels of MSX2, BMP2, KLF4 and RUNX2. TLR4 was the target of miR-140-5p, and offset the effects of miR-140-5p on ß-GP-induced VSMCs. CONCLUSIONS: MiR-140-5p upregulation represses ß-GP-induced calcification of VSMCs via targeting TLR4, providing a potential therapeutic method for vascular calcification.

Distal anastomosis support for bypass grafting with coronary endarterectomy for the severe diseased posterior descending artery.

BACKGROUND: The posterior descending artery is the most common vessel chosen for an endarterectomy, while endarterectomy to the posterior descending artery is associated with decreased graft patency. The purpose of this study was to describe a distal anastomosis support (DAS) technique and retrospectively investigate the effect of DAS on the mid-term graft patency. METHODS: Between January 2016 and December 2018, 200 patients with a PDA severe lesion who underwent off-pump coronary artery bypass (OPCAB) with CE (OPCAB + CE group, n = 95) and OPCAB + CE with DAS for anastomosis of PDA grafted by saphenous vein (SVG) (OPCAB + CE + DAS group, n = 105) were evaluated retrospectively. All patients came back to follow-up visit 6th, 12th, 24th, and 36th postoperative month. The primary endpoint is the graft failure (FitzGibbon B or O) of SVG-PDA on the follow-up CTA or CAG. RESULTS: There was no significant difference in perioperative outcomes. We found significantly improved cumulative graft patency in OPCAB + CE + DAS group at 36 months after operation (84.6% vs 76.5%, p = 0.02). In multivariate Cox regression analysis, plaque length larger than 2 cm (hazard ratio [HR], 13.108, 95% confidence interval [CI], 2.842-60.457, p = 0.001), and peak TNI ⩾70× ULN within 48 hours of surgery (HR, 3.778, 95% CI, 1.453-9.823, p = 0.006) were independent predictors of graft failure, whereas PDA diameter greater than 1.5 mm (HR, 0.231, 95% CI, 0.081-0.654, p = 0.006), and DAS use (HR, 0.336, 95% CI, 0.139-0.812, p = 0.015) were significant protective factors. CONCLUSIONS: Concomitant DAS conferred superior mid-term patency of SVG-PDA. Adding the DAS procedure to OPCAB + CE may be a promising surgical option for patients with a PDA severe lesion, especially when PDA diameter less than 1.5 mm and plaque length greater than 2 cm.

Venoarterial extracorporeal membrane oxygenation for cardiogenic shock after coronary endarterectomy.

BACKGROUND: Clinical outcomes of cardiogenic shock patients who were supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary endarterectomy (CE) have not yet been reported. We conducted a retrospective observational study to evaluate the short-term outcomes of patients supported with VA-ECMO after CE. METHODS: Patients (n = 32) who received VA-ECMO refractory cardiogenic shock after CE between January 2011 and December 2020 at the Beijing Anzhen Hospital were reviewed retrospectively. Multivariable logistic regression analysis was used to identify factors independently associated with in-hospital mortality. RESULTS: Twenty patients (63%) could be weaned from VA-ECMO, and 12 patients (38%) survived to hospital discharge. The median (interquartile range [IQR]) time on VA-ECMO support was 4 (3-6) days. The median (IQR) length of ICU stay and hospital stay were 9 (5-13) and 20 (15-27) days, respectively. Neurological complications were observed in 4 (13%) of the patients. ECMO-related complications occurred in 9 (28%) of the patients. SAVE score was identified as an independent protective factor for in-hospital mortality (OR, 0.70; 95% CI, 0.54-0.91; p = 0.009). The area under the receiver operating characteristic curve for SAVE score was 0.83 (95% CI, 0.67-0.98). SOFA score (0.78; 95% CI, 0.62-0.94) and EuroSCORE (0.79; 95% CI, 0.62-0.97) also exhibited good performances. CONCLUSIONS: VA-ECMO is an acceptable technique for the treatment of cardiogenic shock in patients undergoing CE. SAVE score might be a useful tool to predict survival for these patients. Prospective studies are needed to assess long-term outcomes of hospital survivors.

The main trunk of RCA may be the best choice of sequential vein graft distal end-to-side anastomosis.

OBJECTIVE: The purpose of this study was to investigate the effect of different anastomotic positions on the early patency of the distal end-to-side anastomosis of sequential saphenous vein grafts (SVG) in off-pump coronary artery bypass grafting (OPCAB). METHODS: A total of 259 patients who underwent OPCAB between August 2014 and August 2019 and presented for coronary computed tomography angiography (CCTA) to evaluate graft patency at 1 year post-OPCAB were analyzed. There are two kinds of distal end-to-side anastomosis of SVG, to posterior descending artery (PDA) and main trunk of right coronary artery (RCA). In all, 1044 distal coronary anastomoses on 518 grafts which included 180 left internal mammary artery (LIMA) grafts, individual 79 SVG and 259 sequential SVG were assessed using CCTA. The blood flow (BF), pulsatility index (PI), and patency of every anastomosis were recorded. Besides, comprehensive data of SV-PDA and SV-RCA patients was also compared. RESULTS: The mean BF of SV-RCA was significantly higher than that of SV-PDA (31.71 ± 18.60 vs 22.62 ± 14.48, p = 0.001), and the PI value of SV-RCA was significantly lower than that of SV-PDA (2.57 ± 1.17 vs 3.50 ± 1.69, p = 0.001). The patency of RCA system was significantly lower than that of the LAD and the left circumflex system (79.25% vs 90.13%, 90.23% respectively, p = 0.001). In sequential SVG, the patency of SV-PDA was significantly lower than that of SV-RCA (74.01% vs 86.59%, p = 0.001). Although, there was no significant difference in left ventricular ejective fraction, the left ventricular end-diastolic diameter (LVDd) in SV-PDA group was significantly larger than that in SV-RCA (52.67 ± 8.72 mm vs 47.34 ± 7.55, p = 0.001). In addition, the target vessel diameter in SV-PDA group was smaller than that in SV-RCA group (1.52 ± 0.41 mm vs 3.17 ± 0.88 mm, p = 0.001). CONCLUSION: The early patency of sequential SVG end to RCA after OPCAB is generally superior to that of to PDA, especially for patients with large LVDd.

Adventitial Collagen Crosslink Reduces Intimal Hyperplasia in a Rabbit Arteriovenous Graft Model.

BACKGROUND: Intimal hyperplasia (IH) is the initial lesion of vein graft failure after coronary artery bypass grafting. The weak venous wall is likely one of the primary reasons for IH after exposure to the arterial environment. We investigate whether adventitial collagen cross-link by glutaraldehyde (GA) reinforces the venous wall and then reduces IH. MATERIALS AND METHODS: Adventitial collagen cross-link by 0.3% GA was performed on the rabbit jugular veins. The degree of cross-link was accessed by tensile test. The jugular vein with or without cross-link was implanted into the carotid artery of rabbit. Vein dilatation at the immediate anastomosis and pathological remodeling of vein graft after 4 wk was assessed. RESULTS: Tensile test indicated that the mechanical property of 3-min cross-linked veins more closely resembled that of the carotid artery. In rabbit arteriovenous graft models, 3-min adventitial collagen cross-link limited overdistension (diameter: 3.24 mm versus 4.65 mm, P < 0.01) at the immediate anastomosis and reduced IH (intima thickness: 78.83 µm versus 140.19 µm, P < 0.01) of vein grafts 4 wk after implantation in the cross-link group as compared with the graft group (without cross-link). Compared with the cross-link group, the expression of proliferating cell nuclear antigen and vascular cell adhesion molecule-1 increased significantly at both the mRNA and protein levels within the graft group (P < 0.01), but the expression of smooth muscle-22α decreased significantly (P < 0.01). CONCLUSIONS: Adventitial collagen cross-link by GA increased the vessel stiffness and remarkably reduced IH in a rabbit arteriovenous graft model.

Open chest epicardial and transapical endocardial substrate ablation for ventricular tachycardia with left ventricular aneurysm in a porcine model.

BACKGROUND: Endo-epicardial radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) as a first-line strategy has been shown to improve outcomes. This study sought to evaluate the feasibility and validity of open-chest epicardial and transapical endocardial substrate ablation for VT with left ventricular aneurysm (LVA) applying to routine cardiac surgery. METHODS: Porcine models of LVA with VT were developed and were divided into a study group (RFCA from the epicardium via direct-view and endocardium via transapical access) and a control group (endocardial RFCA via retrograde transaortic access). Substrate-based mapping and ablation targeting abnormal potentials were performed under thoracotomy. Outcomes, including procedural success and acute freedom from VT, were analysed. RESULTS: Twenty-four of 35 (68.57%) acute myocardial infarction (AMI) pigs developed LVA with VT in a 6-week survival period and were randomly divided into a study group (n=12) and a control group (n=12). All animals in the study group successfully underwent endocardial mapping and ablation by transapical access. The scar size of the endocardium and the left ventricular chamber volume were similar in the two groups. Acute freedom from VT in the study group was remarkably superior to that in the control group (88.33% vs. 58.33%, p=0.04). CONCLUSIONS: Combined, direct epicardial and transapical endocardial substrate mapping and ablation appeared to be feasible and effective for treating VT with LVA under thoracotomy.

Observation of local cardiac electrophysiological changes during off-pump coronary artery bypass grafting using epicardial mapping.

OBJECTIVES: At present, there is no effective method of evaluating the electrophysiological changes in cardiac myocytes during off-pump coronary artery bypass grafting (OPCAB). Therefore, we preliminarily explored the relationship between electrophysiological characteristics and the changes in cardiac function of 24 patients undergoing OPCAB. METHODS: We used the CARTO3 system for epicardial electrophysiological mapping before surgery, during left anterior descending branch anastomosis, diagonal branch anastomosis and after surgery for 24 patients undergoing OPCAB. Data, including local activation time (LAT), bipolar voltage value (BV) and conduction velocity, were processed and analyzed by the system. Intraoperative invasive blood pressure, heart rate and arterial blood gas analysis data were recorded. Continuous electrocardiography (ECG) monitoring was performed three days after surgery. Routine resting myocardial perfusion imaging (MPI) and adenosine stress-gated MPI were performed before surgery. Patients were re-examined before discharge. RESULTS: By analyzing the change in the LAT value, we found that the order of excitation of local myocardial cells changed after surgery. In addition, the LAT change in myocardial cells closer to the anastomosis was more significant. The earliest pacing point on the left anterior descending (LAD) coronary artery territory map was the third point (from the proximal to distal LAD) before OPCAB, but the earliest pacing point moved down to the fourth point (closer to the anastomosis) after the diagonal (DIA) anastomosis was complete. On the DIA territory map, the earliest pacing point was the fourth point before OPCAB; this moved up to the third point (closer to the anastomosis) after DIA bypass grafting. The voltages of all points were increased after myocardial revascularization. Compared with the preoperative period, the third, fourth and fifth points on the LAD territory map increased significantly after LAD anastomosis was complete (p=0.007, p=0.001, p=0.009, respectively). On the DIA territory map, the voltages of the first, second and third points were remarkably increased after completing the DIA anastomosis compared to before OPCAB and after LAD anastomosis completion (p=0.001, p=0.008, p<0.001 and p=0.006, p=0.032, p=0.002, respectively). The average conduction velocity (ACV) of all mapped points increased after OPCAB compared with before OPCAB (p<0.05). Postoperative resting MPI and adenosine stress-gated MPI showed that left ventricular global systolic function improved, the left ventricular ejection fraction (LVEF) increased significantly (p<0.05) and the left ventricular end systolic volume (LVESV) decreased significantly (p<0.05) compared to the preoperative MPI. CONCLUSIONS: Adequate surgical coronary revascularization could lead to more stable electrical activity of local cardiomyocytes, thus, illustrating the specific mechanism of coronary revascularization for improving the cardiac function from an electrophysiological perspective.

Surgical linear ablation for ventricular tachycardia with postinfarction ventricular aneurysm.

BACKGROUND: Left ventricular aneurysm (LVA) might be an arrhythmogenic substrate. Endocardiectomy and cryoablation for ventricular tachycardia (VT) with LVA can cause extensive myocardial damage. We aimed to evaluate the feasibility of surgical radial linear ablation for VT with LVA guided by electrophysiological mapping. MATERIALS AND METHODS: Porcine models of VT with LVA were developed. Endocardial and epicardial substrate mapping during sinus rhythm were performed under thoracotomy. Surgical radial linear ablation was achieved by a bipolar radiofrequency ablation device. Outcomes, including procedural success and acute freedom of VT, were analyzed. RESULTS: Fifteen of 20 pigs developed LVA in a 6-wk survival period. A total of 28 sustained monomorphic VTs were initiated in 13 of 15 pigs (86.67%). The number of potential points captured from the endocardium and epicardium were 319 ± 45 and 358 ± 52 per animal, respectively. The ablative targets containing abnormal potentials were located largely on the border zone of LVA. Eight linear lesions from core to border zone of LVA were achieved per animal in a radial and even manner continuously, and ablation was repeated three times to transect border zone. The acute freedom of VT was 84.62%, P < 0.05. CONCLUSIONS: Surgical linear endo-epicardial ablation seemed to be feasible in a porcine model with VT and LVA.

Atherosclerosis T1-weighted characterization (CATCH): evaluation of the accuracy for identifying intraplaque hemorrhage with histological validation in carotid and coronary artery specimens.

BACKGROUND: Coronary high intensity plaques (CHIPs) detected using cardiovascular magnetic resonance (CMR) coronary atherosclerosis T1-weighted characterization with integrated anatomical reference (CATCH) have been shown to be positively associated with high-risk morphology observed on intracoronary optical coherence tomography (OCT). This study sought to validate whether CHIPs detected on CATCH indicate the presence of intraplaque hemorrhage (IPH) through ex vivo imaging of carotid and coronary plaque specimens, with histopathology as the standard reference. METHODS: Ten patients scheduled to undergo carotid endarterectomy underwent CMR with the conventional T1-weighted (T1w) sequence. Eleven carotid atherosclerotic plaques removed at carotid endarterectomy and six coronary artery endarterectomy specimens removed from patients undergoing coronary artery bypass grafting (CABG) were scanned ex vivo using both the conventional T1w sequence and CATCH. Both in vivo and ex vivo images were examined for the presence of IPH. The sensitivity, specificity, and Cohen Kappa (k) value of each scan were calculated using matched histological sections as the reference. k value between each scan in the discrimination of IPH was also computed. RESULTS: A total of 236 in vivo locations, 328 ex vivo and matching histology locations were included for the analysis. Sensitivity, specificity, and k value were 76.7%, 95.3%, and 0.75 for in vivo T1w imaging, 77.2%, 97.4%, and 0.78 for ex vivo T1w imaging, and 95.0%, 92.1%, and 0.84 for ex vivo CATCH, respectively. Moderate agreement was reached between in vivo T1w imaging, ex vivo T1w imaging, and ex vivo CATCH for the detection of IPH: between in vivo T1w imaging and ex vivo CATCH (k = 0.68), between ex vivo T1w imaging and ex vivo CATCH (k = 0.74), between in vivo T1w imaging and ex vivo T1w imaging (k = 0.83). None of the coronary artery plaque locations showed IPH. CONCLUSION: This study demonstrated that carotid CHIPs detected by CATCH can be used to assess for IPH, a high-risk plaque feature.

Short-term outcomes of preoperative intra-aortic balloon pump use in patients undergoing adjunctive coronary endarterectomy: a retrospective observational study.

BACKGROUND: Coronary artery bypass grafting (CABG) combined with coronary endarterectomy (CE) can be associated with high operative mortality and morbidity. An intra-aortic balloon pump (IABP) has been the most widely used mechanical circulatory support device during perfusion treatment. However, the benefits of preoperative IABP in CABG combined with CE remain unknown. We conducted a retrospective observational study to evaluate the efficacy of preoperative IABP therapy in patients undergoing adjunctive right coronary artery (RCA) endarterectomy. METHODS: Between May 2013 and May 2016, 120 patients undergoing off-pump coronary artery bypass grafting (OPCABG) with RCA endarterectomy who received preoperative IABP support (IABP group, n=56) or who did not receive preoperative IABP support (control group, n=64) were evaluated retrospectively. RESULTS: Patients in the IABP group had a significantly lower mean preoperative ejection fraction and a significantly higher mean EuroSCORE (both <0.05). The incidence of inferior myocardial infarction (MI) was significantly lower in the IABP group than in the control group (3.6% vs 15.6%, RR = 0.23, 95% CI 0.05-1.00, p=0.03). Hospital mortality was similar in the two groups (3.6% vs 4.7%, RR= 0.76, 95% CI 0.13-4.40, p=0.76). There were no significant differences between the two groups with respect to the rates of prolonged ventilation, low cardiac output syndrome, renal failure requiring dialysis, re-operation for bleeding or IABP-related complications. Preoperative IABP may be a protective factor of inferior MI (HR = 0.031, 95% CI 0.004-0.211, p<0.001) Conclusions: The preoperative use of IABP could reduce the incidence of postoperative MI in patients undergoing CABG with CE and seemed to shift high-risk patients into a lower-risk category.

Distal Anastomosis Support for Coronary Artery Bypass Grafting: A New Surgical Technique and Current Outcomes.

BACKGROUND: Saphenous vein graft (SVG) failure remains the Achilles' heel of coronary artery bypass grafting (CABG) and grafts performed on the right coronary artery (RCA) system always have the worst patency compared with those performed on the left coronary system. The aim of this study was to introduce the distal anastomoses support (DAS) procedure and investigate the effect of DAS on the mid-term graft patency of SVG-PDA. METHODS: Between May and September 2013, 100 patients with an RCA severe lesion who underwent isolated OPCABG (CABG alone group, n=50) or CABG with DAS for anastomoses of SVG-PDA (CABG plus DAS group, n=50) were evaluated retrospectively. RESULTS: Patency rates of SVG-PDA at two years were significantly higher in the CABG plus DAS group compared to the CABG alone group (94.0% vs 74.0%, p = 0.006). However, there was no significant difference between the two groups with regard to freedom from MACCE at two years (92.0±3.8% versus 82.0±5.4%, p=0.08). No death occurred in both groups, and freedom from angina at two years did not differ significantly between two groups (80.0% vs 92.0%, p=0.62). In multivariate logistic regression analysis, diffuse disease was the independent predictor of graft occlusion (OR=11.05, 95% CI 2.14-57.12, p=0.004), but concomitant DAS (OR=0.04, 95% CI 0.003-0.350, p=0.004), proximal stenosis > 75% (OR=0.09, 95% CI 0.02-0.50, p=0.006), and male gender (OR=0.05, 95% CI 0.007-0.301, p=0.001) were protective factors. CONCLUSIONS: Concomitant DAS could improve mid-term patency of SVG-PDA. Adding the DAS procedure to CABG may be a new choice for patients with an RCA severe lesion.

Short- and Medium-Term Effects of Combined Mitral Valve Surgery and Coronary Artery Bypass Grafting Versus Coronary Artery Bypass Grafting Alone for Patients with Moderate Ischemic Mitral Regurgitation: A Meta-Analysis.

OBJECTIVE: To investigate the short- and medium-term effects of combined mitral valve surgery (MVS) and coronary artery bypass grafting (CABG) versus CABG alone for patients with moderate ischemic mitral regurgitation (IMR). DESIGN: Meta-analysis of 4 randomized controlled trials (RCTs) and 5 observational studies. SETTING: Hospitals that perform cardiac surgery. PARTICIPANTS: The study included 1,256 cardiac surgery patients from 4 RCTs and 5 observational studies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four RCTs and 5 observational studies were included in this meta-analysis. Concomitant MVS significantly reduced the residual rate of postoperative IMR (moderate or severe) (RCTs: OR -0.32, 95% confidence interval [CI] -0.58 to -0.07, p = 0.01; observational studies: OR -0.23, 95% CI -0.34 to -0.12, p<0.0001) and the proportion of surviving patients with New York Heart Association class III or IV (RCTs: OR 0.45, 95% CI 0.31-1.8, p = 0.008), but did not improve early mortality (RCTs: OR 0.91, 95% CI 0.30-2.74, p = 0.87; observational studies: OR 1.63, 95% CI 0.88-3.05, p = 0.12) or medium-term mortality (RCTs: OR 0.89, 95% CI 0.46-1.74, p = 0.73; observational studies: OR 0.94, 95% CI 0.65-1.37, p = 0.48) compared with CABG alone. Moreover, adding the mitral valve procedure did not significantly increase the risk of stroke (RCTs: OR 2.27, 95% CI 0.73-7.08, p = 0.16; observational studies: OR 0.55, 95% CI 0.10-3.06, p = 0.50). CONCLUSIONS: The potential benefits of combined MVS and CABG could outweigh its risks for patients with moderate IMR.

Influence of diabetes mellitus on long-term outcomes of patients with unprotected left main coronary artery disease treated with either drug-eluting stents or coronary artery bypass grafting.

Whether the effect of diabetes on patients with unprotected left main coronary artery (ULMCA) disease differs according to different strategies of revascularization was unknown. This study was conducted to evaluate the impact of diabetes on patients with ULMCA disease treated with either percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG).A total of 922 patients with ULMCA disease who received drug-eluting stent (DES) (n = 465) implantation or underwent CABG (n = 457) were retrospectively analyzed. We compared the effects of these 2 treatments on clinical outcomes (death, myocardial infarction, stroke, repeat revascularization, and the composite of death, myocardial infarction, or stroke), according to diabetic status.During the median follow-up of 7.1 years (interquartile range, 5.3 to 8.2 years), no difference was found between PCI and CABG in the adjusted occurrence of death (P = 0.112) and the composite endpoints of death, myocardial infarction, and stroke (P = 0.235). Significantly higher incidence of repeat revascularization (P < 0.001) was observed in the DES group, whereas the CABG group had a significantly higher rate of stroke (P = 0.001). These trends were consistent in both diabetic and nondiabetic patients. We did not observe significant interactions between treatment outcomes and the presence or absence of diabetes after adjustment for covariates (P(interaction) = 0.580 for the composite of death, MI and stroke, P(interaction) = 0.685 for death, P(interaction) = 0.416 for MI, P(interaction) = 0.470 for stroke, and P(interaction) = 0.502 for repeat revascularization).Presence of diabetes was not important for decision-making between CABG and PCI in patients with ULMCA disease.

[Comparison of pedicled and scheltoned endoscopic methods harvesting saphenous vein in shank].

OBJECTIVE: To compare the efficacies of endoscopic harvesting saphenous vein as sequential graft by pedicled and scheltoned technique. METHODS: From June 2013 to December 2013, a total of 93 patients undergoing coronary artery bypass with endoscopic vein harvesting in shank were recruited. Saphenous veins were harvested by pedicled method in group A (n =46) and scheltoned method in group B (n =47). Harvesting method was decided by a random number for each patient. Saphenous veins were used as sequential grafts during off-pump coronary artery bypass. Inter-group comparisons were made in time for harvesting, time for repairing, venous injuries and perioperative effect of saphenous vein. The postoperative follow-up period was 30 days. Early failure of saphenous vein graft was evaluated with coronary computed tomography (CT) angiography. RESULTS: All saphenous veins in shank were harvested successfully. No significant difference existed in vein length. In groups A and B, average time for harvesting was (21. 7 ± 5. 6) and (27. 4 ± 6. 4) min (P < 0. 05) and time for repairing (7. 2 ± 2. 7) and (10. 6± 4. 4) min respectively (P <0. 05). No severe injury resulted in non-using of saphenous in both groups. The repair rates of saphenous vein were 10. 9% and 38. 3% respectively (P < 0. 05). For each repaired saphenous vein, the average number of locations was (1. 6 ± 0. 5) and (3. 1 ± 1. 0) sites respectively (P < 0. 05). All patients were discharged uneventfully. There was no perioperative onset of myocardial infarction or malignant arrhythmia. For groups A and B, 89. 1% and 93. 6% were followed up for 1 month post-operation. No angina, myocardial infarction or heart failure occurred. For groups A and B, 32 and 37 cases were re-examined on CT coronary angiography and all saphenous vein grafts maintained patency. CONCLUSIONS: Pedicled method is more safe and reliable for endoscopic saphenous vein harvesting. It can ensure the quality of sequential graft, shorten harvesting time and reduce the risks of vein injury.

[Long-term outcomes of patients with unprotected left main coronary artery disease post revascularization].

OBJECTIVE: To compare the long-term real-world outcomes of consecutive patients with unprotected left main coronary artery disease (ULMCA) underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and coronary artery bypass grafting (CABG). METHODS: Consecutive patients with ULMCA (defined as stenosis ≥ 50%) undergoing DES implantation or CABG between January 2003 to July 2009 in Beijing Anzhen Hospital were enrolled. The follow-up period extended through August 2013. The end points of the study were death, cardiac death, repeat revascularization, myocardial infarction (MI), stroke, the composite of cardiac death, MI or stroke and MACCE (major adverse cardiac and cerebrovascular events, the composite of cardiac death, MI, stroke or repeat revascularization). RESULTS: From January 2003 to July 2009, 922 ULMCA patients were enrolled in this study (465 PCI patients, and 457 CABG patients). The median follow-up was 7.1 years (interquartile range 5.3 to 8.2 years). The crude relative risk was as follows: overall death rate (13.0% (41/465) vs. 22.1% (72/457), P = 0.009), stroke rate (5.8% (11/465) vs. CABG 18.9% (46/457), P < 0.001) were significantly lower whereas the rate of repeat revascularization (32.3% (110/465) vs. CABG 19.2% (58/457), P < 0.001) was significantly higher in PCI group than in CABG group. MI rate was similar between PCI and CABG group (13.9% (33/465) vs. 6.7% (26/457), P = 0.196). MACCE rate was also similar between the 2 groups (42.9% (145/465) vs. 42.5% (142/457), P = 0.122). After multivariate adjusting, there was no significant difference in rates of death, MI and a composite of serious outcomes (cardiac death, MI, or stroke) between the 2 groups. Rates of MACCE were significantly higher in the PCI group (P = 0.009) due to increased rate of repeat revascularization (P < 0.001). However, stroke rate was still significantly higher in CABG group (P = 0.001) after multivariate adjusting. CONCLUSION: During a follow-up up to 8.2 years, the survival rate is similar between the PCI and the CABG group in patients with ULMCA disease. The rate of repeat revascularization is significantly higher and stroke rate is significantly lower in the PCI group compared to CABG group.