Does Timing of Coronary Artery Bypass Grafting after ST-Elevation Myocardial Infarction Impact Early- and Long-Term Outcomes?

BACKGROUND: The optimal timing of surgical revascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-term outcomes in these patients. METHODS: Retrospective single-center analysis of patients with STEMI undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptom onset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and 10-year survival. RESULTS: During the study period, 437 consecutive patients underwent surgical revascularization in the setting of STEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality including patients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 (p = 0.31), whereas 10-year survival was 48.5, 57.3, and 54.9% (log-rank: p = 0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing of surgery had no influence on early- and long-term survival. CONCLUSION: In patients with STEMI, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularization strategy. Hence, when indicated, an early CABG strategy has no disadvantages in comparison to a delayed strategy.

Temporal Trends in Predictors of Early and Late Mortality After Emergency Coronary Artery Bypass Grafting for Cardiogenic Shock Complicating Acute Myocardial Infarction.

BACKGROUND: Cardiogenic shock after acute myocardial infarction is an indication for emergent coronary artery bypass grafting in patients not amenable to percutaneous coronary intervention. Our study aimed to evaluate and identify risk factors for early and long-term outcomes in such patients. METHODS: A total of 508 patients who underwent coronary artery bypass grafting for cardiogenic shock complicating acute myocardial infarction between January 2000 and June 2014 were divided into 3 time cohorts: 2000 to 2004 (n=204), 2005 to 2009 (n=166), and 2010 to 2014 (n=138). Predictors of in-hospital mortality for each time cohort and long-term mortality for all patients were identified by logistic and Cox regression analyses, respectively. RESULTS: Mean age was 68.3±9.8 years. Of the 508 patients, 78.5% had 3-vessel and 47.1% had left main disease. Left ventricular function <30% was observed in 44.1% of patients, with 30.4%, 37.9%, 52.9%, and 3.1% requiring preoperative resuscitation, ventilation, intra-aortic balloon pump, and extracorporeal membrane oxygenation support, respectively. Overall in-hospital mortality was 33.7%; declined from 42.2% to 30.7% to 24.6%, respectively, for the 3 time cohorts (P=0.02); and was independently predicted by serum lactate >4 mmol/L (odds ratio [OR], 4.78; 95% confidence interval, 2.88-7.95; P<0.0001), ST-segment-elevation myocardial infarction (OR, 2.10; 95% confidence interval, 1.36-3.26; P=0.001), age >75 years (OR, 2.01; 95% confidence interval, 1.06-3.85; P=0.03), and left ventricular ejection fraction <30% (OR, 1.83; 95% confidence interval, 1.15-2.91; P=0.01). Cumulative survival was 42.6±2.0% and 33.4±2.0% at 5 and 10 years, respectively, and correspondingly improved to 64.3±3.0% and 49.8±3.0% in hospital survivors. Serum lactate >4 mmol/L (OR, 2.2; P<0.0001), incremental age (OR, 1.05; P<0.0001), New York Heart Association class IV (OR, 1.33; P=0.02), diabetes mellitus (OR, 1.39; P=0.005), and preoperative inotropic (OR, 2.61; P=0.001) and extracorporeal membrane oxygenation (OR, 1.68; P=0.05) support predicted late mortality. CONCLUSIONS: Emergency coronary artery bypass grafting in patients with acute myocardial infarction complicated by cardiogenic shock is associated with a high in-hospital mortality, which showed a significant decline with time. Hospital survivors have good long-term outcomes, which demonstrate the beneficial effect of surgical revascularization. Preoperative serum lactate >4 mmol/L is a strong predictor of both early and late mortality.

Does Timing of Coronary Artery Bypass Surgery Affect Early and Long-Term Outcomes in Patients With Non-ST-Segment-Elevation Myocardial Infarction?

BACKGROUND: Current guidelines do not provide recommendations for optimal timing of coronary artery bypass surgery (CABG) in patients with non-ST-segment-elevation myocardial infarction. Our study aimed to determine the impact of CABG timing on early and late outcomes in patients with non-ST-segment-elevation myocardial infarction. METHODS AND RESULTS: A total of 758 patients underwent CABG within 21 days after non-ST-segment-elevation myocardial infarction between January 2008 and December 2012 at our institution. The patients were divided into 3 groups according to the time interval between symptom onset and CABG: group A, <24 hours (133 patients); group B, 24 to 72 hours (192 patients); and group C, >72 hours to 21 days (433 patients). Predictors of in-hospital and long-term mortality were identified by logistic and Cox regression analyses, respectively. Overall in-hospital mortality was 5.1% (39 patients): 6.0%, 4.7%, and 5.1% in groups A, B, and C (P=0.9), respectively. A total of 118 patients died during follow-up. The 5-year survival was 73.1±2%, with a nonsignificant trend toward better survival in groups A (78.2±4%) and C (75.4±3%) compared with group B (63.6±5%; log-rank P=0.06). Renal insufficiency and LMD were independent predictors of in-hospital (odds ratio, 3.1; P=0.001; and odds ratio, 3.1; P=0.002) and long-term mortality (hazard ratio, 1.7; P=0.004; and hazard ratio, 1.5; P=0.02), whereas administration of P2Y12 inhibitors was protective (odds ratio, 0.3; P=0.01). CONCLUSIONS: Emergent CABG within 24 hours of non-ST-segment-elevation myocardial infarction is associated with in-hospital mortality and long-term outcomes similar to those of CABG performed after 3 days, despite a higher risk profile. CABG performed between 24 to 72 hours showed a nonsignificant trend toward poorer long-term outcomes. Dual antiplatelet therapy until surgery is beneficial, whereas renal insufficiency and left main disease increase the risk of early and late death.

Impact of expeditious management of perioperative myocardial ischemia in patients undergoing isolated coronary artery bypass surgery.

BACKGROUND: To analyze the effect of immediate treatment of perioperative myocardial ischemia (PMI) because of early graft failure or incomplete revascularization in patients undergoing coronary artery bypass grafting (CABG) surgery. METHODS AND RESULTS: Between January 2004 and December 2010, 7461 patients underwent isolated CABG at our institution. All patients showing evidence of PMI (n=399; 5.3% of total) underwent emergent coronary angiography. A total of 900 grafts and 1061 distal anastomoses were examined. Two hundred fifty-five patients had 360 distal anastomoses compromised because of early graft failure or incomplete revascularization (ie, abnormal postoperative coronary angiogram). Revision CABG or percutaneous coronary intervention was performed in 130 (51.0%) and 34 (13.3%) patients with abnormal angiograms, respectively. Nonsurgical therapy was implemented in the remaining 91 patients (35.7%) with abnormal angiograms. One hundred forty-four patients had normal postoperative graft-related angiograms. In-hospital mortality was 7.3% and 2.9% in patients with and without PMI (P<0.001). In patients with PMI, in-hospital mortality was 9.4% and 3.5% in patients with abnormal and normal postoperative angiograms, respectively (P=0.03). Significant multivariable predictors of in-hospital mortality were hemodynamic deterioration, preangiography creatine kinase-MB isoenzyme rise >2 × normal, and time interval between primary CABG and coronary angiography >30 hours. Five-year survival in patients without PMI (85.7 ± 0.5%) was significantly better than those with PMI and abnormal angiograms (74.9 ± 2.9%; P<0.001 log-rank). When in-hospital mortality was excluded, however, this difference in midterm survival disappeared (P=0.9). CONCLUSIONS: PMI is associated with increased in-hospital mortality in patients undergoing isolated CABG. Expeditious management of bypass graft failure results in similar midterm survival to nonischemic patients in hospital survivors.

Total Arterial Multivessel Minimally Invasive Coronary Artery Bypass Surgery: 5-Year Outcomes.

BACKGROUND: Total arterial revascularization is associated with superior outcomes to conventional coronary artery bypass graft (CABG) surgery performed with the left internal thoracic artery (ITA) and veins. It is often performed with bilateral ITAs that increase risk of sternal wound infection. Minimally invasive multivessel CABG through a left anterior minithoracotomy eliminates sternal wound complications. However, being performed only in a few specialized centers, there is a paucity in follow-up outcome data. We, therefore, describe our 5-year single-center experience with such operations. METHODS: Between 2015 and 2021, 186 patients underwent elective, total arterial minimally invasive CABG in our institution. Patient data were prospectively collected in the institutional database and retrospectively analyzed. Primary end points were in-hospital mortality and 5-year survival. The secondary end points included freedom from major adverse cerebrovascular and cardiac events. RESULTS: Patients were a mean age of 66 ± 9 years, and 23 (12%) were women. The mean number of bypass grafts performed was 2.4 ± 0.5 (range, 2-4 grafts). Bilateral ITAs were used in 163 patients (88%) and left ITA and radial arteries in 22 (12%). The mean procedure time was 277 ± 58 minutes. There was 1 hospital death. Perioperative myocardial infarction, repeat thoracotomy, and conversion to sternotomy was observed in 6 (3%), 12 (6.5%), and 2 patients (1.1%), respectively. The mean 5-year survival was 93.3% ± 2.2%, and freedom from major adverse cardiac and cerebrovascular events was 83.8% ± 4.1%. CONCLUSIONS: Total arterial minimally invasive CABG is a feasible surgical approach yielding excellent short- and midterm results when performed in selected patients in specialized high-volume cardiac centers.

Role of tricuspid valve repair for moderate tricuspid regurgitation during minimally invasive mitral valve surgery.

BACKGROUND: The aim of this study was to investigate the impact of short- and mid-term survival of tricuspid valve (TV) repair versus conservative therapy in patients with preoperative moderate functional tricuspid regurgitation (TR) undergoing minimally invasive mitral valve (MV) surgery. METHODS: Between January 2002 and December 2009, a total of 430 patients with pure mitral regurgitation and concomitant moderate TR underwent minimally invasive MV surgery for mitral regurgitation at the Leipzig Heart Center without (n = 336; group A) and with (n = 94; group B) TV surgery. Mean age was 66.7 ± 10.3 years, mean LVEF was 58.0 ± 13.8%, and 206 patients (47.9%) were male. Average logEuroSCORE was 12.4 ± 11.4%. Follow-up was on average 4.6 ± 2.4 years and 97% completed. RESULTS: Predischarge echocardiography showed no or mild TR in 51.1% of patients in group A versus 84.2% of patients in group B (p < 0.01). Overall 30-day mortality was 2.8% with no differences between both groups. Five-year survival was 82.9 ± 4.1% for patients with TV repair versus 85.0 ± 2.2% for patients without TV repair (p = 0.1) and it was 85.7 ± 3.3% in patients with moderate and more postoperative TR versus 90.1 ± 2.5% in patients with less than moderate postoperative TR (p = 0.08). Five-year freedom from TV-related reoperation was 98.8 ± 0.7% for patients in group A versus 98.9 ± 0.1% for patients in group B (p = 0.8). CONCLUSIONS: Patients undergoing MV surgery with moderate functional TR do not experience increased perioperative complication rates when a concomitant TV repair is performed. Our observations, combined with those of other groups, support current recommendations to perform concomitant TV repair in such patients, particularly if tricuspid annular dilation is present.

Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience.

OBJECTIVE: Minimally invasive direct coronary artery bypass (MIDCAB) surgery involving left anterior descending coronary artery grafting with the left internal thoracic artery through a left anterior small thoracotomy is being routinely performed in some specified centers for patients with isolated complex left anterior descending coronary artery disease, but very few reports regarding long-term outcomes exist in literature. Our study was aimed at assessing and analyzing the early and long-term outcomes of a large cohort of patients who underwent MIDCAB procedures and identifying the effects of changing trends in patient characteristics on early mortality. METHODS: A total of 2667 patients, who underwent MIDCAB procedures between 1996 and 2018, were divided into 3 groups on the basis of the year of surgery: group A, 1996-2003 (n = 1333); group B, 2004-2010 (n = 627) and group C, 2011-2018 (n = 707). Groupwise characteristics and early postoperative outcomes were compared. Long-term survival for all patients was analyzed and predictors for late mortality were identified using Cox proportional hazards methods. RESULTS: The mean age was 64.5 ± 10.9 years and 691 (25.9%) patients were female. Group C patients (log EuroSCORE I = 4.9 ± 6.9) were older with more cardiac risk factors and comorbidities than groups A (log EuroSCORE I = 3.1 ± 4.5) and B (log EuroSCORE I = 3.5 ± 4.7). Overall and groupwise in-hospital mortality was 0.9%, 1.0%, 0.6%, and 1.0% (P = .7), respectively. Overall 10-, 15-, and 20-year survival estimates for all patients were 77.7 ± 0.9%, 66.1 ± 1.2%, and 55.6 ± 1.6%, respectively. CONCLUSIONS: MIDCAB can be safely performed with very good early and long-term outcomes. In-hospital mortality remained constant over the 22-year period of the study despite worsening demographic profile of patients.

Mid-term outcomes following the Hemi-Commando procedure for complex infective endocarditis involving the aortomitral junction.

OBJECTIVES: Perivalvular abscesses with destruction of the aortomitral junction (AMJ) are a severe complication of infective endocarditis (IE) and are associated with high mortality and complex management. The Hemi-Commando procedure is a mitral valve-sparing alternative to the Commando procedure in suitable patients with complex IE and paravalvular destruction. This study reviews the mid-term outcomes in patients undergoing the Hemi-Commando procedure for treating IE with destruction of the AMJ. METHODS: The clinical outcomes of patients with IE and AMJ involvement who underwent the Hemi-Commando procedure between 2015 and 2021 at the Leipzig Heart Center were retrospectively analysed. Primary outcomes were 30-day mortality and 1-year survival. Secondary outcome was 1-year freedom from reoperation. RESULTS: A total of 22 patients underwent the Hemi-Commando procedure during the study period. The patients' mean age was 59.8 ± 18.3 years. The study population was predominantly male (86.4%). Preoperative sepsis was present in 6 (27.3%) patients, and the median EuroSCORE II was 28.5%. Almost two-thirds (N = 14; 63.6%) of the patients presented with native IE. Streptococci were the most common pathogens (N = 8; 36.4%). Paravalvular abscess was found intraoperatively in 16 (72.7%) patients. The 30-day mortality was 13.6%. The estimated 1- and 3-year survival rates were 77.5% and 66.4%, respectively. The estimated freedom from reoperation at 1 and 3 years was 92.3%. CONCLUSIONS: The Hemi-Commando procedure offers an acceptable mid-term survival chance with low reoperation rates and is, therefore, a reasonable mitral valve-sparing alternative to the Commando procedure in suitable patients with extensive IE and perivalvular involvement.

Off-pump coronary artery bypass grafting is safe and effective in patients with severe left ventricular dysfunction.

OBJECTIVES: Severe left ventricular dysfunction (LVD) is associated with increased risk following coronary artery bypass grafting (CABG). Due to a dearth of reports on the choice of CABG technique in patients with LVD, this study aims to compare the outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) in such patients. METHODS: Retrospective single-centre propensity-matched analysis comparing early- and long-term outcomes of OPCAB and ONCAB in patients with severe LVD. Primary outcome was long-term all-cause mortality. RESULTS: Between 2002 and 2014, a total of 1161 consecutive patients with severe LVD underwent isolated CABG [442 patients underwent OPCAB and 719 ONCAB (430 matched pairs)]. Incomplete revascularization was observed more frequently among OPCAB than ONCAB patients (35.3% vs 21.6%; P < 0.01). The overall 30-day mortality was 5% and was comparable between the matched groups [OR 0.64 (0.34-1.22); P = 0.18]. OPCAB patients had shorter median hospital stay (11 vs 12 days; P = 0.02) and lower packed red blood cell transfusion rates [2.7 (2.21-3.19) vs 4.4 (3.56-5.24); P < 0.01]. Estimated adjusted survival was 86.0% vs 85.8%, 69.1% vs 65.5% and 59.9% vs 49.1% at 1, 5 and 10 years for OPCAB and ONCAB patients, respectively (P = 0.99). Long-term risk of mortality was similar between groups [hazard ratio (HR) 0.94 (0.66-1.32); P = 0.7]. Incomplete revascularization was weakly associated with increased risk of long-term all-cause mortality [HR 1.33 (0.99-1.77); P = 0.05]. CONCLUSIONS: OPCAB is safe and effective in patients with severe LVD. Although incomplete revascularization is more commonly observed in patients undergoing OPCAB, it is not associated with increased late mortality.

Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: Early outcomes and angiographic patency.

OBJECTIVE: Multivessel minimally invasive coronary artery bypass grafting, performed chiefly with left internal thoracic artery and saphenous vein grafts through a left anterolateral thoracotomy, has recently emerged as an alternative to conventional coronary artery bypass grafting. The present study involves our initial experience with respect to early postoperative and angiographic outcomes after total arterial multivessel off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries. METHODS: A total of 88 consecutive patients undergoing total arterial off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries without ascending aortic manipulation were included in this study. Bilateral internal thoracic arteries were harvested under direct vision through a left anterolateral thoracotomy and used as Y or in situ grafts. Multivessel grafting was performed off pump. Postoperative graft assessment was performed in 51 patients. RESULTS: The mean age of patients was 67.1 ± 7.2 years, and 79 patients (89.8%) were male. The mean body mass index and ejection fraction were 26.7 ± 2.7 kg/m2 and 57.6% ± 6.6%, respectively, and 40 patients (45.5%) had left main disease. No intraoperative conversions to cardiopulmonary bypass or sternotomy occurred. A total of 209 distal anastomoses (mean 2.4 ± 0.5) were performed, with 57 patients undergoing double, 29 patients undergoing triple, and 2 patients undergoing quadruple coronary artery bypass grafting. There was no in-hospital mortality, and 5 patients underwent reexploration for bleeding. No patient had stroke or chest wound infections. Predischarge coronary angiography revealed an overall graft patency rate of 96.8%. CONCLUSIONS: Off-pump minimally invasive coronary artery bypass grafting using total arterial revascularization with bilateral internal thoracic arteries is a feasible and safe operation that is associated with excellent short-term outcomes and early graft patency. Future studies should focus on improving the generalizability and reproducibility of this technique.

Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.

OBJECTIVES: Non-leaflet resection techniques including loop chordal replacement are being used with increasing frequency, but the long-term results of these techniques are still unknown. The aim of this study was to compare the long-term results of loop neochord replacement with leaflet resection techniques in patients undergoing minimally invasive mitral valve (MV) repair for MV prolapse. METHODS: Between 1999 and 2014, 2134 consecutive MV prolapse patients underwent minimally invasive MV repair with isolated loop (n = 1751; 82.1%) or resection techniques (n = 383, 17.9%) at our institution. Follow-up data were available for 86% of patients with a mean follow-up time of 6.1 ± 4.3 years. RESULTS: The 30-day mortality was 0.8% for all patients (loop: 0.7%, resection: 1.6%; P = 0.09). Leaflet resection was associated with more moderate or more mitral regurgitation on predischarge echocardiography (P = 0.003). The 1-, 5- and 10-year survival rates were 98 ± 1%, 95 ± 1% and 86 ± 2% for the loop technique versus 97 ± 1%, 92 ± 1% and 81 ± 2% for resection patients, respectively (P = 0.003). Significant predictors for late mortality were MV repair technique (P = 0.004), left ventricular ejection fraction (P < 0.001), age (P < 0.001) and myocardial infarction (P < 0.001). Freedom from MV reoperation at 1, 5 and 10 years was 98 ± 1%, 97 ± 1%, 97 ± 1% and 97 ± 1%, 97 ± 1%, 96 ± 1% for patients operated on with the loop technique and leaflet resection (P = 0.4). CONCLUSIONS: In our patient cohort, MV repair with loop chordal replacement is associated with less early recurrent mitral regurgitation and very good long-term results when compared to classical leaflet resection techniques for MV prolapse and is therefore an excellent option for such patients.

Early and Long-Term Outcomes in Patients Undergoing Cardiac Surgery Following Iatrogenic Injuries During Percutaneous Coronary Intervention.

Background Iatrogenic coronary artery injuries during percutaneous coronary interventions ( PCI ) often require emergent surgical management. Our study evaluated the early and long-term outcomes in patients undergoing surgical treatment of iatrogenic PCI complications and identified the predictors of operative and long-term mortality. Methods and Results Pre-, intra- and post-operative data and hospital outcomes of 168 consecutive patients undergoing cardiac surgical procedures for iatrogenic complications following PCI between December 1999 and July 2015, were prospectively collected in our computerized database. Logistic and Cox regression analyses were used to identify the independent predictors of operative and long-term mortality. The mean age was 68.5±10.2 years and 35.7% were females. PCI complications included left anterior descending (38.7%), right coronary (29.2%), circumflex (13.1%), left main coronary artery injuries (19.0%), and acute myocardial infarction (66.7%), Type A aortic dissection (7.7%), cardiac tamponade (17.9%), and cardiogenic shock ( CS ) (46.4%). Operative mortality for corrective surgery was 20.8% and was independently predicted by critical preoperative state (odds ratio: 3.5; P=0.01). The 5- and 10-year survival for all patients was 63.9±4.0% and 49.6±5.0%, which improved remarkably in hospital survivors (79.0±4.0% and 64.0±6.0%). Risk factors for long-term mortality were critical preoperative state (hazard ratio: 3.5; P<0.0001) and coronary artery occlusion during PCI (hazard ratio: 2.6; P=0.002). The 5- and 10-year freedom from major adverse cardiac and cerebrovascular events was 59.7±4.0% and 41.9±5.0%. Conclusions Iatrogenic injuries after PCI or coronary angiography requiring surgical correction are associated with a high operative and long-term mortality. Patients developing acute coronary artery occlusion have a more guarded long-term prognosis. Hospital survivors, however, have a superior long-term survival.