Two-stage hybrid strategy for multivessel coronary artery disease and functional ischemic mitral regurgitation: A case series.

The optimal treatment strategy of high surgical risk patients with multivessel coronary artery disease (CAD) and functional mitral regurgitation (MR) remains controversial. We present two cases in which two-stage hybrid treatment with prior transcatheter mitral valve edge-to-edge repair (TEER) followed by off-pump coronary artery bypass grafting (OPCAB) was successfully performed in patients with CAD and functional ischemic MR. In both cases, the patient showed good hemodynamic stability during OPCAB without an increase in MR. A two-stage hybrid strategy with prior TEER followed by OPCAB may be an ideal treatment option for high surgical risk patients with multivessel CAD and functional ischemic MR. Learning objective: To recognize the effectiveness of a two-stage hybrid approach with transcatheter edge-to-edge repair and off-pump coronary artery bypass grafting in high surgical risk patients with multivessel coronary artery disease and functional mitral regurgitation.

Examining the Outcomes of Hybrid Coronary Revascularization in Acute ST-Elevation Myocardial Infarction (STEMI) Patients.

BACKGROUND: Acute ST-segment elevation myocardial infarction (STEMI) is a critical cardiovascular condition requiring timely intervention to restore coronary blood flow and minimize myocardial damage. While percutaneous coronary intervention (PCI) remains the gold standard, it is often insufficient for patients with complex coronary anatomy, such as multivessel disease or left main coronary artery involvement. Hybrid coronary revascularization (HCR), which combines PCI and coronary artery bypass grafting (CABG), offers a novel approach to managing these complex cases. OBJECTIVE: The primary objective of this study was to evaluate the outcomes of HCR in patients presenting with acute STEMI, particularly those with high-risk features such as multivessel disease or left main coronary artery involvement. METHODS: This prospective cohort study was conducted at Shalamar Hospital, a tertiary care center in Lahore, Pakistan. The study enrolled 342 patients diagnosed with acute STEMI between January 1, 2023, and December 31, 2023. Participants underwent HCR, consisting of PCI with drug-eluting stents and minimally invasive CABG. Key outcomes included the incidence of major adverse cardiovascular events (MACE) within one year, graft patency at six months, and overall procedural success. Data were collected through patient records and follow-up assessments, and statistical analysis was performed using SPSS Statistics version 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.). RESULTS: The one-year MACE rate was 14.6%, with 6.1% of patients experiencing myocardial infarction, 4.4% requiring repeat revascularization, and 4.1% experiencing cardiac death. Graft patency at six months was 94.7%, and the overall procedural success rate was 98.2%. One-year survival was observed in 95.3% of the patients. CONCLUSION: HCR is a safe and effective strategy for managing acute STEMI, particularly in patients with complex coronary anatomy. It offers a balanced approach by reducing the need for invasive procedures and improving patient outcomes. Further multicenter studies are necessary to confirm these findings and establish standardized guidelines for HCR.

Outcomes of Single versus Sequential Vein Grafts in Isolated Coronary Artery Bypass Surgery: Insights from a Large Tertiary Care Center.

BACKGROUND: Saphenous venous grafts (SVG) remain the most widely used conduits in coronary artery bypass graft surgery (CABG). Data comparing outcomes of single saphenous venous grafting (SinCABG) versus sequential venous grafting (SeqCABG), however, are limited. METHODS: Between 2002 and 2012, 2,375 patients with 3-vessel coronary artery disease underwent isolated elective CABG at the Leipzig Heart Center with a left internal mammary artery graft to left anterior descending artery and ≥2 distal SVG anastomoses. Of these, 1,278 received ≥2 singular saphenous venous grafts (SinCABG) and 563 received ≥1 sequential saphenous vein grafts with >1 distal anastomoses (SeqCABG). The primary end point was long term survival. Secondary outcomes included short-term survival, early postoperative outcomes as well as early and late graft patency. RESULTS: At 30-days, mortality was 1.3% following SinCABG as compared to 2.3% after SeqCABG (p=0.13). The postoperative complications rate did not differ between groups. Early postoperative coronary angiographies were performed in 127 patients (7%), while clinically indicated follow-up coronary angiographies were performed in 372 patients (20%) over a median follow up of 5 years (IQR 1.7-8.9). No differences in early or late patency rates were found between both grafting techniques (p=0.79 and p=0.39, respectively). The median duration of long-term clinical follow-up was 8.4 years (IQR 5.6-11.4). Long-term survival rates at 1, 5, 10 and 15 years in SinCABG versus SeqCABG were 95% versus 94%, 83% versus 82%, 63% versus 62%, and 47% versus 41%, respectively (p=0.22). CONCLUSIONS: Short and long-term mortality as well as early and late graft patency rates did not differ in patients undergoing SinCABG as compared to patients undergoing SeqCABG.

Effectiveness of the Individualized Self-Care Program Based on Orem's Self-Care Theory: Impact on Learning Needs and Self-Care Behaviors Following Coronary Artery Bypass Surgery - A Randomized Controlled Trial.

PURPOSE: This study aimed to investigate the specific learning needs of patients within the experimental group after receiving the Individualized Self-Care Program (ISCP) at two key time points: Time 2 (Day 2, Week 1) and Time 3 (Day 15, Week 3). Furthermore, it aimed to compare the effectiveness of the ISCP in improving self-care behavior between the experimental group and the control group, which received standard health education. METHODS: The study utilized a Randomized Controlled Trial (RCT) design and included a consecutive sample of 128 patients who had undergone their first CABG procedure. These patients were randomly divided into two groups: the experimental group (n = 64) and the control group (n = 64). The experimental group received an ISCP at Time 2 and Time 3 after being discharged, whereas the control group received standard health education. Statistical analyses included paired t-tests to assess differences in learning needs over time and Repeated Measures Analysis of Variance (ANOVA) to evaluate the effectiveness of the ISCP on self-care behavior. RESULTS: A paired t-test indicated a statistically significant difference in the total number of learning needs identified within the experimental group between Time 2 and Time 3 assessments. Patients in the experimental group initially identified more learning needs at Time 2 (4.3±1.5), but their knowledge significantly improved at Time 3, leading to fewer learning needs (2.6±1.1). Furthermore, an ANOVA comparing the experimental and control groups showed that the ISCP effectively improved self-care behavior in the experimental group, with significantly greater improvements compared to the control group, which received standard health education. CONCLUSION: ISCP delivered in early recovery enhances self-care behaviors and addresses postdischarge gaps. The study also revealed that patients' learning needs change over time during home recovery, emphasizing the importance of tailored self-care programs for CABG patients after discharge.

The effect of spironolactone in reducing the risk of postoperative atrial fibrillation in patients undergoing coronary artery bypass graft surgery: randomized single-blind placebo-controlled study.

BACKGROUND: Postoperative atrial fibrillation (POAF), one of the most common cardiac arrhythmias following coronary artery bypass graft (CABG) surgery is associated with unfavorable outcomes. OBJECTIVES: This study investigated the effect of spironolactone administered two weeks before surgery on the incidence of POAF in patients undergoing CABG. METHODS: This randomized single-blind placebo-controlled study was conducted on 130 CABG patients. All patients were randomly divided into intervention and control groups including 65 cases for each group. In the intervention group, patients received 50 mg of spironolactone orally daily for 2 weeks before surgery, and in the control group patients received placebo daily from 2 weeks before surgery. All patients were continuously monitored for the occurrence of POAF for two weeks postoperatively. RESULTS: The mean age of the patients in the intervention and control groups was 61.7 ± 5.4 and 60 ± 6.7 years, respectively. The incidence of POAF in the intervention and control groups was 7.7% and 20%, respectively (Odds Ratio = 0.33, P = 0.042). All demographic and clinical variables were similar in patients with and without POAF (all P > 0.05). CONCLUSIONS: Our findings revealed that in comparison to placebo, the use of spironolactone is associated with reduced incidence of POAF in CABG candidates.

[Rehabilitation potential of patients with ischemic heart disease who underwent autovenous coronary artery bypass surgery in the evaluation of rehabilitation treatment effectiveness]. / Reabilitatsionnyi potentsial patsientov s ishemicheskoi bolezn'yu serdtsa, perenesshikh autovenoznoe aortokoronarnoe shuntirovanie, v otsenke effektivnosti vosstanovitel'nogo lecheniya.

The search for methods to assess the rehabilitation potential (RP) of patients with ischemic heart disease (IHD) who underwent coronary artery bypass surgery (CABS), which will allow to personalize approaches to the administration of necessary for the certain patient treatment complexes, increasing their effectiveness and reducing the probability of complications, remains relevant. OBJECTIVE: To develop a method for RP evaluation in patients with IHD who underwent CABS and to assess its role in predicting the effectiveness of therapeutic activities in the early rehabilitation period. MATERIAL AND METHODS: The study consisted of two parts. A method for RP assessment in 118 patients with IHD aged 36-85 years (mean age 62.3±2.0 years) who underwent CABS was developed in the 1st part based on the analysis of hospital discharge reports using mathematical modeling methods. The results of rehabilitation activities were analyzed in the 2nd part of the study in patients who were transferred to the cardiovascular department of the Angara Clinical Resort after the cardiovascular surgery department for the second stage of rehabilitation. The multidisciplinary team evaluated the effectiveness of patients' treatment after the rehabilitation completion using integral indicators characterizing clinical condition of the patient who underwent CABS. RESULTS: A methodological algorithm was created in the 1st part of the study, namely a formalized patient chart was formed, the evidence base was represented by 99 indicators. The values of linear classification functions' coefficients were assigned to certain indicators, according to which the patient was classified into one of four groups: the 1st group - without RP; the 2nd group - with medium RP; the 3rd group - with high RP and the 4th group - with low RP. The values of RP were determined in the second part of the study for predicting the effectiveness of therapeutic measures in the early rehabilitation period (the second stage of medical rehabilitation). It has been found that the greatest effect was observed in subjects of the 3rd group with high RP in the patients' testing after treatment at the health resort. The lesser effect has been noted in patients of the 2nd group and especially of the 4th group. CONCLUSIONS: The use of RP assessment method based on mathematical modeling in patients who underwent CABS allows to predict the results of patients' medical rehabilitation at the second stage in the health resort conditions.

Safety and efficacy of surgical revascularization with percutaneous ventricular assist device for acute myocardial infarction complicated by cardiogenic shock: Japanese national registry study.

BACKGROUND: This study aims to assess the safety of coronary artery bypass grafting (CABG) with percutaneous ventricular assist device (PVAD) in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). METHODS: A retrospective analysis was conducted on 1198 patients with AMI-CS from the J-PVAD registry, who underwent PVAD support using Impella® (Abiomed Inc., Danvers, MA) and subsequent revascularization between February 2020 and December 2021. Patients were divided into two groups based on the method of coronary revascularization: percutaneous coronary intervention (PCI, n = 1084) and CABG (n = 114). The study assessed short-term all-cause and cardiac-related mortality. RESULTS AND CONCLUSION: The CABG group exhibited significantly lower short-term all-cause mortality compared with the PCI group (30-day: 26.2% vs. 39.9%, 90-day: 45.5% vs. 58.4%, log-rank p = 0.004). Short-term cardiac-related mortality was similar toward low in the CABG group compared with the PCI group (30-day: 18.7% vs. 25.6%, 90-day: 29.4% vs. 35.5%, log-rank p = 0.084). Multivariable analysis using the Cox proportional hazard model did not identify revascularization strategy as a risk factor for both all-cause mortality (Hazard ratio (HR): 0.743, 95% confidence intervals (CI): 0.457-1.208, p = 0.231) and cardiac-related mortality (HR: 0.762, 95% CI: 0.390-1.490, p = 0.427). These results were not attenuated even in subgroup analyses separately comparing CABG alone and hybrid therapy with PCI after propensity score matching. Thus, CABG can be a treatment option with feasible short-term outcomes in patients with AMI-CS under PVAD support.

Surgery for a giant atherosclerotic left main trifurcation saccular coronary artery aneurysm.

Aneurysms of the left main coronary artery are rare clinical entities with an incidence of 0.1%. We herein report a case of left main trifurcation aneurysm in a 57-year-old woman whose coronary angiography demonstrated a giant saccular aneurysm of trifurcation of the left main coronary artery, measuring 32 × 21 mm with tight post-aneurysmal stenosis in the intermediate artery. The patient underwent coronary artery bypass grafting following the resection of CAA and reconstruction with saphenous vein roof-plasty, which ensured the preservation of the native coronary vasculature. At the 6-month follow-up, she remained asymptomatic and preserved preoperative left ventricular function.

Effectiveness of Dexamethasone in Reducing Arrhythmia in Patients Undergoing Coronary Artery Bypass Grafting.

Introduction Coronary artery bypass grafting (CABG) carries the risk of postoperative arrhythmias. Our study focusses on the efficacy of dexamethasone in both on-pump CABG (ONCAB) and off-pump CABG (OPCAB). Methods This single center randomized control trial was conducted from July 1st, 2018 to January 20th, 2019 in patients undergoing conventional ONCAB and OPCAB at the National Cardiovascular Center Harapan Kita (NCCHK). All arrhythmia incidents were recorded postoperatively with routine monitoring done every hour until the patient was discharged. Results One hundred and twenty patients were included in the study and arrhythmias occurred in 24.2% of patients. In the ONCAB groups, there was an association between dexamethasone versus placebo in reducing the incidence of arrhythmias (p = 0.02; OR 0.23 [0.064-0.831]). However, in patients who underwent OPCAB, there was no association between dexamethasone administration and the incidence of arrhythmias (p = 0.347; OR 0.55 [0.157-1.931]). Patients on dexamethasone in both ONCAB and OPCAB groups showed a significant decrease in IL-6, CRP, and procalcitonin (p = 0.001 for all). Overall, arrhythmic subjects had significantly higher levels of inflammatory markers IL-6 (p = 0.013), CRP (p = 0.025), and procalcitonin (p = 0.001). Conclusion Dexamethasone reduced postoperative arrhythmias, likely by modulating systemic inflammation, as shown by the decrease in inflammatory markers in ONCAB patients compared to those given a placebo.

Small incisions still require great anesthesia: anesthesiology techniques to enhance recovery in robotic coronary bypass grafting.

Robotic coronary artery bypass grafting (CABG) has emerged as a promising minimally invasive surgical technique for the treatment of coronary artery disease. This paper provides an in-depth analysis of the anesthetic management for robotic CABG. Challenges associated with robotic CABG are discussed and various anesthetic techniques, perioperative elements and pain management modalities that can contribute to enhanced patient recovery are explored.

Step-by-step technique of robotic-assisted minimally invasive direct coronary artery bypass.

Coronary artery bypass grafting (CABG) is the treatment of choice for coronary artery disease. The traditional method of performing CABG via a full sternotomy has its drawbacks, including increased postoperative morbidity, a higher incidence of complications, and extended hospitalizations. Although minimally invasive and robotic-assisted technology offer promising alternatives, they have not gained wide acceptance, largely because of the limited amount of literature supporting hybrid and robotic-assisted CABG. Since 2005, Lankenau Heart Institute's cardiothoracic surgical team has been developing and refining for selected patients a method for coronary revascularization that involves robotic harvesting of the left internal mammary artery (LIMA) and beating heart surgery through a limited minithoracotomy. This technique precisely places the robotic endoscopic port over the target site of the left anterior descending (LAD) artery. The LIMA is harvested using the enhanced visualization and precision of the robotic platform. The robotic instruments are then removed, and the endoscopic port site is slightly enlarged to become the minithoracotomy, allowing for LIMA-to-LAD anastomosis. The other two robotic ports are used for drains, eliminating the need for additional incisions. The method has been used in over 2,850 patients. The method has been used in over 2,850 patients. This article describes in detail our standardized technique for robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB).

Ten-year outcomes of hybrid coronary revascularization at a single center.

Background: Hybrid coronary revascularization (HCR) is a well-established technique for treating multi-vessel coronary disease. There remains a paucity of discussion assessing the efficacy of HCR with respect to the timing of the surgical component relative to that of the percutaneous coronary intervention (PCI). Methods: A retrospective review was undertaken of our prospectively collected database from January 2009 to December 2019. Of 395 HCR patients analyzed, we examined the outcomes of 109 pairs of propensity-matched patients who either underwent robotic-assisted minimally-invasive direct coronary artery bypass (MIDCAB) first, or who had PCI prior to surgery. Results: Thirty-day mortality was 0.25% (1 death) for the entire cohort. Mid-term survival for the total 'MIDCAB-first' group was 94.1% (17 deaths), not significantly different to that for the 'PCI-first' cohort (8 deaths, 92.7%), and this was also statistically comparable after propensity matching. Perioperative morbidity was not different between patient groups. Freedom from major adverse cardiac and cerebrovascular events (MACCE) and the incidence of repeat revascularization was similar between the two groups at up to 11-year follow-up. Elevated serum creatinine independently predicted increased MACCE for all patients, irrespective of the sequence of HCR revascularization employed. Conclusions: In appropriately selected patients with multi-vessel coronary disease, HCR is associated with excellent short and longer-term results, irrespective of whether the MIDCAB or PCI procedure is performed first.

How to advance from minimally invasive coronary artery bypass grafting to totally endoscopic coronary bypass grafting: challenges in Europe versus United States of America.

Robotic coronary and intra-cardiac surgery has been available for more than 25 years. In this period, multiple studies have demonstrated the beneficial effects of robotic surgery over conventional open surgery. Throughout the years, technical developments have enabled us to perform totally endoscopic coronary artery bypass (TECAB) grafting. But these techniques remained in the hands of a small group of pioneers because of a lack of structured training programs and the absence of long-term results at that time. Currently, a renewed interest and a wide dispersion of robotic platforms, thanks to use of robotics in other disciplines, has led to an exponential increase in robotic cardiac centers both in Europe and USA. Nonetheless, this increase was slowed down in Europe as a result of the uncertainty introduced by the implementation of a revised regulatory framework for medical devices [Regulation 2017/745, 'Medical Device Regulation' ('MDR')]. The MDR was introduced with the goal of increasing patient safety and supporting innovation. Implementing the MDR has proven to be exceptionally challenging and risks to the supply of essential devices have been identified. Changes to both regulatory and market dynamics led to a circumstance where the only available robotic platform for cardiac surgery decided to cease marketing of essential accessories for conducting surgery. This resulted in the disappearance of dedicated tools such as the Endowrist stabilizer, essential for TECAB, and the atrial retractor which is essential for intra-cardiac surgery. In the mean-time, further clinical evidence was published demonstrating the superiority of robotic cardiac surgery over other minimally invasive approaches. This has demonstrated the need to better define the clinical evidence requirements for regulatory purposes to ensure that dedicated tools for evidence-based interventions in robotic coronary surgery remain available such that TECAB can continue in Europe.

Does the experience of the endoscopic vein harvester matter to the quality of the vein conduit: A critical thematic literature review.

Coronary artery bypass graft surgery remains the golden standard surgical option for multiple vessel disease. Harvesting the long saphenous vein using endoscopic vein harvesting requires advanced surgical skills dexterity, but the lack of a national standardised training programme allows for variance in the learning curve and the quality of the vein during the learning cycle is unknown. A search of bibliographic databases: CINHAL Plus, Embase, Pubmed and the Cochrane register for randomised controlled trials identified 11 articles eligible for review. The themes emerging were learning curve-associated injuries to the long saphenous vein, intimal wall remodelling of the long saphenous vein and incidence of graft patency rates. Harvesting practitioners with less than 100 cases of experience inflict more conduit injuries leading to endothelial remodelling and narrowed vein grafts at the six-month point resulting in lumen loss. Practitioners with more than 100 cases demonstrated reduced learning curve-related injuries on the conduit. Adopting a formalised structured training programme such as the Manchester Endoscopic Learning Tool has shown to reduce endothelial injury to the long saphenous vein minimising early vein graft failure during the learning cycle.

Effect of mild hypothermia vs normothermia cardiopulmonary bypass on postoperative bleeding in patients undergoing coronary artery bypass grafting: protocol of a multi-center, randomized, controlled trial.

BACKGROUND: Coronary artery bypass grafting (CABG) is often performed with hypothermic cardiopulmonary bypass (CPB) to reduce metabolic demands and protect the myocardium. However, hypothermia can increase bleeding risks and other complications. METHODS: This is a prospective, multi-center, randomized controlled trial. From September 2023 to December 2024, a total of 336 eligible patients planning to undergo on-pump CABG will be enrolled. All participants will be randomly divided into mild hypothermia CPB group (target oxygenator arterial outlet blood temperature at 32-33℃) or normothermia CPB group (target oxygenator arterial outlet blood temperature at 35-36℃). The primary endpoint is Universal Definition of Perioperative Bleeding (UDPB) class 2-4. Secondary endpoints are class of UDPB, levels of coagulation and inflammatory factors, in-hospital mortality, perioperative related complications, ICU length of stay, and hospital length of stay. DISCUSSION: This clinical trial aims to compare the effects of different target temperature during CPB on postoperative bleeding and to explore optimal temperature strategy to provide new clinical evidence. TRIAL REGISTRATION: Chictr.org.cn : ChiCTR2300075405. The trial was prospectively registered on 4 September 2023.

Diaphragmatic Dysfunction Following Endoscopic Coronary Artery Bypass Grafting in a Patient With Concomitant Sleep Disordered Breathing: A Case Report.

Unilateral diaphragmatic paralysis (UDP) is a frequent complication following cardiac surgery, usually affecting the left hemidiaphragm. Here, we present a case of a right-sided UDP following endoscopic coronary artery bypass grafting (CABG), which is far more uncommon. A 60-year-old male patient presented at our outpatient clinic with exertional dyspnoea and orthopnoea. Breathing sounds were diminished upon auscultation of the right lung base. He recently underwent a CABG through video-assisted thoracoscopic surgery (VATS). We documented a new right-sided UDP as well as severe obstructive sleep apnoea syndrome (OSAS) in this patient. We started inspiratory muscle training for the diaphragm palsy as well as continuous positive airway pressure (CPAP) therapy to ameliorate his OSAS since this is negatively influenced by UDP. The combination of this particular surgical method, the concomitant OSAS, and the right side of the UDP make this a unique case. In this report, we will briefly summarize several aspects of diaphragmatic dysfunction in the post-CABG setting, with a thorough focus on the role of ultrasound in its diagnosis and follow-up.