Clinical Outcomes After the Surgical Treatment of Hypertrophic Obstructive Cardiomyopathy With Left Ventricular Apical Aneurysm.

BACKGROUND: Left ventricular apical aneurysm (LVAA) is a rare complication of hypertrophic obstructive cardiomyopathy (HOCM). This study aimed to illustrate the clinical characteristics and surgical outcomes of these patients. METHOD: Patients with HOCM and LVAA who underwent modified extended Morrow myectomy and surgical left ventricular reconstruction (SLVR) between October 2012 and March 2021 were retrospectively recruited. Patients with coronary artery disease were excluded. Clinical characteristics were summarised. Time-to-event outcomes were calculated using the Kaplan-Meier method and compared by a log-rank test. RESULTS: Fifteen eligible patients were identified; the mean age was 39.9±17.2 years and 40.0% of them were female. All patients had dyspnoea, 46.7% presented with syncope and/or chest pain, and 13.3% had a family history of hypertrophic cardiomyopathy. The mean LVAA size was 36.9±12.3 mm in length and 28.5±11.3 mm in width. Echocardiography showed LV outflow tract obstruction in seven (46.7%) patients, mid-cavity LV obstruction in 12 (80.0%), while systolic anterior motion (SAM) was seen in seven (46.7%). The symptoms were resolved in all patients postoperatively. During a median follow-up of 22.0 months, one (6.7%) patient had sudden cardiac death, one (6.7%) had a haemorrhagic stroke, and the LVAA recurrence was 40.0%. Subgroup analysis showed that signs of SAM and larger LVAA (≥30 mm) were associated with an increased tendency for a longer hospital stay. CONCLUSIONS: Patients with HOCM and LVAA present with high-risk profiles. Modified extended Morrow myectomy combined with SLVR is useful in relieving the symptoms and improving the prognosis, although there might be recurrent LVAA.

Is 3-6 months anticoagulation with warfarin necessary after left ventricular thrombectomy with left ventricular aneurysm surgery?

OBJECTIVES: No recommendation exists on the optimal antithrombotic therapy after left ventricular thrombus (LVT) resection in the current guidelines. The study aimed to investigate the role of prophylactic anticoagulation with warfarin for 3-6 months in LVT recurrence and other clinical outcomes after LVT resection and left ventricular aneurysm (LVA) surgery. METHODS: All consecutive patients undergoing LVT resection together with LVA surgery in our institution between 2010.1.1 and 2021.4.1 were included in the study. Individuals included were divided into two groups based on whether warfarin was administered at discharge. Patients with warfarin were matched to their counterparts without warfarin based on the baseline characteristics via propensity score matching (PSM) at the ratio of 1:1. The primary outcome was LVT recurrence. The secondary outcomes were major adverse cardiac and cerebrovascular events (MACCEs) and the composite endpoint of LVT recurrence and MACCEs. RESULTS: After PSM, a total of 118 patients were included in the study, among whom 59 received warfarin therapy at discharge and 59 didn't. During the median follow-up of 56.5 months, 21 out of 118 patients had LVT recurrence and the recurrence rate was 17.8% There was no systemic embolism resulting from the recurrent LVT. Kaplan-Meir analysis showed no significant difference in LVT recurrence (p = .86), MACCEs (p = .48) and the composite endpoint of LVT recurrence, and MACCEs (p = .89). Cox proportional hazards regression model showed that history of PCI (hazard ratio [HR] 2.778, 95% confidence interval [CI] 1.087-7.100, p = .033) and LVA surgical strategy of linear suture (HR 8.768, 95% CI 1.139-67.517, p = .037) were independent risk factors of LVT recurrence. CONCLUSIONS: Prophylactic anticoagulation with warfarin for 3-6 months may be unnecessary with no benefit in terms of LVT recurrence and other clinical outcomes.

Long-Term Outcomes of Left Ventricular Restoration in Patients Ineligible for Concomitant Coronary Artery Bypass Grafting.

BACKGROUND: The prognosis of severe coronary artery disease (CAD) patients undergoing left ventricular restoration (LVR) and ineligible for concomitant coronary artery bypass grafting (CABG) is unclear. This study illustrates the clinical characteristics and the long-term survival of these patients in a retrospective cohort. METHODS: From January 1999 to March 2021, a total of 78 patients underwent surgical left ventricular restoration without concomitant CABG at our center. The primary endpoint was the major adverse cardiovascular and cerebrovascular events (MACCE). Kaplan-Meier analysis was performed to calculate survival, and compared by log-rank test, followed by multiple adjustments using Cox regression. RESULTS: The mean age was 55.3 ± 11.4 years. There were 76 (97.4%) true and 2 (2.6%) pseudo-aneurysms. Forty-six (59.0%) patients presented NYHA functional class III or IV. The mean EuroSCORE was 10.6 ± 3.2. Concomitant surgeries included mitral valve repair (N = 3), mitral valve replacement (N = 2), tricuspid valve repair (N = 2), ventricular septal defect closure (N = 18), maze procedure (N = 1), and appendage ligation (N = 1). Reoperation for bleeding was performed in one patient (1.3%). Prolonged ventilation was observed in 21 (26.9%) patients. Fourteen (17.9%) patients presented with low cardiac output and were supported with IABP. Operative death occurred in one (1.3%) patient. The median duration of echocardiographic follow-up was 53 months (interquartile range, 81.5) and was obtained in 46 (59.0%) patients. Left ventricular ejection fraction (LVEF) improved from 41.1% ± 10.5% to 45.6% ± 7.9% (P < 0.001), and the left ventricular end-diastolic dimension (LVEDD) fell from 57.8 ± 6.6 mm to 52.0 ± 6.2 mm (P < 0.001). The median patient follow-up time was 79.5 months (interquartile range, 53.5). Overall, 1-, 5-, and 10-year survival rates were 98.7%, 95.5% and 82.3%, respectively. CONCLUSIONS: Patients with severe CAD and ineligible for concomitant CABG are in critical condition, and LVR could be a reliable approach to improving cardiac function with satisfactory early and long-term outcomes.

Coronary endarterectomy combined with coronary artery bypass grafting might decrease graft patency: A cohort study.

BACKGROUND: Little is known about the graft patency after coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG). This study aimed to investigate the graft patency after CABG + CE. METHODS: Eligible patients hospitalized at our center during September 2008 and July 2022 with complete follow-up coronary angiographic data available were retrospectively enrolled. The primary end point was the follow-up graft patency of CE targets. Logistic regression was performed to explore the potential predictors of the CE-targeted graft failure. RESULTS: A total of 160 patients (age: 59.4 ± 9.3 years, male: 75.6%) were enrolled, and 560 grafts were anastomosed. CE was performed on 166 sites, including LAD (36.1%), right coronary artery (RCA, 48.2%), left circumflex artery (9.6%), and diagonal branches (6.0%). Postoperative myocardial infarction was observed in 7 (4.4%) of the patients. During a median follow-up of 12.1 months, the CE-targeted graft patency was 69.9%. The CE-targeted graft patency rate was much higher among the LAD-CE patients than the non-LAD-CE patients (80.0% vs. 64.2%, P = 0.032) but lower than non-endarterectomized LAD (80.0% vs. 92.9%, P = 0.013). No difference was observed regarding the graft patency between off-pump and on-pump surgery (P = 0.585). In the logistic regression, RCA-CE was associated with an increased risk of graft failure even after multiple adjustments (odds ratio: 2.35, 95% confidence interval: 1.05-5.28, P = 0.028). CONCLUSIONS: CABG + CE might be associated with decreased graft patency, especially in those who received RCA-CE, irrespective of surgical technique or antiplatelet/anticoagulation regimen. A multi-center prospective, possibly randomized study with a larger sample size is warranted.

Partial CArdiac Denervation to Prevent Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting (pCAD-POAF): Study Protocol for a Randomized Controlled Trial.

Postoperative atrial fibrillation (POAF) is commonly seen in patients who underwent coronary artery bypass grafting (CABG), increasing the risk of morbidity, mortality, and hospital expenses. This study aimed to evaluate the effect of partial cardiac denervation, which is achieved by cutting off the ligament of Marshall and resecting the fat pad along the Waterston groove, on the prevention of POAF after CABG. Patients planned for CABG at our center were screened for eligibility in this study. A total of 430 patients were randomized into the intervention (partial cardiac denervation) group and control group. Intraoperative high-frequency electrical stimulation and further histologic analysis were performed in a certain number of patients to confirm the existence of ganglia. All patients were continuously monitored for the incidence of POAF through an electrophysiologic device until the sixth day postoperatively, and required to complete a 30-day follow-up (12-lead electrocardiogram and echocardiogram assessment) after discharge. The primary end point is the incidence of POAF, whereas the secondary end points are the cost-effectiveness and safety outcomes. In conclusion, this trial will evaluate whether partial cardiac denervation through cutting off the ligament of Marshall and resecting the fat pad along the Waterston groove can reduce the incidence of POAF after CABG. If this procedure is revealed to be effective and safe, it may provide a potential therapeutic approach to prevent POAF in this group of patients.

Clinical outcomes of on-pump versus off-pump coronary-artery bypass surgery: a meta-analysis.

BACKGROUND: The ongoing debate regarding off-pump CABG and on-pump CABG has endured for over three decades. Although numerous randomized controlled trials (RCTs) and meta-analyses have been reported, new evidence has emerged. Therefore, an updated and comprehensive meta-analysis to guide clinical practice is essential. MATERIALS AND METHODS: A comprehensive search for eligible articles published after 2000, reporting RCTs involving at least 100 patients and comparing off-pump CABG with on-pump CABG, was performed throughout the databases including Embase, Ovid Medline and Web of Science. The primary interested outcomes included the short-term incidence of stroke and long-term mortality. The primary analysis utilized Fixed-effect model with the inverse variance method. The Grade of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the certainty of evidence. RESULTS: After thorough screening, 39 articles were included, consisting of 28 RCTs and involving a total of 16090 patients. Off-pump CABG significantly reduced the incidence of short-term stroke (1.27% vs. 1.78%, OR: 0.74, P=0.03, high certainty). However, it was observed to be associated with increased mid-term coronary reintervention (2.77% vs. 1.85%, RR: 1.49, P<0.01, high certainty) and long-term mortality (21.8% vs. 21.0%, RR: 1.09, P=0.02, moderate certainty). CONCLUSIONS: Off-pump CABG significantly reduces the short-term incidence of stroke, but it also increases the incidence of mid-term coronary reintervention. Moreover, it may increase long-term mortality.

Prognostic value of carbohydrate antigen 125 in patients undergoing surgical left ventricular reconstruction.

BACKGROUND: Carbohydrate antigen 125 (CA125) is a biomarker often used in diagnosis of ovarian tumors. Studies also show that elevated CA125 implicates worse outcomes among patients with heart failure, while latter of which plays an important role in the pathophysiology of left ventricular aneurysm (LVA). However, the prognostic value of CA125 in LVA patients undergoing surgical left ventricular reconstruction (SLVR) remains unclear. METHODS: In this single-centered cohort study, a total of 309 patients with LVA undergoing SLVR were retrospectively recruited. Univariable regression analysis was performed to identify the potential confounders for each outcome, followed by multivariable adjustment to confirm the association between CA125 and outcomes. The primary outcome was the overall mortality, and the secondary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE) and perioperative outcomes. A receiver operating characteristic (ROC) curve was use to find the optimal cut-off value of CA125. RESULTS: The median follow-up time was 55 months. The cohort was predominantly male (86.4%), with an average age of 58.6 years. Log (CA125) was associated with overall mortality (hazard ratio [HR]: 2.15, 95% confidence interval [CI]: 1.06-4.36, P = 0.033), prolonged hospital-stay time (HR:1.07, 95%CI: 1.03-1.12, P = 0.001) and increased risk of postoperative ventricular support (HR: 2.81, 95%CI: 1.10-7.18, P = 0.031) after multivariate adjustment. The optimal cut-off value for the CA125 for all-cause mortality was 13.825 U/ml with the area under curve of 0.675. CONCLUSION: Elevated-CA125 implicates poorer short- and long-term prognosis in LVA patients undergoing SLVR.

Risk Prediction After Coronary Artery Bypass Grafting Combined With Coronary Endarterectomy.

Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) is used for complete revascularization of diffusely diseased coronary arteries. Nevertheless, studies reported an increased risk after this procedure. Therefore, risk prediction in these patients is essential. Patients who underwent CABG + CE during September 2008 and July 2022 at our center were retrospectively recruited. A total of 32 characteristics were analyzed. The least absolute shrinkage and selection operator regression were used for the feature selection, and multivariable Cox regression was applied to develop a nomogram for risk prediction. The primary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE), a composite of all-cause death, nonfatal myocardial infarction, repeat revascularization, and stroke. A total of 570 patients with 601 CE targets, including left anterior descending (41.4%), right coronary artery (43.9%), left circumflex artery (6.8%), and diagonal branches/intermedius ramidus (8.0%), were enrolled. The mean age was 61.0 ± 8.9 years, and 77.7% were men. A total of 4 features were identified as the predictors of MACCE, including age ≥65 years (hazard ratio [HR] 2.12, 95% confidence interval [CI] 1.38 to 3.25, p <0.001), left main disease (HR 2.56, 95% CI 1.46 to 4.49, p = 0.001), mitral regurgitation (≥mild, HR 1.91, 95% CI 1.01 to 3.65, p = 0.049), and left anterior descending endarterectomy (HR 1.69, 95% CI 1.09 to 2.62, p = 0.018), and a nomogram for the 1- and 3-year MACCE prediction was developed. The model showed relatively good discrimination (C-index 0.68), calibration, and clinical usefulness. In conclusion, the nomogram provides estimation of the 1- and 3-year MACCE risk after CABG + CE.

Mid-term outcomes of patients with subclinical hypothyroidism after coronary bypass surgery.

OBJECTIVES: Subclinical hypothyroidism (SCH) is characterized by an elevated thyroid-stimulating hormone and normal free thyroxine. This study aimed to evaluate the influence of SCH on mid-term outcomes of patients after coronary artery bypass grafting (CABG). METHODS: From January 2015 to December 2018, 548 SCH patients and 6718 euthyroid patients who underwent CABG were identified. Propensity score matching was used to create 2 cohorts with similar baseline characteristics (n = 544 in each group). The mid-term follow-up outcomes were compared. Adjusted hazard ratios (HRs) were calculated using Cox proportional hazards models. RESULTS: The mean follow-up for all patients was 39.7 ± 17.3 months. The unadjusted Kaplan-Meier estimate for mortality at 5-year follow-up was higher in patients with SCH compared with euthyroid patients (5.3% vs 1.6%, log-rank P = 0.03). After adjusting for covariates, the risk of mortality was higher in patients with SCH compared with euthyroid patients [HR, 2.40; 95% confidence interval (CI), 1.03-5.58; P = 0.04]. The adjusted risk of major adverse cardiovascular and cerebral event (HR, 2.16; 95% CI, 1.51-3.08; P < 0.001) and angina (HR, 2.44; 95% CI, 1.41-4.24; P = 0.001) was higher in patients with SCH compared with euthyroid patients. CONCLUSIONS: SCH is associated with an increased risk of mortality, major adverse cardiovascular and cerebral event and angina compared with euthyroidism in patients undergoing CABG.

Impact of concomitant mitral valve surgery on the clinical outcomes of patients with moderate functional mitral regurgitation and HFpEF undergoing aortic valve replacement: a cohort study.

BACKGROUND: Functional mitral regurgitation (FMR) worsens the prognosis of patients with heart failure with preserved ejection fraction (HFpEF). While concomitant mitral valve surgery (MVS) is recommended for severe FMR during aortic valve replacement (AVR), the optimal treatment of moderate FMR, especially in those with HFpEF, remains unclear. This study aimed to evaluate the effect of MVS in patients with moderate FMR and HFpEF undergoing AVR. METHODS: A total of 212 consecutive patients (AVR: 34.0%, AVR-MVS: 66.0%) during 2010 and 2019 were enrolled. Survival outcomes were compared. Inverse probability treatment weighting (IPTW) was used to balance the baseline characteristics. Kaplan-Meier curve and log-rank test were applied to compare the survival outcomes. The primary endpoint was the overall mortality. RESULTS: The mean age was 58.9 [Formula: see text] 11.9 years, and 27.8% of them were female. During a median follow-up of 16.4 months, AVR-MVS did not reduce the risk of mid-term MACCE (hazard ratio [HR]: 1.53, 95% confidence interval [CI]: 0.57-4.17, Plog-rank = 0.396), while it showed a tendency toward higher MACCE risk in the IPTW analysis (HR: 2.62, 95% CI: 0.84-8.16, Plog-rank = 0.096). In addition, AVR-MVS increased the risk of mortality as compared to isolated AVR (0 vs. 10%, Plog-rank = 0.016), which was sustained in the IPTW analysis  (0 vs. 9.9%, Plog-rank<0.001). CONCLUSION: In patients with moderate FMR and HFpEF, isolated AVR might be more reasonable than AVR-MVS.

A Meta-Analysis of Early, Mid-term and Long-Term Mortality of On-Pump vs. Off-Pump in Redo Coronary Artery Bypass Surgery.

We aimed to compare the early, mid-term, and long-term mortality between on-pump vs. off-pump redo coronary artery bypass grafting (CABG). We conducted a systematic search for studies comparing clinical outcomes of patients who underwent on-pump vs. off-pump redo CABG. We pooled the relevant studies quantitatively to compare the early (perioperative period, whether in hospital or within 30 days after discharge), mid-term (≥1 year and <5 years), and long-term (≥5 year) mortality of on-pump vs. off-pump redo CABG. A random-effect model was applied when there was high heterogeneity (I2 > 50%) between studies. Otherwise, a fixed-effect model was utilized. After systematic literature searching, 22 studies incorporating 5,197 individuals (3,215 in the on-pump group and 1,982 in the off-pump group) were identified. A pooled analysis demonstrated that compared with off-pump redo CABG, on-pump redo CABG was associated with higher early mortality (OR 2.11, 95%CI: 1.54-2.89, P < 0.00001). However, no significant difference was noted in mid-term mortality (OR 1.12, 95%CI: 0.57-2.22, P = 0.74) and long-term mortality (OR 1.12, 95%CI: 0.41-3.02, P = 0.83) between the two groups. In addition, the complete revascularization rate was higher in the on-pump group than the off-pump group (OR 2.61, 95%CI: 1.22-5.60, P = 0.01). In conclusion, the off-pump technique is a safe and efficient alternative to the on-pump technique, with early survival advantage and similar long-term mortality to the on-pump technique in the setting of redo CABG, especially in high-risk patients. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021244721.

Results of different therapeutic strategies for left ventricular aneurysm with mitral regurgitation.

OBJECTIVE: This study aims to compare the midterm outcomes of left ventricular reconstruction (LVR) added to coronary artery bypass grafting (CABG) with those of CABG alone in patients with left ventricular aneurysm (LVA) and mild or moderate mitral regurgitation (MR). We also assessed the impact of LVR on the degree of MR. METHODS: A total of 130 patients (77 who underwent CABG plus LVR and 53 who underwent CABG alone) with concomitant mild or moderate MR were included in the study population. All-cause mortality was considered the primary endpoint. Major adverse cardiovascular and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and subsequent mitral valve surgery, were considered secondary endpoints. Kaplan-Meier analysis was performed to evaluate event-free survival. MR was graded 0 to 4+ by echocardiogram. RESULTS: The median follow-up time among all patients was 22 months. There was a significant difference between the CABG plus LVR and CABG alone groups with regard to all-cause mortality ( P = 0.019). However, the statistical difference was not observed in cardiogenic mortality ( P = 0.186) and MACCEs ( P = 0.107). In the grade of MR, the two groups both resulted in the decreased grade of MR, but the CABG plus LVR group had a significant number of patients improving to 0 or 1+ ( P = 0.030). CONCLUSION: The clinical outcomes of CABG alone are comparable with those of CABG plus LVR in patients with LVA and mild or moderate MR. However, CABG+LVR demonstrated greater reduction in MR severity after surgery than CABG alone.

Effect of ß-blocker on patients with moderate functional mitral regurgitation undergoing surgical aortic valve replacement.

AIMS: The optimal treatment for severe aortic valve disease complicated with moderate function mitral regurgitation (FMR) remains controversial. Although isolated surgical aortic valve replacement (SAVR) is reasonable, previous studies also show that moderate FMR might deteriorate after surgical treatment and result in poorer prognosis. Because the left ventricular remodelling plays a critical role in the development of FMR, these patients might potentially benefit from the administration of ß-blocker (BB). Unfortunately, relevant clinical evidence is lacking. This study aimed to investigate the impact of post-operative administration of BB on the outcomes of moderate FMR patients undergoing isolated SAVR. METHODS: In this single-centre cohort study, patients who underwent isolated SAVR and complicated with pre-operative moderate FMR during 2010 and 2019 at our centre were retrospectively recruited. Patients were divided into two groups according to postoperative administration of BB (BB group vs. control group). The cumulative survival rates were calculated using the Kaplan-Meier method and tested by the log-rank test, followed by inverse probability treatment weighting (IPTW) analysis to further control the between-group imbalances. The primary outcome was the major adverse cardiovascular and cerebrovascular events (MACCE), a composite endpoint of all-cause death, repeat heart valve surgery, non-fatal myocardial infarction, stroke, and hospitalization for heart failure. RESULTS: A total of 165 patients were enrolled, 57 (34.6%) of whom were female, and the mean age was 59.2 ± 12.2 years. Eighty (48.5%) patients received post-operative BB therapy. The median follow-up time was 18.4 months. The administration of BB was not associated with lower risk of MACCE [hazard ratio (HR): 0.68, 95% confidence interval (CI): 0.29-1.62, P = 0.388] or all-cause death (HR: 1.03, 95% CI: 0.30-0.56, P = 0.967). In the IPTW dataset, the total number of patients were 326.89, and the outcomes regarding the risk of MACCE (HR: 0.79, 95% CI: 0.31-1.97, P = 0.607) and all-cause death (HR: 1.33, 95% CI:0.35-5.05, P = 0.674) were in line with the unmatched analysis. The follow-up echocardiographic results were available for 72.2% of the overall cohort, and the use of BB was observed to be associated with higher improvement rate of follow-up FMR according to the IPTW analysis (92.2% vs. 98.3%, P = 0.033). CONCLUSIONS: The administration of BB after SAVR was not associated with lower risk of MACCE for patients of severe aortic valve disease complicated with moderate FMR, but was potentially beneficial for improving FMR.

Surgical treatment of patients with aortic valve disease complicated with moderate functional mitral regurgitation and heart failure with midrange ejection fraction: a cohort study.

Background: Controversies exist on the treatment of moderate functional mitral regurgitation (FMR) in patients with severe aortic valve disease undergoing the aortic valve replacement (AVR). While a substantial proportion of these patients can be complicated with heart failure with midrange ejection fraction (HFmrEF), established studies show that the latter might compromise the patient outcome. This study was aimed to evaluate the prognostic value of concomitant mitral valve surgery during AVR in patients with severe aortic valve disease followed by moderate FMR and HFmrEF. Methods: A total of 78 consecutive patients were retrospectively recruited. Patients were divided into control (isolated AVR) and treatment (AVR + mitral valve surgery) groups. Follow-up outcomes were compared by Kaplan-Meier method, followed by multiple adjustment with inverse probability treatment weighting (IPTW) analysis. The primary outcome was the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE). Results: Thirty-six patients received isolated AVR, while 42 received AVR with mitral valve repair or replacement. The median follow-up time was 28.7 months. Unadjusted analysis showed that there was no significant difference in the rate of MACCE between the two groups [hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.48-2.69, Plogrank=0.770], which was sustained in IPTW analysis (HR: 1.64, 95% CI: 0.59-4.55, Plogrank=0.342). In addition, while concomitant mitral valve surgery improved follow-up FMR more completely (P=0.026) in the IPTW analysis, the ejection fraction was comparable between the two groups (P=0.276). Furthermore, IPTW analysis also showed that mitral valve surgery was associated with the increased risk of postoperative acute kidney injury (P=0.007). Conclusions: In patients with aortic valve disease followed by moderate FMR and HFmrEF, mitral valve surgery concomitant to AVR may not bring extra benefit in the MACCE-free survival and the improvement of HFmrEF. However, while concomitant mitral valve surgery has priority on the complete improvement of FMR, it might increase the risk of postoperative acute kidney injury.

Time Trends of Ventricular Reconstruction and Outcomes among Patients with Left Ventricular Thrombus and Aneurysms.

Background: Clinical guidelines recommend surgical intervention when left ventricular thrombus (LVT) is complicated with left ventricular aneurysm (LVA). Objectives: This study aimed to review the changes in the treatment of LVT combined with LVA over the past 12 years at our center and to compare the efficacy of medical therapy and surgical treatment on patient outcomes. Methods: Between January 2009 and June 2021, 723 patients with LVT combined with LVA were enrolled, of whom 205 received surgical ventricular reconstruction (SVR) therapy and 518 received medical therapy. The following clinical outcomes were gathered via observation: all-cause death, cardiovascular death, and major adverse cardiovascular and cerebrovascular events (MACCEs; defined as the composite of cardiovascular death, ischemic stroke, and acute myocardial infarction). The median follow-up time was 1403 [707, 2402] days. Results: The proportion of SVR dropped yearly in this group of patients, from a peak of 64.5% in 2010 to 7.5% in 2021 (p for trend < 0.001). Meanwhile, the proportion of anticoagulant use increased quickly, from 8.0% in 2016 to 67.9% in 2021 (p for trend < 0.001). The incidence rates of all-cause mortality, cardiovascular death, and MACCEs were 12.9% (n = 93), 10.5% (n = 76), and 14.7% (n = 106), respectively. In the multivariable analysis, there were no significant differences in all-cause death (HR of 0.60, 95% CI of 0.32−1.13, p = 0.11), cardiovascular death (HR of 0.79, 95% CI of 0.41−1.50, p = 0.5), and MACCEs (HR of 0.82, 95% CI of 0.49−1.38, p = 0.5) between the two groups. The competing risk regression performed in the propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) analyses was in line with the unmatched analysis. Conclusions: The rate of SVR dropped significantly among patients with both LVT and LVA, while there was an improvement in oral anticoagulant utilization. SVR with thrombus removal did not improve all-cause mortality and cardiovascular outcomes in patients with LVT and LVA. Ventricular aneurysm with thrombus may not be an indication for surgery.

Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting.

OBJECTIVES: The aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events. METHODS: A total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan-Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes. RESULTS: The median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37-9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32-9.77; P = 0.013). CONCLUSIONS: When performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.

Comparison of dual antiplatelet therapies after coronary endarterectomy combined with coronary artery bypass grafting: a cohort study.

BACKGROUND: Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) can be the only option for complete revascularization in some patients with diffuse coronary artery disease. Unfortunately, CE can cause the lack of endothelium, resulting in increased risk of thrombotic events. Therefore, antithrombotic therapy is very important after surgery. However, there's no consistent protocol exists till now. The aim of this study was to compare the effectiveness and safety of dual antiplatelet therapies (DAPT) including aspirin plus clopidogrel (AC) or ticagrelor (AT) after CE + CABG. METHOD: A total of 137 continuous patients (mean age 60.0 ± 9.0 years) underwent CE + CABG from January 2016 to July 2018 in our center, and patients who received dual antiplatelet therapy (DAPT) after surgery (n = 121) were included in this study. All of the patients received aspirin 100 mg daily therapy after surgery, and 67 of the patients received extra clopidogrel 75 mg (AC) daily therapy, whereas 54 received extra ticagrelor 90 mg (AT) twice daily. All patients continued aspirin monotherapy after 1 year. Occurrence of ischemic events and bleeding events between two groups were compared. Kaplan-Meier survival was used to compare freedom from major adverse cardiovascular and cerebrovascular events (MACCE) between two groups, and log-rank test was used to confirm statistical difference. RESULTS: Follow-up was completed by 99.2%, and median follow-up time was 30.0(22.5, 35.2) months. No operative death was observed, while perioperative myocardial infarction was observed in 2(1.7%) patients (AC 1.5% vs. AT 1.9%, p = ns). One patient in AC group suffered from cardiac tamponade. During the follow-up period, no death was observed. Ischemic events including nonfatal myocardial infarction, repeat revascularization and ischemic stroke were observed in 6(5.0%) patients (AC 4.5% vs. AT 5.6%, p = ns). Overt bleeding had occurred in 3(2.5%) patients (AC 3.0% vs. AT 1.9%, p = ns). Kaplan-Meier analysis indicated that MACCE-free survival of the two groups at 3 years was 97.0% in the AC group versus 94.1% in the AT group (p = ns). CONCLUSION: In patients undergoing CE + CABG, DAPT therapy can be effective and safe with comparable results between AC and AT therapy in terms of ischemic and bleeding events. Further studies are needed.