The impact of Heart Team discussion on decision making for coronary revascularization in patients with complex coronary artery disease.

BACKGROUND AND AIM: Revascularization guidelines support routine Heart Team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes has not been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. METHODS: We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease (CAD) referred for HT discussion between 2016 and 2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005 and 2015 (No HT group). RESULTS: There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery score (2.5 ± 3 vs 3 ± 3; P = .32) and the mean SYNTAX score was low and similar in both groups (21 ± 6 vs 19 ± 6; P = .59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the No HT group (P < .01). HT discussion led to a significant delay to PCI (8 ± 5 vs 1.8 ± 4 days; P = .02), while surgical revascularization times were not affected. CONCLUSION: HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated.

Retroaortic right internal thoracic artery grafting of circumflex artery targets.

BACKGROUND: Retroaortic right internal thoracic artery grafting has failed to gain popularity. We aimed to delineate patient correlates of eligibility, distribution of targets, and effects of target remoteness on outcome and risk of retroaortic bleeding. METHODS: Data of 861 patients undergoing skeletonized bilateral internal thoracic artery grafting (2007-2012) were analyzed according to retroaortic (n = 300) or T-graft configuration. Retroaortic graft subgroups were categorized according to proximal (first obtuse marginal, ramus) or distal (2nd, 3rd, or sequential 1st-2nd obtuse marginal) circumflex artery targets. RESULTS: LOESS curve analyses revealed that taller patients had a higher likelihood of retroaortic grafting. The distribution of 337 retroaortic graft targets (300 patients) was first obtuse marginal in 74.5%, 2nd marginal in 12.4%, ramus in 11.2%, 3rd marginal in 1.9% and sequential 1st-2nd marginal in 12.3%. The success rate in reaching proximal and distal circumflex artery targets was 97% and 30%, respectively, 5-year survival (92.2%) and freedom from major adverse cardiac and cerebrovascular events (85.8%) were comparable between proximal and distal retroaortic graft subgroups. Distal circumflex artery targets had no effect on the occurrence of major adverse cardiac and cerebrovascular events. The incidence of retroaortic bleeding from skeletonized retroaortic grafts was 0.6%. CONCLUSIONS: Taller patients have a greater likelihood of qualifying for retroaortic grafting. This technique is highly reproducible for proximal but not distal circumflex artery targets. Distal circumflex artery targets are not independent correlates of early or late adverse outcomes. The risk of retroaortic bleeding is low despite retroaortic right internal thoracic artery skeletonization.

Concomitant grafting of both postbifurcation internal thoracic artery branches.

OBJECTIVE: We aimed to assess the clinical outcome and graft patency after concomitant grafting of both postbifurcation internal thoracic artery (ITA) branches. METHODS: Between 2007 and 2013, 17 patients (14 men; mean [SD] age, 60 [9.3] years) underwent skeletonized bifurcated ITA grafting. Respective targets were restricted to non-left anterior descending (LAD) area. In all patients, a complementary standard ITA was used to graft the LAD artery. Graft patency was assessed by standard coronary angiography or serial multidetector computed tomography. RESULTS: Of the bifurcated conduits, 94% were right ITA. Respective right ITA target sets were first and second obtuse marginal arteries (M1-M2) (n = 12), ramus-M1 (n = 2), and distal right coronary artery-posterior descending artery (n = 2). Right ITAs were mobilized retroaortic (via the transverse sinus) in 14 patients (82%) (to circumflex artery targets). Circumflex artery targets comprised 88.2% of all anastomoses (30/34). There were no early mortalities, myocardial infarctions, or hypoperfusion syndromes. During median follow-up of 44 months (range, 3-63), there was no late mortality. Overall reintervention rate was 11.7%, and bifurcated ITA-related reintervention rate was 5.8%. At 5 years, freedom from major adverse cardiac or cerebrovascular event related to bifurcated ITA respective territory was 87% (Kaplan-Meier). Coronary imaging was achieved in 76% of the patients (elective multidetector computed tomography, n = 9; symptoms-directed coronary catheterization, n = 4). Bifurcation branch patency rate was 88.4% (23/26) at a median of 3.5 years. CONCLUSIONS: Grafting both postbifurcation ITA branches is technically feasible and may be selectively considered. Current observations are valid for skeletonized conduits and limited to non-LAD targets. These preliminary findings should be corroborated by larger data sets.

Bilateral internal thoracic artery grafting in insulin-treated diabetes.

BACKGROUND: We sought to assess the risk and late outcome of bilateral internal thoracic artery grafting in eligible insulin-treated diabetic subsets. METHODS: 147 insulin-treated diabetic patients undergoing arterial revascularization were grouped as: skeletonized bilateral internal thoracic artery (n = 83) or internal thoracic artery-radial artery (n = 64). Chronic lung disease or overweight and female constituted exclusion criteria for bilateral internal thoracic artery grafts. RESULTS: Patients who had bilateral internal thoracic artery grafts were younger and comprised fewer females. Left-sided bilateral internal thoracic artery configurations were predominantly applied. Despite mean hemoglobin A1c of 8.0% ± 1% (range, 7%-13.5%) respective rates of deep sternal infection in bilateral internal thoracic artery and radial artery patients were 1.2% and 0%; superficial wound infection occurred in 3.1% and 3.6%, respectively. One sternoplasty was performed. Bilateral internal thoracic artery grafting did not correlate with sternal complications (odds ratio = 2.24, 95%CI: 0.56-8.95, p = 0.256). Of the radial artery conduits, 98% were adequate, and procurement-site complications occurred in 3.1%. Follow-up was 2-58 months (median, 25 months). Five-year survival was comparable in the 2 groups (p = 0.360). Bilateral internal thoracic artery grafting did not reduce late major adverse cardiac events (p = 0.729) or late mortality (p = 0.384). CONCLUSIONS: Skeletonized bilateral internal thoracic artery grafts can be used with acceptable risk in a substantial portion of insulin-treated diabetic patients, so it should not be automatically denied, but the choice of such grafts is not associated with midterm cardiac benefits.

[Incidence and predictors of atrial fibrillation after coronary artery bypass grafting in the Negev--are we different from the rest of the world?].

BACKGROUND: Atrial fibrillation (AF) remains a common problem after coronary artery bypass grafting (CABG). AF increases the risk for stroke and is associated with increased length of hospitalization and mortality. AIM: This study aimed to determine incidence, timing and predictors of post CABG AF in a prospectively evaluated cohort of patients undergoing CABG in the Negev. METHODS: Preoperative clinical data, intraoperative, intensive care and postoperative events including AF episodes were prospectively evaluated in 156 consecutive patients undergoing CABG during a nine month period ending on July 2003. RESULTS: Mean age was 64.9 years (SD = 9.7, range 41 - 84 years); 76.3% (119) were male. The in-hospital mortality was 1.2% (2 patients). The incidence of AF was 32.1% (50), with 40% of the AF episodes occurring on the second postoperative day (range 1-6 days). Univariate analyses identified the following variables as risk factors for AF: female gender, older age, ethnic origin, BMI > 30, hypertension, dyslipidemia, pre CABG nitrate, Ca blockers and furosemide treatment, left atrial diameter, renal failure and post CABG respiratory complications (p <0.05). By multivariate analysis, three variables were identified as independent predictors: BMI>30 (odds ratio 2.4; 95% CI 1.2-4.8); Sephardic Jews (OR 11.2; CI 1.0-114); enlarged left atrium (OR 4.6; CI 1.5-14.1). CONCLUSIONS: Consistent with previous studies, enlarged left atrium was a predictor of post CABG AF. In addition ethnic origin (Sephardic Jews) and BMI> 30 were also found to be important predictors of post CABG AF. In comparison with other studies, we not found moderate differences in outcomes and mortality in population that underwent CABG in the Negev in comparison to studies of the world.

Night-time cough in children with acute wheezing and with upper respiratory tract infection.

AIMS: To evaluate night-time cough patterns in children with either acute wheezing or an URTI, and to correlate them to the clinical diagnosis. METHODS: Night-time cough variables of 49 children diagnosed with acute wheezing and with URTI were compared using a portable cough monitoring instrument placed in the child's room. RESULTS: Children with acute wheezing had significantly more coughs per night, a longer duration of cough sounds, a higher number of coughing bouts per night, and a higher number of coughs per second within a bout, than children with an URTI. Children with acute wheezing coughed significantly more between 23.00 and 01.00, whereas between 01.00 and 06.00 there was no significant difference in the number of coughs between the two groups. CONCLUSIONS: Significant differences were found in night-time cough variables between children with an acute episode of wheezing and children with an URTI. This could be useful in clinical practice.