Early and late outcomes after minimally invasive direct coronary artery bypass vs. full sternotomy off-pump coronary artery bypass grafting.

Objectives: Minimally-invasive direct coronary artery bypass (MIDCAB) is a less-invasive alternative to full sternotomy off-pump coronary artery bypass (FS-OPCAB) revascularization of the left anterior descending artery (LAD). Some studies suggested that MIDCAB is associated with a greater risk of graft occlusion and repeat revascularization than FS-OPCAB LIMA-to-LAD grafting. Data comparing MIDCAB to FS-OPCAB with regard to long-term follow-up is scarce. We compared short- and long-term results of MIDCAB vs. FS-OPCAB revascularization over a maximum follow-up period of 10 years. Patients and methods: From December 2009 to June 2020, 388 elective patients were included in our retrospective study. 229 underwent MIDCAB, and 159 underwent FS-OPCAB LIMA-to-LAD grafting. Inverse probability of treatment weighting (IPTW) was used to adjust for selection bias and to estimate treatment effects on short- and long-term outcomes. IPTW-adjusted Kaplan-Meier estimates by study group were calculated for all-cause mortality, stroke, the risk of repeat revascularization and myocardial infarction up to a maximum follow-up of 10 years. Results: MIDCAB patients had less rethoracotomies (n = 13/3.6% vs. n = 30/8.0%, p = 0.012), fewer transfusions (0.93 units ± 1.83 vs. 1.61 units ± 2.52, p < 0.001), shorter mechanical ventilation time (7.6 ± 4.7 h vs. 12.1 ± 26.4 h, p = 0.005), and needed less hemofiltration (n = 0/0% vs. n = 8/2.4%, p = 0.004). Thirty-day mortality did not differ significantly between the two groups (n = 0/0% vs. n = 3/0.8%, p = 0.25). Long-term outcomes did not differ significantly between study groups. In the FS-OPCAB group, the probability of survival at 1, 5, and 10 years was 98.4%, 87.8%, and 71.7%, respectively. In the MIDCAB group, the corresponding values were 98.4%, 87.7%, and 68.7%, respectively (RR1.24, CI0.87-1.86, p = 0.7). In the FS group, the freedom from stroke at 1, 5, and 10 years was 97.0%, 93.0%, and 93.0%, respectively. In the MIDCAB group, the corresponding values were 98.5%, 96.9%, and 94.3%, respectively (RR0.52, CI0.25-1.09, p = 0.06). Freedom from repeat revascularization at 1, 5, and 10 years in the FS-OPCAB group was 92.2%, 84.7%, and 79.5%, respectively. In the MIDCAB group, the corresponding values were 94.8%, 90.2%, and 81.7%, respectively (RR0.73, CI0.47-1.16, p = 0.22). Conclusion: MIDCAB is a safe and efficacious technique and offers comparable long-term results regarding mortality, stroke, repeat revascularization, and freedom from myocardial infarction when compared to FS-OPCAB.

Predictors of failure after high urgent listing for a heart transplant.

OBJECTIVES: As waiting times for a heart transplant (HTx) increase, the decision of whether a patient should have a high urgent (HU) listing or mechanical circulatory support becomes crucial for further prognosis. The aim of this study was to determine the characteristics that predict failure of an HU listing (death/delisting due to urgent mechanical circulatory support implant or poor clinical condition), the 5-year survival rate, the 1-year post-transplant survival rate and the prognostic accuracy of the cardiac allocation score of patients on the HU list. METHODS: A total of 447 patients who were on the HU list at our institution between 2005 and 2016 were analysed and stratified according to occurrence of therapy failure or reception of an HTx. RESULTS: A total of 114 patients suffered from HU listing failure after a median HU time of 31.5 (15-69) days; 320 patients had a primary HTx after a median time of 51.5 (26-90) days on the HU list; 13 patients were excluded from data analysis because of an ongoing HU listing or delisting due to improvement in their haemodynamic condition. In multivariable logistic regression analysis, blood group 0 [odds ratio (OR) 2.48, 95% confidence interval (CI) 1.43-4.3; P = 0.001], INTERMACS Class 1 or 2 (OR 5.1, 95% CI 2.7-9.4; P < 0.001), vasoactive inotropic score (OR 1.18, 95% CI 1.09-1.27; P < 0.001) and brain natriuretic peptide levels (OR 1.00, 95% CI 1.00-1.00; P = 0.001) were identified as independent predictors of HU listing failure. Cardiac allocation score was not independently associated with listing failure. Estimated 5-year and 1-year post-HTx survival rates were similar in the primary HTx group and in patients receiving an HTx after HU therapy failure (P = 0.48 and P = 0.7, respectively). CONCLUSIONS: INTERMACS levels 1 and 2 and vasoactive inotropic score were the strongest predictors of HU listing failure.

Predictive value of gene expression profiling for long-term survival after heart transplantation.

OBJECTIVES: Identifying patients at risk for impaired long-term survival after heart transplantation (HT) remains a clinical challenge. The aim of this analysis was to investigate whether the gene expression profiling test AlloMap® is related to long-term survival after HT. METHODS: 46 patients who underwent HT between 2006 and 2007 who were originally included into the CARGO II trial at our institution were investigated. Patients were divided in two groups according to an increase or decrease of the AlloMap® score between 6 and 9months after HT. The primary endpoint of this study was long-term all-cause mortality. RESULTS: 23 patients showed an increase of the AlloMap® score between 6 and 9months after HT whereas the remaining 23 patients presented with a decrease of the score. After a median follow-up time of 8.1years (interquartile range 7.6-8.6), all-cause mortality was significantly elevated in patients with an AlloMap® increase compared with patients who showed a decrease of the score (log-rank p=0.005). A ratio of the AlloMap® at 9months to 6months of 1.02 or less was associated with a negative predictive value for all-cause mortality of 100%. CONCLUSIONS: Dynamic changes of the AlloMap® score between 6 and 9months after HT were strongly related to all-cause long-term survival after HT. These results suggest that AlloMap® potentially displays a useful tool to estimate the patients' risk for long-term mortality.

One-Year Clinical Outcome in End-Stage Heart Failure: Comparison of "High Urgent" Listing for Heart Transplantation with Mechanical Circulatory Support Implantation.

BACKGROUND: Heart transplantation (HTx) is still considered the therapeutic gold standard in end-stage heart failure. METHODS: In "high urgent" (HU)-listed patients for HTx (n = 274) and patients receiving left ventricular assist device (LVAD) implants (n = 332), we compared 1-year overall survival (primary endpoint) and 1-year probability of HTx and therapy failure (the need for LVAD implantation in HU-listed patients or the need for HU listing in LVAD patients) (secondary endpoints). RESULTS: In the HU and LVAD group, 1-year survival was 86.8 and 64.7%, respectively (p < 0.001). The propensity score (PS)-adjusted hazard ratio of mortality did not differ between the groups and for the LVAD group (reference = HU group) was = 1.36 (95% confidence interval [CI]: 0.85-2.19; p = 0.198). The PS-adjusted hazard ratio for the failure to receive HTx for the LVAD group (reference = HU group) was = 9.77 (95% CI: 6.00-15.89; p < 0.001). The corresponding hazard ratio for therapy failure for the LVAD group was = 0.16, 95% CI: 0.10-0.27; p < 0.001). CONCLUSION: Despite considerable differences in the probability of HTx and therapy failure, 1-year overall survival was similar in HU and LVAD patients.