Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients With Non-ST-Elevation Myocardial Infarction and Left Main or Multivessel Coronary Disease.

Current recommendations on the optimal revascularization strategy in Non-ST-elevation myocardial infarction (NSTEMI) with left main (LM) or multivessel coronary disease (MVD) are based upon randomized clinical trials conducted in stable coronary artery disease. In a real-world contemporary observational registry, we compared the long-term outcome of NSTEMI patients with LM/MVD (n = 1,104) submitted to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimized medical therapy (OMT). The primary end point was 5-year all-cause mortality. Results were assessed in the entire population (CABG 289, PCI 399, and OMT 416) and in a propensity score-matched cohort of CABG (n = 159) and PCI (n = 159). Crude 5-year mortality rates in CABG and PCI were 25.3% versus 29.6%, respectively (unadjusted hazard ratio [HR] 1.2; 95% confidence intervals [CI] 0.9 to 1.6; p = 0.212); OMT, however, was associated with a twofold higher risk of mortality when compared with any revascularization strategy (unadjusted HR 2.0; 95% CI 1.7 to 2.5; p < 0.001). After propensity score-matching and multivariate analysis, there was a trend toward a higher incidence of the primary end point in patients who underwent PCI versus CABG (31% vs 21%; adjusted HR 1.52; 95% CI 0.93 to 2.50; p = 0.094). This was a consistent finding over subgroups deemed clinically relevant, such as in patients with LM or proximal left anterior descending disease, SYNergy between percutaneous coronary intervention with TAXus ≥23 and left ventricle ejection fraction <40%. In conclusion, in a real-world cohort of NSTEMI patients with LM/MVD, those selected for OMT had a dire outcome. Although adjusted 5-year mortality was statistically similar between revascularization strategies, there was a trend favoring CABG, which might be the preferred option in LM, proximal LAD, SYNergy between percutaneous coronary intervention with TAXus ≥23, and left ventricle ejection fraction <40% subgroups.

CABG: To CBP or Not To CBP - A Propensity Score Matched Survival.

INTRODUCTION: Over the past 3 decades two main strategies have been employed for surgical coronary revascularization (CABG): on- pump CABG with cardioplegia (ONCAB) and off-pump CABG (OPCAB). The objective of this study is to evaluate the short-term and long-term survival of the two strategies. METHODS: This study consists of 8-year cohort, retrospective single-center analysis with an intention-to-treat design. 2954 patients underwent CABG (OPCAB n=2123; ONCAB= 831) for CAD. As these two groups were statistically different regarding several parameters, a propensity score model was applied and a more homogeneous cohort (n= 1441; OPCAB= 885; ONCAB=556) was analyzed. Univariate analysis, Kaplan-Meier curves and when appropriate a multivariate analysis was applied to the overall group and 6 subgroups: 2 vessel disease, 3 vessel disease, left stem disease, diabetic patients; patients with creatinin clearance bellow 50ml/min; and patients with body mass index above 30 kg/m2. RESULTS: Our study show: No difference in 30-days mortality, long-term survival (mean 71 months follow-up), AKY and stroke rates; Higher rates of bypass per patient (2.3% vs 2.8%, p<0,001) and complete revascularization (76% vs 83%) in the ONCAB group; Fewer re-operation for bleeding (0.8 vs 3.8%, p<0.001), fewer peak troponin>19mg/ dl (4.7% vs 9.9%, p<0,001), and fewer IABP use (1.5% vs 3.3%, p=0,027) in the OPCAB group. Sub-group analysis showed no difference between the two groups with exception of a higher rate of troponin peak >19mg/dl adjusted for CAD extension in the left-main stem disease group undergoing ONCAB (OR=2,3 +-0.8 p=0,018). CONCLUSION: The major randomized controlled trials comparing the two strategies show: No difference in 30-days mortality, 1-year survival, AKY and stroke rates; Less re-revascularization rates and higher bypass per patient and bypass patency with ONCAB. Despite the large volume of evidence generated around both on-pump and off-pump CABG strategies, studies fail to demonstrate clear benefit of either strategy regarding mortality and most common complications. Our results are similar of those found in the literature as neither strategy has unequivocal superior results. ONCAB shows consistently higher rates of complete revascularization and higher number of grafts. OPCAB shows lesser troponin levels suggestive of less myocardial damage. Major limitations include: analysis not matched for surgeon performance; cardiac related events, re-revascularization need and graft patency not evaluated; isolated use of troponin levels for evaluation myocardial damage.

Marfan syndrome with ascending aortic aneurysm: value of cardiac computed tomography.

We report the case of a 40-year-old man with known Marfan syndrome who presented with severe aortic valve regurgitation secondary to significant aortic root dilatation. To rule out coronary artery disease and to evaluate the rest of the thoracic aorta before surgery, cardiac computed tomography (CT) was performed. A brief review of the literature shows how cardiac CT can, in selected cases, rule out coronary artery disease before non-coronary cardiothoracic surgery.