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.

Persistent Hypoxemia After Acute Myocardial Infarction: An Unexpected Culprit.

Hypoxemia after myocardial infarction (MI) is usually explained by common culprits, including congestive heart failure, pre-existing lung disease, and pulmonary infection. We report a case of a 60-year-old woman who experienced severe persistent hypoxemia caused by a patent foramen ovale in the setting of anterior MI complicated by a contained left ventricular rupture.

Pulmonary Hypertension in Valvular Heart Disease Surgery: Risk and Prognosis.

INTRODUCTION: Left heart disease is the most common cause of pulmonary hypertension (PH), and when present is associated with higher surgical risk. OBJECTIVES: Analyze the effect of PH severity on morbidity, early and late mortality in patients with pulmonary artery systolic pressure (PASP) over 30mmHg that underwent valvular heart surgery. METHODS: Retrospective observational study including all patients with PH, defined as PASP>30 mmHg that underwent isolated valvular heart surgery, between 2007 and 2016. Exclusion criteria were: active endocarditis, congenital heart disease, transcatheter aortic valve implantation, reoperations and emergent surgery. The study population included 607 patients with a mean age of 69.6 years and a mean PASP of 52.5 mmHg. Mean follow-up for all-cause mortality was 4.4(0-11) years in 99.7% of patients. MACCE (Major Adverse Cardiac and Cerebrovascular event) was defined as at least one of the following: in-hospital mortality, stroke, post-operative myocardial infarction, severe arrhythmia or multiple organ failure. PASP was evaluated as a continuous variable. Simple and multivariable logistic regression was performed to evaluate the in-hospital mortality and MACCE. Cox regression was used for long term follow-up and one-sample log-rank test for comparison with age adjusted general population. RESULTS: The in-hospital mortality was 3.2% and PASP was an independent predictor on univariable analysis (OR:1.06; 95%CI:1.03- 1.09; p<0.001). On multivariable logistic regression PH remains an independent predictor of in- -hospital mortality (OR:1.08; 95%CI:1.04-1.12; p<0.001) in addition to age (OR:1.08; 95%CI:1.01-1.17; p=0.044). MACCE was observed in 11.4% and PASP was an independent predictor on univariable analysis (OR:1.03; 95%CI:1.01- 1.04; p<0.001). On multivariable logistic regression PASP remains an independent predictor of MACCE (OR:1.02; 95%CI:1.01-1.04; p=0.011) as well as hemodialysis (OR:7.16; 95%CI:1.73-29.63; p=0.007). The independent predictors of long term mortality were male gender (p=0.011), older age (p<0.001), higher body mass index (p=0.013), urgent surgery (p=0.027), pulmonary disease (p=0.042) and more than one valve procedure (p=0.004 for 2 valves and p=0.006 for 3 valves). PASP was not an independent predictor of long term mortality (p=0.142). Compared with an age adjusted general population, patients with PH had a significantly lower survival rate(p<0.001), more evident 4 years after the procedure. CONCLUSIONS: Higher PASP is a risk factor for in-hospital mortality and MACCE, but there was no significant impact on long term mortality.

Coronary artery bypass grafting in octogenarians: long-term results.

INTRODUCTION: As surgical revascularization is becoming more frequent in octogenarians, we reviewed our data to analyze the impact of coronary artery bypass grafting on short- and long-term morbidity and mortality. METHODS: We performed a retrospective study of 101 consecutive patients aged 80 years or older, who underwent coronary artery bypass in a single cardiac center between January 2002 and December 2007. The patients were divided into two groups: off-pump (64.4%) and on-pump (35.6%), depending on whether the surgery was performed with cardiopulmonary bypass. Early results and those up to 6 years after surgery were assessed. RESULTS: Baseline characteristics were similar between the groups and follow-up was 90% complete. There were no significant differences between groups in mean age (off-pump = 82.7 +/- 18 years vs. on-pump = 82.2 +/- 2.2 years; p = NS) or in logistic EuroSCORE (off-pump = 11.2 +/- 12.3 vs. on-pump = 8.5 +/- 5.1; p = NS). However, the off-pump group had less complete revascularization (off-pump = 43.1% vs. on-pump = 83.3%, p = 0.0001) and shorter mean hospital stay (off-pump = 9.3 +/- 5.4 days vs. on-pump = 11.5 +/- 7.3 days; p = 0.09). Both groups showed low hospital mortality (off-pump = 1.5% vs. on-pump = 2.8%, p = NS). At 6-year follow-up, off-pump surgery patients had the same late prognosis (total survival: off-pump = 80% vs. on-pump = 77.4%, p = NS; cardiovascular mortality: off-pump = 15% vs. on-pump = 16.1%, p = NS). CONCLUSION: In octogenarians coronary artery bypass grafting had excellent results. The off-pump technique, even though it can mean less complete revascularization, leads to shorter hospital stay and has the same 6-year results as in patients operated under cardiopulmonary bypass.