Single versus multiple arterial coronary artery bypass grafting in men and women: results from Polish National Registry of Cardiac Surgery Procedures.

BACKGROUND: The objective of this multicenter study aimed to investigate the impact of sex on long-term survival among patients with multivessel coronary artery disease undergoing coronary artery bypass grafting (CABG) using multiple arterial grafting (MAG) or a single artery with saphenous vein grafts. MATERIALS AND METHODS: Data were obtained from the Polish National Registry of Cardiac Surgery Procedures database. This study included 81 136 patients who underwent CABG for multivessel disease between January 2012 and December 2020 (22.9 were women and 77.1% were men). MAG was performed in 8.3 and 11.7% of female and male patients, respectively. A 1:1 propensity score (PS)-matching was performed. Long-term mortality was compared between matched groups of men and women. Subgroup analyses of patients aged <70 and ≥70 years, with an ejection fraction (EF) >40% and ≤40%, and with and without diabetes, obesity, peripheral artery disease (PAD), or chronic lung disease (CLD) were performed separately in women and men. RESULTS: MAG was associated with lower long-term mortality than saphenous vein grafts in 1528 PS-matched female pairs [hazard ratio (HR): 0.74; 95% CI: 0.59-0.92; P =0.007) and 7283 PS-matched male pairs (HR: 0.80; 95% CI: 0.72-0.88; P <0.001). Subgroup analyses confirmed the results among female patients aged <70 years, with diabetes and EF >40%, and without PAD or CLD, and of male patients aged <70 and ≥70 years; with EF >40%; with or without diabetes, obesity, or PAD; and without CLD. CONCLUSIONS: In patients undergoing CABG, MAG was associated with significantly improved survival in both sexes. The long-term benefits of MAG observed across subgroups of men and women support the consideration of a multiarterial revascularization strategy for a broader spectrum of patients.

Stabilization of Graphene Oxide Dispersion in Plasma-like Isotonic Solution Containing Aggregating Concentrations of Bivalent Cations.

Graphene oxide's (GO) intravascular applications and biocompatibility are not fully explored yet, although it has been proposed as an anticancer drug transporter, antibacterial factor or component of wearable devices. Bivalent cations and the number of particles' atom layers, as well as their structural oxygen content and pH of the dispersion, all affect the GO size, shape, dispersibility and biological effects. Bovine serum albumin (BSA), an important blood plasma protein, is expected to improve GO dispersion stability in physiological concentrations of the precipitating calcium and magnesium cations to enable effective and safe tissue perfusion. METHODS: Four types of GO commercially available aqueous dispersions (with different particle structures) were diluted, sonicated and studied in the presence of BSA and physiological cation concentrations. Nanoparticle populations sizes, electrical conductivity, zeta potential (Zetasizer NanoZS), structure (TEM and CryoTEM), functional groups content (micro titration) and dispersion pH were analyzed in consecutive preparation stages. RESULTS: BSA effectively prevented the aggregation of GO in precipitating concentrations of physiological bivalent cations. The final polydispersity indexes were reduced from 0.66-0.91 to 0.36-0.43. The GO-containing isotonic dispersions were stable with the following Z-ave results: GO1 421.1 nm, GO2 382.6 nm, GO3 440.2 nm and GO4 490.1 nm. The GO behavior was structure-dependent. CONCLUSION: BSA effectively stabilized four types of GO dispersions in an isotonic dispersion containing aggregating bivalent physiological cations.

Platelet reactivity expressed as a novel platelet reactivity score is associated with higher inflammatory state after coronary artery bypass grafting.

Introduction: Despite therapy, patients operated using a cardiopulmonary bypass demonstrate increased platelet aggregation, which rebounds to above preoperative levels. The aim of the study was to test the interaction between platelet reactivity/activation and selected inflammatory markers in the post-operative period. Material and methods: In total, 103 patients with non-ST elevation acute coronary syndrome (NSTE-ACS) who were not eligible for percutaneous coronary interventions (PCI), and required urgent revascularization, were included. Platelet reactivity was measured using the PFA-100 platelet analyser, multiple electrode aggregometry, and was expressed as a novel platelet reactivity score (PRS). Patients were divided using their PRS scores into high platelet relativity or low platelet reactivity subgroups (HPR or LPR). Platelet basal activation was measured using immunoassays for soluble P-selectin and soluble CD40L. We measured high-sensitivity C-reactive protein (CRP), and used immunoassays for tumour necrosis factor α (TNF-α) and interleukin 6 (IL-6) as inflammation markers. Results: Significant differences between HPR and LPR groups were found for CRP (mg/l): 81.5 vs. 44.6, p < 0.02; and TNF-α (pg/l): 3.51 vs. 2.37, p < 0.02. A significant association was found between CRP, TNF-α, IL-6 and platelet reactivity (platelet reactivity score). Cohen's k showed: CRP = 0.49, p < 0.0001, TNF-α = 0.37, p < 0.002. Perioperative myocardial infarction and rhythm disturbances occurred more frequently in the high platelet reactivity group: 7 (16.3%) vs. 2 (3.3%), p < 0.04, and 9 (20.9%) vs. 4 (6.7%), p < 0.04, respectively. Conclusions: Inflammatory parameters CRP and TNF-α are strongly associated with platelet reactivity (expressed as PRS) in cardiopulmonary bypass graft patients. Platelet hyperreactivity in the early post-operative period combined with a systemic inflammatory state correlates with a higher risk of post-operative rhythm disturbances and myocardial infarction.

Lower Preoperative Verbal Memory Performance Is Associated with Delirium after Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study.

OBJECTIVE: Cognitive impairment constitutes one of the major risk factors of delirium after coronary artery bypass graft (CABG) surgery; however, it is unclear whether only patients with global cognitive decline are at increased risk for delirium or if individuals with preserved global cognitive functions but impairments in specific cognitive domains are also more vulnerable to developing delirium. Thus, this study aimed to analyze the neurocognitive status of patients scheduled for CABG surgery with the use of an advanced computerized cognitive battery (CNS Vital Signs) and to investigate possible associations between impaired performance in selective cognitive areas and the risk of postoperative delirium development. METHODS: The study enrolled 127 participants with a median age of 67 years (IQR: 63-71). Postoperative delirium developed in 32 (25%) patients.Before surgery, the patients were screened for global cognitive impairment with the use of the Mini-Mental State Examination Test, and the individuals were asked to perform the CNS Vital Signs battery to investigate 12 specific cognitive domains. The Confusion Assessment Method and the Memorial Delirium Assessment Scale were used to screen for a diagnosis of delirium postoperatively. RESULTS: In multivariate models, a lower score of verbal memory-assessed preoperatively was independently associated with the risk of postoperative delirium development. Other independent predictors of delirium included more advanced age, gender female, depression, postoperative pyrexia, and the presence of extracorporeal circulation. CONCLUSIONS: As decreased verbal memory constitutes an independent risk factor for postoperative delirium, a verbal memory test may be a useful predictor of postoperative delirium development.

Acute kidney injury as the most important predictor of poor prognosis after interventional treatment for aortic stenosis.

BACKGROUND: Aortic stenosis (AS) is the most common acquired valvular disease. There are two methods of interventional treatment: surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). The choice between SAVR and TAVI depends on the assessment of individual perioperative risk and long-term treatment outcomes. It is essential to identify factors that may influence the outcomes of the treatment to minimize their negative effects. AIMS: The study aimed to identify the most important risk factor which affects treatment outcomes in patients with AS undergoing SAVR/TAVI. METHODS: This study reviewed retrospectively patients with AS who underwent SAVR or TAVI. The primary outcomes included incidences of major adverse cardiovascular events (MACE) defined as cardiovascular death, stroke, and hospitalization for cardiovascular issues assessed over a one-year follow-up period. An occurrence of postprocedural AKI (acute kidney injury) was identified as an independent predictor of MACE. RESULTS: The study included 78 patients, with the same number of subjects in each group (SAVR/TAVI [n = 39]). Twenty-nine patients developed AKI. It was similar in both groups (SAVR [n = 15]; TAVR [n = 14]). In the SAVR group, 13 (33%) patients developed at least one MACE compared to 5 (13%) patients in the TAVI group. AKI and the type of procedure (SAVR) were shown to be significantly and independently associated with the development of MACE (P = 0.01 and P = 0.03, respectively) as shown in the Cox multivariable regression model. CONCLUSIONS: Our study demonstrated that AKI is the strongest predictor of major adverse cardiovascular events after using both methods of aortic valve replacement (SAVR/TAVI).

Increased postoperative myeloperoxidase concentration associated with low baseline antioxidant capacity as the risk factor of delirium after cardiac surgery.

BACKGROUND: Though risk factors of postoperative delirium are well described, its pathophysiology is still undiscovered. The primary objective of the current study is to assess whether increased pre- and postoperative myeloperoxidase (MPO) levels are associated with postoperative delirium in the population of cardiac surgery patients. The secondary objective is to evaluate the correlation between MPO levels and serum antioxidant capacity (AC). METHODS: The patients' cognitive status was assessed one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder and anxiety disorders was established based on DSM-5 criteria. Blood samples for MPO and AC levels were collected both pre- and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used to screen for a diagnosis of delirium. RESULTS: Delirium occurred in 34% (61 of 177) of patients. Multivariable logistic regression analysis revealed that increased postoperative MPO concentration was independently associated with postoperative delirium development, and negatively correlated with lower baseline serum AC. CONCLUSIONS: Cardiac surgery patients with less efficient antioxidative mechanisms experience a higher postoperative peak of serum MPO, which in turn may predispose to postoperative delirium development.KEY MESSAGESMPO is a lysosomal enzyme with strong pro-oxidative and pro-inflammatory properties.Cardiac surgery patients who have increased concentration of postoperative MPO are at significantly higher risk of postoperative delirium development.This higher level of postoperative MPO is negatively correlated with baseline antioxidant capacity (AC).It can be hypothesized that individuals with decreased baseline AC experience a higher peak of MPO post-surgery due to less efficient antioxidative mechanisms, which in turn contributes to postoperative delirium development.

Oxidative stress and soluble receptor for advanced glycation end-products play a role in the pathophysiology of delirium after cardiac surgery.

Coronary-artery bypass graft (CABG) surgery is known to improve cardiac function and decrease mortality, albeit, this method of treatment is also associated with a neuropsychiatric complications including postoperative delirium. The pathophysiology of delirium after cardiac surgery remains poorly understood. Thus, the purpose of this study was to investigate whether oxidative stress reflected by decreased preoperative and postoperative plasma antioxidant activity is independently associated with delirium after cardiac surgery. The second aim was to assess whether decreased antioxidant activity is stress-related or mediated by other pathologies such as major depressive disorder (MDD), anxiety disorders, and cognitive impairment. Furthermore, the putative relationship between pre- and postoperative soluble receptor for advanced glycation end-products (sRAGE) overexpression and plasma antioxidant capacity was evaluated. The patients cognitive status was assessed 1 day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of MDD and anxiety disorders was established on the basis of DSM-5 criteria. Blood samples for antioxidant capacity and sRAGE levels were collected both preoperatively and postoperatively. The Confusion Assessment Method for the Intensive Care Unit was used within the first 5 days postoperatively to screen for a diagnosis of delirium. Postoperative delirium was diagnosed in 34% (61 of 177) of individuals. Multivariate logistic regression analysis revealed that low baseline antioxidant capacity was independently associated with postoperative delirium development. Moreover, increased risk of delirium was observed among patients with a preoperative diagnosis of MDD associated with antioxidant capacity decreased postoperatively. According to receiver operating characteristic analysis, the most optimal cutoff values of the preoperative and postoperative antioxidant capacity that predict the development of delirium were 1.72 mM and 1.89 mM, respectively. Pre- and postoperative antioxidant capacity levels were negatively correlated with postoperative sRAGE concentration (Spearman's Rank Correlation - 0.198 and - 0.158, p < 0.05, respectively). Patients with decreased preoperative antioxidant activity and those with depressive episodes complicated with lower postoperative antioxidant activity are at significantly higher risk of delirium after cardiac surgery development. sRAGE overexpression may be considered as protective mechanism against increased oxidative stress and subsequent cell damage.

Elevated Monocyte Chemoattractant Protein-1 as the Independent Risk Factor of Delirium after Cardiac Surgery. A Prospective Cohort Study.

BACKGROUND: The pathogenesis of postoperative delirium is largely unknown. The primary objective of this study is to assess whether increased levels of monocyte chemoattractant protein-1 (MCP-1) and high-sensitivity C-reactive protein (hsCRP) are associated with postoperative delirium in patients who have undergone cardiac surgery. The secondary objective is to investigate whether any association between raised inflammatory biomarkers levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing psychiatric conditions associated with raised pro-inflammatory markers levels. METHODS: The patients were screened for cognitive impairment one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder (MDD) and anxiety disorders was established on the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Blood samples were collected pre- and postoperatively for hsCRP and chemokine levels. RESULTS: Postoperative delirium developed in 34% (61 of 177) of patients. Both pre- and postoperative hsCRP, and preoperative MCP-1 levels were associated with postoperative delirium in univariate comparisons; p = 0.001; p < 0.001; p < 0.001, respectively. However, according to a multivariable logistic regression analysis, only a raised MCP-1 concentration before surgery was independently associated with postoperative delirium, and related to advancing age, preoperative anxiety disorders and prolonged intubation. CONCLUSIONS: The present study suggests that an elevated preoperative MCP-1 concentration is associated with delirium after cardiac surgery. Monitoring of this inflammatory marker may reveal the cardiovascular disease (CVD) patients who are at risk of neuropsychiatric syndromes development.

Quality of life in patients after coronary artery bypass grafting with bilateral internal thoracic artery versus single internal thoracic artery.

INTRODUCTION: The left internal thoracic artery to the left anterior descending artery graft is recognized as the gold standard for coronary revascularization. We compared quality of life (QoL) in patients who received bilateral internal thoracic arteries (BITA) and those with a single internal thoracic artery (SITA) graft. AIM: To assess QoL during a 10-year follow-up in patients who underwent coronary artery bypass grafting (CABG) with BITA vs. SITA. MATERIAL AND METHODS: We recruited 300 patients with multivessel coronary artery disease who underwent CABG from January 2005 to October 2010. Mean duration (standard deviation - SD) of follow-up was 3568 ±409 days. QoL was measured subjectively using a Likert scale and objectively by the WHOQOL-BREF questionnaire. Patients were interviewed by telephone. RESULTS: BITA patients reported marked improvement and improvement more often than SITA patients (58% vs. 43.3%, p = 0.02). Marked deterioration was noted by 2% of BITA patients and 3.3% of SITA patients (p = 0.03). Summarized results of the WHOQOL-BREF questionnaire showed significantly better QoL in the BITA group (median: 15.0) vs. SITA group (median: 14.75) (p = 0.02). There were more angina-free patients in the BITA group (84%) compared to SITA patients (72.7%) (p = 0.006). QoL did not correlate with patients' body mass index (p = 0.10) or residence status (p = 0.51), but there was a weak negative correlation between QoL and patients' age (r = -0.14, p = 0.01). CONCLUSIONS: Surgical coronary revascularization using BITA improves QoL, particularly when measured by a Likert scale.

Early stage of atherosclerosis in aortocoronary saphenous vein grafts: intravascular ultrasound study

Abstract Introduction: Angiographically visible plaques in patent vein grafts are usually detected years after surgery. Our aim was to examine early plaque formation in vein grafts. Methods: Bypass angiography and intravascular ultrasonography (IVUS) examination were performed on 77 aortocoronary saphenous vein grafts (SVGs) implanted in 36 patients during the first 2 years after CABG. In each graft, a good quality 25 mm ultrasound image was analyzed. We measured: plaque area, lumen area, external elastic membrane (EEM) area, graft area and wall area. For the comparative assessment of SVGs, the index plaque area/EEM area was calculated. Data were analyzed for the following 4 time periods: I - 0-4 months (22 grafts), II - 5-8 months (23 grafts), III - 9-12 months (19 grafts) and IV - 13-16 months (13 grafts) after CABG. Student's t and Fisher-Snedecor tests were used for the purpose of statistical analysis in this retrospective study. Results: In period I, plaque formation (neointimal) was observed in 10 grafts (45%), with a mean plaque area of 1.59 mm., in 6 grafts (26%) in period II, with a mean plaque area of 1.03 mm. and in 15 grafts (71%) in period III, with a mean plaque area of 1.41 mm., and in all (100%) grafts in period IV, with mean plaque area of 2,3 mm.. Average index plaque area/EEM area in periods I, II, III and IV were 0.12, 0.08, 0.13 and 0.22. We have showed a significant plaque increase between periods II and IV(P=0.038). Conclusion: IVUS showed plaque in about 40% of venous grafts during the first year after CABG. Between 13-16 months plaque was visible in all studied grafts.

Early Stage of Atherosclerosis in Aortocoronary Saphenous Vein Grafts: Intravascular Ultrasound Study.

INTRODUCTION: Angiographically visible plaques in patent vein grafts are usually detected years after surgery. Our aim was to examine early plaque formation in vein grafts. METHODS: Bypass angiography and intravascular ultrasonography (IVUS) examination were performed on 77 aortocoronary saphenous vein grafts (SVGs) implanted in 36 patients during the first 2 years after CABG. In each graft, a good quality 25 mm ultrasound image was analyzed. We measured: plaque area, lumen area, external elastic membrane (EEM) area, graft area and wall area. For the comparative assessment of SVGs, the index plaque area/EEM area was calculated. Data were analyzed for the following 4 time periods: I - 0-4 months (22 grafts), II - 5-8 months (23 grafts), III - 9-12 months (19 grafts) and IV - 13-16 months (13 grafts) after CABG. Student's t and Fisher-Snedecor tests were used for the purpose of statistical analysis in this retrospective study. RESULTS: In period I, plaque formation (neointimal) was observed in 10 grafts (45%), with a mean plaque area of 1.59 mm., in 6 grafts (26%) in period II, with a mean plaque area of 1.03 mm. and in 15 grafts (71%) in period III, with a mean plaque area of 1.41 mm., and in all (100%) grafts in period IV, with mean plaque area of 2,3 mm.. Average index plaque area/EEM area in periods I, II, III and IV were 0.12, 0.08, 0.13 and 0.22. We have showed a significant plaque increase between periods II and IV(P=0.038). CONCLUSION: IVUS showed plaque in about 40% of venous grafts during the first year after CABG. Between 13-16 months plaque was visible in all studied grafts.

Regional left ventricular function does not predict survival in ischaemic cardiomyopathy after cardiac surgery.

OBJECTIVES: To define the prognostic contribution of global and regional left ventricular (LV) function measurements in patients with ischaemic cardiomyopathy randomised to coronary artery bypass graft surgery (CABG) with (n=501) or without (n=499) surgical ventricular reconstruction (SVR). METHODS: Novel multivariable methods to analyse global and regional LV systolic function were used to better formulate prediction models for long-term mortality following CABG with or without SVR in the entire cohort of 1000 randomised SVR hypothesis patients. Key clinical variables were included in the analysis. Regional function was classified according to the discreteness of anteroapical hypokinesia and akinesia into those most likely to benefit from SVR, those least likely and those felt to have intermediate likelihood of benefit from SVR. RESULTS: The most prognostic clinical variables identified in multivariable models include creatinine, LV end-systolic volume index (ESVI), age and NYHA (New York Heart Association) class. Addition of LV ejection fraction, LV end-diastolic volume index and regional function assessment did not contribute additional power to the model. Subgroup analysis based on regional function did not identify a cohort in which SVR improved mortality. CONCLUSIONS: ESVI is the single parameter of LV function most predictive of mortality in patients with LV systolic dysfunction following CABG with or without SVR in multivariable models that include all key clinical and LV systolic function parameters. Assessment of regional cardiac function does not enhance prediction of mortality nor identify a subgroup for which SVR improves mortality. These results do not support elective addition of LV reconstruction surgery in patients undergoing CABG. TRIAL REGISTRATION NUMBER: NCT00023595.

Neointima development in externally stented saphenous vein grafts.

INTRODUCTION: The main limitation of coronary artery bypass grafting (CABG) is rapid neointimal hyperplasia leading to graft failure. AIM: To assess plaque formation in saphenous vein grafts (SVG) covered by an external Dacron stent in comparison with the classical technique. MATERIAL AND METHODS: In the study group vein grafts covered by external stent mesh made of Dacron were implanted. An intravascular ultrasonography (IVUS) study was performed in 35 aorto-coronary SVG covered by an external Dacron stent and in 64 normal SVG during the first year after CABG. In each SVG 25 mm of good quality IVUS image, volumes of lumen, plaque (neointima), outer border of the vein graft (external SVG) and adventitia were calculated in three time periods: 0-130 days, 130-260 days and 260-390 days. RESULTS: Between the first and second time period, lumen volume (mm3) was reduced from 10.33 ±4.4, to 6.80 ±2.23 in the second period and 5.69 ±1.26 in the third one. This effect was much less marked in normal grafts. The corresponding lumen volume (mm3) was: 10.90 ±3.9, 9.15 ±2.94 and 8.92 ±2.93 in consecutive time periods. Plaque volume (mm3) did not change in control grafts during the course of the study, but it increased very significantly in stented grafts from 0.86 ±1.24 in the first period to 2.70 ±1.58 in the second and 3.29 ±2.66 in the third one. CONCLUSIONS: The experimental technique of implanting SVG covered with an external elastic Dacron stent seems to be inferior to traditional ones. This is probably due to the more complicated process of vein implantation and higher micro-injury occurrence during the surgery.

Cardiac resynchronization therapy combined with coronary artery bypass grafting in ischaemic heart failure patients: long-term results of the RESCUE study.

OBJECTIVES: Totally epicardial cardiac resynchronization therapy (CRT) is a novel treatment modality for patients with heart failure (HF) and systolic dyssynchrony undergoing coronary artery bypass grafting (CABG). In this study, we have prospectively evaluated the long-term outcomes of totally epicardial CRT. METHODS: Between September 2007 and June 2009, one hundred and seventy-eight patients were randomly assigned to the CABG alone group (n = 87) and CABG with concomitant epicardial CRT implantation (n = 91). The primary end-point of the study was all-cause mortality in the two groups between the day of surgery and 13 August 2013 (common closing date). The secondary outcomes included mode of death, adverse cardiac events and lead performance. RESULTS: The mean follow-up was 55 ± 10.7 months. According to per-protocol analysis with treatment as a time-dependent variable to account for conversion from CABG to CABG + CRT, there were 24 deaths (35.8%) in the CABG group and 17 deaths (15.3%) in the CABG + CRT group. When compared with CABG alone, concomitant CRT was associated with reduced risk of both all-cause mortality [hazard ratio (HR) 0.43, 95% confidence interval (CI) 0.23-0.84, P = 0.012] and cardiac death (HR 0.39, 95% CI 0.21-0.72, P = 0.002). Eleven (12.6%) sudden deaths were observed in the CABG group in comparison with 4 (4.4%) in the CABG + CRT group (P = 0.048). Hospital readmission was required for 9 (9.9%) patients in CABG + CRT group and for 25 (28.7%) patients in the CABG group (P = 0.001). There were 4 (1.5%) epicardial lead failures. CONCLUSIONS: The results of our study suggest that the procedure of CABG and totally epicardial CRT system implantation is safe and significantly improves the survival of patients with HF and dyssynchrony during long-term follow-up. CLINICAL TRIAL REGISTRATION: NCT 00846001 (http://www.clinicaltrials.gov).