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2.
Ann Thorac Surg ; 2019 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-31479637

RESUMO

BACKGROUND: There is high demand for minimally invasive mitral valve repair; however, it is unclear whether the minimally invasive approach provides the same performance of conventional sternotomy in a context of complex mitral valve disease. Here, we compared outcomes of minimally invasive and sternotomy procedures for bileaflet and Barlow's mitral valve disease. METHODS: We performed a pooled meta-analysis of studies reporting early and late follow-up of mitral valve repair for complex mitral valve regurgitation (MR). The primary outcome was moderate MR recurrence and need for re-operation. Secondary outcomes included: operation time, reopening for bleeding, associated tricuspid procedures, failed repair, and in-hospital mortality. Incidence rates (IRs) were calculated for long-term follow-up. Effect estimates were calculated as IRs with 95% confidence intervals. When Kaplan-Meier curves were available, event rates were estimated from the curves with Plot Digitizer software; otherwise, reported event rates were used to calculate IRs. RESULTS: Eighteen studies including 1905 patients (654 minimally invasive and 1251 sternotomy) with a mean follow-up of 51.6 months (range, 14-138 months) were meta-analyzed with a random model. There were no significant between-group differences in moderate MR recurrence and re-operation (minimally invasive vs. sternotomy, 1.7%, [1.0-2.9%] vs. 1.3% [0.9-1.8%], p = 0.22). Patients in the minimally invasive group were exposed to significantly longer cross clamp and cardiopulmonary bypass times (p < 0.01); however, there were no additional between-group differences in secondary outcomes. CONCLUSIONS: This is the first meta-analysis to demonstrate that minimally invasive and sternotomy approaches produce comparable results for complex mitral valve repair.

3.
Ann Thorac Surg ; 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31445916

RESUMO

BACKGROUND: Ischemic mitral regurgitation is a condition characterized by mitral insufficiency secondary to an ischemic left ventricular.Primarily, the pathology is the result of perturbation of normal regional left ventricular geometry combined with adverse remodeling.We present a comprehensive review of contemporary surgical, medical, and percutaneous treatment options for ischemic mitral regurgitation, rigorously examined by current guidelines and literature. METHODS: We conducted a literature search of the PubMed database, EMBASE and the Cochrane Library (through November 2018) for studies reporting perioperative or late mortality and echocardiographic outcomes following surgical and non-surgical intervention for ischemic mitral regurgitation. RESULTS: Treatment of this condition is both challenging and often requires a multimodality approach.These patients usually have multiple comorbidities that may preclude surgery as a viable option.A multidisciplinary team discussion is crucial in optimizing outcomes.There are several options for treatment and management of ischemic mitral regurgitation with differing benefits and risks.Guideline-directed medical therapy for heart failure is the treatment choice for moderate and severe ischemic mitral regurgitation, with consideration of coronary revascularization, mitral valve surgery, and/or cardiac resynchronization therapy in appropriate candidates.The use of transcatheter mitral valve therapy is considered appropriate in high risk patients with severe ischemic mitral regurgitation, heart failure and reduced left ventricular ejection fraction especially in those with hemodynamic instability. CONCLUSIONS: The role of mitral valve surgery and transcatheter mitral valve therapy continues to evolve.

4.
Ann Thorac Surg ; 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31470012

RESUMO

BACKGROUND: We used a large patient-level dataset including six angiographic randomized trials (RCTs) on coronary artery bypass conduits to explore incidence and determinants of coronary graft failure. METHODS: Patient-level angiographic data of six RCTs comparing long-term outcomes of the radial artery and other conduits were joined. Primary outcome was graft occlusion at maximum follow-up. The analysis was divided as follows: 1) left anterior descending coronary (LAD) distribution, 2) non-LAD distribution (circumflex and right coronary artery). To identify predictors of graft occlusion, mixed model multivariable Cox regression including all baseline characteristics with stratification by individual trials was used. RESULTS: 1091 patients and 2281 grafts were included (921 left internal mammary arteries, 74 right internal mammary arteries, 710 radial artery and 576 saphenous veins; all left internal mammary arteries were used on the LAD, the other conduits were used on the non-LAD distribution; mean angiographic follow up: 65±29 months). Occlusion rate was 2.3%, 13.5%, 9.4%, 17.5% for the left internal mammary arteries, right internal mammary arteries, radial artery and saphenous veins, respectively. At multivariable analysis type of conduit used, age, female gender, left ventricular ejection fraction<50% and use of the Y graft were significantly associated with graft occlusion in the non-LAD distribution. CONCLUSIONS: Our analyses showed that failure of the left internal mammary arteries to LAD bypass is a very uncommon event. For the non-LAD distribution, the non-use of radial artery, age, female gender, left ventricular ejection fraction<50% and use of the Y graft configuration were significantly associated with mid-term graft failure.

5.
J Am Coll Cardiol ; 74(6): 729-740, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31395122

RESUMO

BACKGROUND: Concerns remain for a greater risk of incomplete revascularization and reduced survival with off-pump coronary artery bypass grafting (CABG) surgery compared with on-pump surgery particularly in patients with left main disease and extensive underlying myocardial ischemia. OBJECTIVES: This study sought to compare outcomes following off-pump versus on-pump surgery for left main disease by performing a post hoc analysis from the multicenter, randomized EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial. METHODS: The EXCEL trial was designed to compare percutaneous coronary intervention with everolimus-eluting stents versus CABG in patients with left main disease. CABG was performed with or without cardiopulmonary bypass (on-pump vs. off-pump surgery) according to the discretion of the operator. The 3-year outcomes in the off-pump and on-pump groups were compared using inverse probability of treatment weighting (IPTW) for treatment effect estimation. RESULTS: Among 923 CABG patients, 652 and 271 patients underwent on-pump and off-pump surgery, respectively. Despite a similar extent of disease, off-pump surgery was associated with a lower rate of revascularization of the left circumflex coronary artery (84.1% vs. 90.0%; p = 0.01) and right coronary artery (31.1% vs. 40.6%; p = 0.007). After IPTW adjustment for baseline differences, off-pump surgery was associated with a significantly increased risk of 3-year all-cause death (8.8% vs. 4.5%; hazard ratio: 1.94; 95% confidence interval: 1.10 to 3.41; p = 0.02) and a nonsignificant difference in the risk for the composite endpoint of death, myocardial infarction, or stroke (11.8% vs. 9.2%; hazard ratio: 1.28; 95% confidence interval: 0.82 to 2.00; p = 0.28). CONCLUSIONS: Among patients with left main disease treated with CABG in the EXCEL trial, off-pump surgery was associated with a lower rate of revascularization of the coronary arteries supplying the inferolateral wall and an increased risk of 3-year all-cause death compared with on-pump surgery.

7.
EuroIntervention ; 2019 07 09.
Artigo em Inglês | MEDLINE | ID: mdl-31289019

RESUMO

AIMS: Incidence, associated risk factors and impact on mortality of infections after bypass surgery (CABG) and stenting (PCI) for multivessel coronary disease (MVD) have never been reported in a large randomized trial. The aim of the present study is to evaluate, in patients with MVD, the prevalence of major infections after PCI and CABG and assess their impact on mortality. METHODS AND RESULTS: The SYNTAX trial randomized 1800 MVD patients to either CABG or PCI. Patients were followed up to 5 years. The primary endpoint of this post-hoc analysis was the occurrence of major infection. At 5 years of follow-up, the primary endpoint occurred in 142 (15.8%) patients in the CABG arm and 44 (4.9%) patients in the PCI arm (≤ 60 days- HR 7.9, 95% CI 4.7 to 13.1; p<0.001) (> 60 days- HR 0.79, 95% CI 0.44 to 1.44; p=0.45). Major infections were independently associated with a higher risk of all-cause mortality at 5 years (adjusted HR 2.6, 95% CI 1.8 to 3.8, p<0.001). CONCLUSIONS: CABG is associated with a higher incidence of post-procedure major infections compared to PCI. Major infections are independently associated with all-cause mortality.

8.
Eur Heart J ; 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31155673

RESUMO

AIMS: Visual estimation is the most commonly used method to evaluate the degree of coronary artery stenosis prior to coronary artery bypass grafting. In interventional cardiology, the use of fractional flow reserve (FFR) to guide revascularization decisions has become routine. We investigated whether the preoperative FFR measurement of coronary lesions is associated with anastomosis function 6 months after surgical revascularization using a multiarterial grafting strategy. METHODS AND RESULTS: In this prospective double-blind study, 67 patients were enrolled from two institutions in Europe and Canada. From these patients, 199 coronary lesions were assessed visually and with FFR at the time of the preoperative angiogram. All patients received coronary revascularization using multiple arterial grafts. A post-operative 6-month angiogram was performed to assess anastomosis functionality using a described angiographic method. The primary outcome was the association between preoperative FFR values and anastomosis function 6 months after surgery. Preoperative FFR was significantly associated with 6-months anastomotic function for all conduits and for all targets (P < 0.001). An FFR value of ≤0.78 was associated with an anastomotic occlusion rate of 3%. CONCLUSION: We found a significant association between the preoperative FFR measurement of the target vessel and the anastomotic functionality at 6 months, with a cut-off of 0.78. Integration of FFR measurement into the preoperative diagnostic workup before multiarterial coronary surgical revascularization leads to improved anastomotic graft function. CLINICAL TRIALS. GOV IDENTIFIER: NCT02527044.

9.
BMJ Open ; 9(6): e029388, 2019 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-31167875

RESUMO

INTRODUCTION: 'Real world' bleeding in patients exposed to different regimens of dual antiplatelet therapy (DAPT) and triple therapy (TT, DAPT plus an anticoagulant) have a clinical and economic impact but have not been previously quantified. METHODS AND ANALYSIS: We will use linked Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) data to assemble populations eligible for three 'target trials' in patient groups: percutaneous coronary intervention (PCI); coronary artery bypass grafting (CABG); conservatively managed (medication only) acute coronary syndrome (ACS). Patients ≥18 years old will be eligible if, in CPRD records, they have: ≥1 year of data before the index event; no prescription for DAPT or anticoagulants in the preceding 3 months; a prescription for aspirin or DAPT within 2 months after discharge from the index event. The primary outcome will be any bleeding event (CPRD or HES) up to 12 months after the index event. We will estimate adjusted HR for time to first bleeding event comparing: aspirin and clopidogrel (reference) versus aspirin and prasugrel or aspirin and ticagrelor after PCI; and aspirin (reference) versus aspirin and clopidogrel after CABG and ACS. We will describe rates of bleeding in patients prescribed TT (DAPT plus an anticoagulant). Potential confounders will be identified systematically using literature review, semistructured interviews with clinicians and a short survey of clinicians. We will conduct sensitivity analyses addressing the robustness of results to the study's main limitation-that we will not be able to identify the intervention group for patients whose bleeding event occurs before a DAPT prescription in CPRD. ETHICS AND DISSEMINATION: This protocol was approved by the Independent Scientific Advisory Committee for the UK Medicines and Healthcare Products Regulatory Agency Database Research (protocol 16_126R) and the South West Cornwall and Plymouth Research Ethics Committee (17/SW/0092). The findings will be presented in peer-reviewed journals, lay summaries and briefing papers to commissioners/other stakeholders. TRIAL REGISTRATION NUMBER: 76607611; Pre-results.

10.
Artigo em Inglês | MEDLINE | ID: mdl-31209460

RESUMO

OBJECTIVES: Our goal was to describe the experience at 2 centres with off-pump coronary artery bypass grafting using a left thoracotomy. METHODS: From January 2002 to December 2017, a total of 2528 consecutive patients (578 women, mean age 62.3 ± 9.1 years) were operated on using this technique. Data were collected prospectively and analysed retrospectively. RESULTS: There were no conversions to median sternotomy and 6 patients (0.2%) were converted to on-pump CABG. The mean number of grafts per patient was 2.8 ± 0. 9. The 30-day mortality rate was 1.0% (25 patients). Most patients were extubated in the operating theatre (97.3%), and 47 patients (1.9%) needed re-exploration for bleeding. Seven patients (0.3%) experienced a cerebrovascular event; 4 (0.3%) had a postoperative myocardial infarction; and 84 (3.4%) had new-onset atrial fibrillation. A total of 1510 patients (61.1%) were discharged from the hospital in the first 48 h after surgery. Long-term survival rates were 98.8%, 93.6% and 69.1% at 1, 5 and 10 years, respectively (central image). During the follow-up period, 60 patients (2.9%) were re-examined for recurrence of angina with a new coronary angiogram; of those, 24 (1.2%) required percutaneous coronary intervention and 11 (0.5%) had redo surgery. CONCLUSIONS: A left thoracotomy is a safe alternative to a median sternotomy for coronary artery bypass grafting on the beating heart, with low early complications and good mid- and long-term results.

11.
J Am Coll Cardiol ; 73(18): 2299-2306, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31072574

RESUMO

BACKGROUND: Few studies have evaluated the effect of chronic calcium-channel blocker therapy (CCB) on the angiographic and clinical outcome of radial artery (RA) grafts used for coronary bypass surgery. OBJECTIVES: The purpose of this study was to evaluate if CCB influences midterm clinical and angiographic outcomes of RA grafts. METHODS: Patient-level data of 6 angiographic randomized trials evaluating RA graft status at midterm follow-up were joined in this observational analysis. Cox regression and propensity score methods were used to evaluate the effect of CCB on the incidence of a composite of major adverse cardiac events (MACE) (death, myocardial infarction, and repeat revascularization) and graft occlusion. RESULTS: The study population included 732 patients (502 on CCB). The median clinical follow-up was 60 months. The cumulative incidence of MACE at 36, 72, and 108 months was 3.7% vs. 9.3%, 13.4% vs. 17.6%, and 16.8% vs. 20.5% in the CCB and no CCB groups, respectively (log-rank p = 0.003). Protocol-driven angiographic follow-up was available in 243 patients in the CCB group and 200 in the no CCB group. The median angiographic follow-up was 55 months. The cumulative incidence of RA occlusion at 36, 72, and 108 months was 0.9% vs. 8.6%, 9.6% vs. 21.4%, and 14.3% vs. 38.9% in the CCB and no CCB groups, respectively (log-rank p < 0.001). After controlling for known confounding, CCB therapy was found to be consistently associated with a significantly lower risk of MACE (multivariate Cox hazard ratio: 0.52; 95% confidence interval: 0.31 to 0.89; p = 0.02) and RA graft occlusion (multivariate Cox hazard ratio: 0.20; 95% confidence interval: 0.08 to 0.49; p < 0.001). CONCLUSIONS: In patients with RA grafts CCB is associated with significantly better midterm clinical and angiographic RA outcomes.

13.
Heart ; 105(16): 1237-1243, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30948516

RESUMO

BACKGROUND: The use of bilateral internal thoracic arteries (BITA) for coronary artery bypass grafting (CABG) may improve survival compared with CABG using single internal thoracic arteries (SITA). We assessed the long-term costs of BITA compared with SITA. METHODS: Between June 2004 and December 2007, 3102 patients from 28 hospitals in seven countries were randomised to CABG surgery using BITA (n=1548) or SITA (n=1554). Detailed resource use data were collected from the initial hospital episode and annually up to 5 years. The associated costs of this resource use were assessed from a UK perspective with 5 year totals calculated for each trial arm and pre-selected patient subgroups. RESULTS: Total costs increased by approximately £1000 annually in each arm, with no significant annual difference between trial arms. Cumulative costs per patient at 5-year follow-up remained significantly higher in the BITA group (£18 629) compared with the SITA group (£17 480; mean cost difference £1149, 95% CI £330 to £1968, p=0.006) due to the higher costs of the initial procedure. There were no significant differences between the trial arms in the cost associated with healthcare contacts, medication use or serious adverse events. CONCLUSIONS: Higher index costs for BITA were still present at 5-year follow-up mainly driven by the higher initial cost with no subsequent difference emerging between 1 year and 5 years of follow-up. The overall cost-effectiveness of the two procedures, to be assessed at the primary endpoint of the 10-year follow-up, will depend on composite differences in costs and quality-adjusted survival. TRIAL REGISTRATION NUMBER: ISRCTN46552265.

14.
Contemp Clin Trials ; 78: 126-132, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30739002

RESUMO

OBJECTIVE: Few randomized trials have evaluated the use of non-invasive ventilation (NIV) for early acute respiratory failure (ARF) in non-intensive care unit (ICU) wards. The aim of this study is to test the hypothesis that early NIV for mild-moderate ARF in non-ICU wards can prevent development of severe ARF. DESIGN: Pragmatic, parallel group, randomized, controlled, multicenter trial. SETTING: Non-intensive care wards of tertiary centers. PATIENTS: Non-ICU ward patients with mild to moderate ARF without an established indication for NIV. INTERVENTIONS: Patients will be randomized to receive or not receive NIV in addition to best available care. MEASUREMENTS AND MAIN RESULTS: We will enroll 520 patients, 260 in each group. The primary endpoint of the study will be the development of severe ARF. Secondary endpoints will be 28-day mortality, length of hospital stay, safety of NIV in non-ICU environments, and a composite endpoint of all in-hospital respiratory complications. CONCLUSIONS: This trial will help determine whether the early use of NIV in non-ICU wards can prevent progression from mild-moderate ARF to severe ARF.

15.
J Thorac Cardiovasc Surg ; 157(6): 2216-2225.e4, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30711273

RESUMO

BACKGROUND: Despite several reports, there are still conflicting data on the influence of ethnicity on mortality rates associated with coronary artery bypass grafting (CABG). We aimed to get further insights into the effect of race on mortality following CABG by performing a risk adjusted meta-analysis. METHODS: Relevant studies were searched on PubMed, Embase, BioMed Central, and the Cochrane Central register. Pairwise meta-analysis was used to estimate the relative risk of hospital death of black, Hispanic, and Asian patients using white patients as reference. Risk adjusted meta-analytic estimates were obtained using generic inverse variance methods with random effect model. RESULTS: A total of 28 studies were selected for analysis. A total of 21 studies reported on hospital mortality in black (n = 222,892) versus white (n = 3,884,043) patients, 7 studies reported on Hispanic (n = 91,256) versus white (n = 1,458,524) and 9 studies reported on Asian (n = 27,820) versus white (n = 1,081,642). When compared with white patients, adjusted risk of hospital death was significantly greater for black patients (adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.39; P < .001), and not statistically different for Asian (OR, 1.33; 95% CI, 0.99-1.77; P = .05) and Hispanic patients (adjusted OR, 1.08; 95% CI, 0.94-1.23; P = .26). Meta-regression showed a significant trend toward lower mortality rates in most recent series in both black (P = .02) and white (P = .0007) and Asian (P = .01) but not for Hispanic (P = .41). However, as mortality rates were lower across the different races, the relative disadvantage between the study groups persisted, which may explain the lack of interaction between study period and race effect on mortality for black (adjusted P = .09), Asian (adjusted P = .63), and Hispanic (adjusted P = .97) patients. CONCLUSIONS: The present meta-analysis showed that despite progress is being made in lowering in-hospital mortality rates among the major racial/ethnic groups, ethnical disparities in hospital mortality after CABG remain.

18.
N Engl J Med ; 380(5): 437-446, 2019 01 31.
Artigo em Inglês | MEDLINE | ID: mdl-30699314

RESUMO

BACKGROUND: Multiple arterial grafts may result in longer survival than single arterial grafts after coronary-artery bypass grafting (CABG) surgery. We evaluated the use of bilateral internal-thoracic-artery grafts for CABG. METHODS: We randomly assigned patients scheduled for CABG to undergo bilateral or single internal-thoracic-artery grafting. Additional arterial or vein grafts were used as indicated. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. RESULTS: A total of 1548 patients were randomly assigned to undergo bilateral internal-thoracic-artery grafting (the bilateral-graft group) and 1554 to undergo single internal-thoracic-artery grafting (the single-graft group). In the bilateral-graft group, 13.9% of the patients received only a single internal-thoracic-artery graft, and in the single-graft group, 21.8% of the patients also received a radial-artery graft. Vital status was not known for 2.3% of the patients at 10 years. In the intention-to-treat analysis at 10 years, there were 315 deaths (20.3% of the patients) in the bilateral-graft group and 329 deaths (21.2%) in the single-graft group (hazard ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.12; P=0.62). Regarding the composite outcome of death, myocardial infarction, or stroke, there were 385 patients (24.9%) with an event in the bilateral-graft group and 425 patients (27.3%) with an event in the single-graft group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03). CONCLUSIONS: Among patients who were scheduled for CABG and had been randomly assigned to undergo bilateral or single internal-thoracic-artery grafting, there was no significant between-group difference in the rate of death from any cause at 10 years in the intention-to-treat analysis. Further studies are needed to determine whether multiple arterial grafts provide better outcomes than a single internal-thoracic-artery graft. (Funded by the British Heath Foundation and others; Current Controlled Trials number, ISRCTN46552265 .).


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Artéria Torácica Interna/transplante , Idoso , Causas de Morte , Doença da Artéria Coronariana/mortalidade , Feminino , Seguimentos , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Análise de Sobrevida
19.
J Am Heart Assoc ; 8(2): e010839, 2019 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-30636525

RESUMO

Background There remains uncertainty regarding the second-best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery ( RA ), right internal thoracic artery ( RITA ), and saphenous vein ( SV ). No network meta-analysis has compared these 3 strategies. Methods and Results MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA , SV , and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all-cause long-term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection ( DSWI ). Pairwise and network meta-analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included ( RA , 16 201, SV , 112 018, RITA, 21 683). At NMA , the use of SV was associated with higher long-term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI , 1.12-1.34) and RITA (incidence rate ratio, 1.26; 95% CI , 1.17-1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI , 0.55-0.91). There were no differences for any outcome between RITA and RA , although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI , 0.92-2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used. Conclusions The use of the RA or the RITA is associated with a similar and statistically significant long-term clinical benefit compared with the SV . There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.

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