[Hybrid revascularization: a combined approach to multivessel coronary artery lesions].

Analysis of effectiveness and feasibility of hybrid approach to multivessel coronary artery disease and problems of interaction between cardiac surgeons and interventional cardiologists in deciding on the choice of revascularization method is performed in the article. Hybrid approach to multivessel disease defined as sternal sparing, off-pump, minimally invasive, hand sewn left internal mammary - left anterior descending (LAD) arteries by-pass graft with percutaneous coronary revascularization of non-LAD lesions to achieve functionally complete revascularization is described in detail. Data of multicenter studies and clinical recommendations for myocardial revascularization is discussed.

Appropriateness of percutaneous coronary intervention.

CONTEXT: Despite the widespread use of percutaneous coronary intervention (PCI), the appropriateness of these procedures in contemporary practice is unknown. OBJECTIVE: To assess the appropriateness of PCI in the United States. DESIGN, SETTING, AND PATIENTS: Multicenter, prospective study of patients within the National Cardiovascular Data Registry undergoing PCI between July 1, 2009, and September 30, 2010, at 1091 US hospitals. The appropriateness of PCI was adjudicated using the appropriate use criteria for coronary revascularization. Results were stratified by whether the procedure was performed for an acute (ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, or unstable angina with high-risk features) or nonacute indication. MAIN OUTCOME MEASURES: Proportion of acute and nonacute PCIs classified as appropriate, uncertain, or inappropriate; extent of hospital-level variation in inappropriate procedures. RESULTS: Of 500,154 PCIs, 355,417 (71.1%) were for acute indications (ST-segment elevation myocardial infarction, 103,245 [20.6%]; non-ST-segment elevation myocardial infarction, 105,708 [21.1%]; high-risk unstable angina, 146,464 [29.3%]), and 144,737 (28.9%) for nonacute indications. For acute indications, 350,469 PCIs (98.6%) were classified as appropriate, 1055 (0.3%) as uncertain, and 3893 (1.1%) as inappropriate. For nonacute indications, 72,911 PCIs (50.4%) were classified as appropriate, 54,988 (38.0%) as uncertain, and 16,838 (11.6%) as inappropriate. The majority of inappropriate PCIs for nonacute indications were performed in patients with no angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), or suboptimal (≤1 medication) antianginal therapy (95.8%). Furthermore, although variation in the proportion of inappropriate PCI across hospitals was minimal for acute procedures, there was substantial hospital variation for nonacute procedures (median hospital rate for inappropriate PCI, 10.8%; interquartile range, 6.0%-16.7%). CONCLUSIONS: In this large contemporary US cohort, nearly all acute PCIs were classified as appropriate. For nonacute indications, however, 12% were classified as inappropriate, with substantial variation across hospitals.

Evaluation of revascularization subtypes in octogenarians undergoing coronary artery bypass grafting.

BACKGROUND: Recent data suggest that octogenarians' long-term survival after complete coronary artery bypass graft revascularization is superior to incomplete revascularization. Discriminating between variable definitions of "complete" complicates interpretation of survival data. We aimed to clarify octogenarian long-term survival rates by stratifying revascularization subtypes. METHODS AND RESULTS: From 1986 to 2007, 580 patients 80 to 94 years of age underwent coronary artery bypass graft. Functional complete revascularization was defined as at least 1 graft to all diseased coronary vessels with >50% stenosis. Traditional complete revascularization was defined as 1 graft to each major arterial system with at least 50% stenosis. Incomplete revascularization was defined as leaving diseased, ungrafted regions. Revascularization was functional in 279 (48%), traditional in 181 (31%), and incomplete in 120 (21%). Long-term survival was evaluated by Kaplan-Meier analysis. Of 537 operative survivors, there were 402 late deaths. Cumulative long-term survival totaled 2890 patient-years. Late survival (Kaplan-Meier) was similar between functional (mean, 6.8 years) and traditional (6.7 years) groups (P=0.51), but diminished with incomplete (4.2 years) revascularization (P=0.007). Survival by group at 5 years was: 59+/-3% functional, 57+/-4% traditional, and 45+/-5% incomplete. Survival at 8 years was: 40+/-3% functional, 37+/-4% traditional, and 26+/-5% incomplete. To minimize selection bias in patients with limited life expectancy, Kaplan-Meier analysis was repeated including only patients with survival >12 months. Survival was again impaired with incomplete revascularization (P=0.04), and there was no difference between functional and traditional complete revascularization (P=0.73). CONCLUSIONS: Bypassing all diseased arterial vessels after revascularization does not afford significant long-term survival advantage compared to a traditional approach. Incomplete revascularization, related to more extensive disease, is associated with an 18% decline in survival. These data suggest that it is important to avoid incomplete revascularization in octogenarians, but the supplementary endeavor required to perform functional complete revascularization does not improve survival.

Impact of Routine Invasive Physiology at Time of Angiography in Patients With Multivessel Coronary Artery Disease on Reclassification of Revascularization Strategy: Results From the DEFINE REAL Study.

OBJECTIVES: This study sought to prospectively assess the impact of routine invasive physiology at the time of angiography on reclassification of therapeutic management of multivessel disease (MVD) patients, and to assess how implementation of instantaneous wave-free ratio (iFR) alters the process. BACKGROUND: Routine invasive physiology in intermediate coronary lesions at the time of diagnostic angiography, primarily in patients with single-vessel disease and using fractional flow reserve (FFR), reclassifies coronary revascularization management in 26% to 44% of patients. The role of invasive physiology in patients with MVD is unclear. METHODS: In 18 centers, 484 patients undergoing diagnostic angiography disclosing MVD with lesions >40% by visual assessment were included. Investigators were asked to prospectively define their initial management strategy based on angiography and clinical information. Invasive physiology (FFR or iFR driven) was then performed and final strategy defined. Initial and final vessel, patient, procedural, and overall management were described. Reclassification was defined as the difference between initial and final strategy. RESULTS: The majority of patients were clinically stable (82.2%). Two- and 3-vessel disease was present in 73.3% and 26.7% of patients, respectively. Lesions investigated were "intermediate" with median percent stenosis, median FFR, and median iFR at 60% (interquartile range [IQR]: 50% to 70%), 0.84 (IQR: 0.78 to 0.90), and 0.92 (IQR: 0.85 to 0.96), respectively. Vessel management was reclassified by physiology in 30.0% (249 of 828) of vessels. Patient and overall management were reclassified in 26.9% (130 of 484) and 45.7% (211 of 484) of patients, respectively. Reclassification rates were high irrespective of initial management (optimal medical therapy, percutaneous coronary intervention, or coronary artery bypass grafting), and performance and results of pre-procedural noninvasive tests. Reclassification of overall management in particular increased with the number of vessels investigated (1 vessel: 37.3%; 2 vessels: 45.0%; 3 vessels: 66.7%; p = 0.002). Incorporating iFR in the decision process was associated with investigation of more vessels (p = 0.04) and higher reclassification (p = 0.0001). CONCLUSIONS: In patients with MVD and intermediate coronary lesions, invasive physiology at time of angiography reclassifies revascularization strategy in a large proportion of cases (26.9%) and investigation of more vessels is associated with higher reclassification rates.

Outcomes after surgical coronary artery revascularisation in children with congenital heart disease.

OBJECTIVE: Surgical coronary revascularisation in children with congenital heart disease (CHD) is a rare event for which limited information is available. In this study, we review the indications and outcomes of surgical coronary revascularisation from the Pediatric Cardiac Care Consortium, a large US-based multicentre registry of interventions for CHD. METHODS: This is a retrospective cohort study of children (<18 years old) with CHD who underwent surgical coronary revascularisation between 1982 and 2011. In-hospital mortality and graft patency data were obtained from the registry. Long-term transplant-free survival through 2014 was achieved for patients with adequate identifiers via linkage with the US National Death Index and the Organ Procurement and Transplantation Network. RESULTS: Coronary revascularisation was accomplished by bypass grafting (n=72, median age 6.8 years, range 3 days-17.4 years) or other operations (n=65, median age 2.6 years, range 5 days-16.7 years) in 137 patients. Most revascularisations were related to the aortic root (61.3%) or coronary anomalies (27.7%), but 10.9% of them were unrelated to either of them. Twenty in-hospital deaths occurred, 70% of them after urgent 'rescue' revascularisation in association with another operation. Long-term outcomes were available by external linkage for 54 patients surviving to hospital discharge (median follow-up time 15.0 years, max follow-up 29.8 years) with a 15-year transplant-free survival of 91% (95% CI 83% to 99%). CONCLUSIONS: Surgical coronary revascularisation can be performed in children with CHD with acceptable immediate and long-term survival. Outcomes are dependent on indication, with the highest mortality in rescue procedures.

Trends in coronary revascularization 1989 to 1997: the Bypass Angioplasty Revascularization Investigation (BARI) survey of procedures.

Use of catheter-based and surgical coronary revascularization has steadily increased in North America. Introduction of catheter-based "new devices," including intracoronary stents, has expanded the range of patients who can be treated with percutaneous approaches. We sought to address trends in the practice of catheter-based and surgical coronary revascularization during 1989 to 1997. The 17 North American institutions participating in the NHLBI Bypass Angioplasty Revascularization Investigation (BARI) periodically completed a 5-working day survey of all surgical and catheter-based coronary revascularizations. Data collected included patient demographics, vessel disease, prior interventions, and use of new devices or minimally invasive surgical techniques. The proportion of all procedures that were catheter based (vs surgical) increased from 52.1% in 1989/1990 to 62.0% in 1997 (p <0.001). Among surgically treated patients, prevalence of prior bypass surgery decreased from 13.4% in 1989/1990 to 7.5% in 1997 (p <0.001). In 1997, 3% of surgical procedures used minimal incisions or were performed without cardiopulmonary bypass. Among patients undergoing catheter-based intervention, prevalence of left main disease increased from 2.2% to 5.7% (p <0.001), myocardial infarction within 24 hours increased from 2.4% to 9.7% (p <0.001), and prior bypass surgery increased from 16.2% to 20.8% (p = 0.056). Use of new devices increased from 11.6% of catheter-based procedures in 1990 to 67.0% in 1997 (p <0.001). Compared with the early 1990s, catheter-based revascularization is currently more commonly used for patients with acute myocardial infarction, prior bypass surgery, or severe left main narrowing. These trends are likely due to the proliferation of new devices, especially intracoronary stents, since the mid 1990s.

Changes in the use of coronary artery revascularization procedures in the Department of Veterans Affairs, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample, 1991-1999.

BACKGROUND: There have been dramatic increases in the number of coronary artery bypass surgeries (CABS) and percutaneous coronary interventions (PCI) performed during the last decade. Whether this finding is true for revascularization procedures performed in Department of Veterans Affairs (VA) medical centers is the subject of this paper. METHODS: This study compared the number of revascularization procedures and rates of use in the VA, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample. Included were men who underwent isolated CABS and/or PCI, including stenting, between 1991 and 1999, although data for the Nationwide Inpatient Sample were available only between 1993 and 1997. Age adjusted use rates were calculated with the direct method of standardization. RESULTS: The percent of users of VA healthcare 75 years and older increased from 10% in 1991 to 20% in 1999. In the VA, the number of isolated CABS declined from 6227 in 1991 to 6147 in 1999, whereas age adjusted rates declined from 167.6 per 100,000 in 1991 to 107.9 per 100,000 in 1999. In the 2 national surveys, both the estimated numbers of procedures and use rates increased over time. In all 3 settings, there were increases in both numbers and rate of PCI from 1993, although in the VA, use rates decreased from 191.2 per 100,000 in 1996 to 139.7 per 100,000 in 1999. VA use rates for both CABS and PCI were lower than those in the 2 national surveys. CONCLUSION: Age adjusted rates of CABS and PCI were lower in the VA than in 2 national surveys. Since 1996, there has been a decrease in the rate of use of revascularization procedures in the VA.

Outcomes associated with fractional flow-guided revascularization: a meta-analysis.

BACKGROUND: Deferral of revascularization for abnormal but nonischemic lesions is usually recommended; however, the long-term outcome of this approach is not well known. HYPOTHESIS: Deferral of nonischemic lesions will be associated with a low frequency of adverse events. METHODS: A PubMed search of the MEDLINE database identified studies that reported clinical outcomes among patients who had fractional flow reserve-guided revascularization. We further categorized studies into 2 subgroups: left main and non-left main coronary artery lesions. Baseline demographics and clinical outcome data were extracted by 3 independent reviewers. Fixed and random effects summary risk ratios were constructed using Mantel-Haenszel and DerSimonian-Laird models, respectively. The primary outcome was the composite of death, myocardial infarction, and revascularization. RESULTS: From 741 potential studies, 17 were included in the meta-analysis (n = 2975 participants), 8 in the left main subgroup (n = 595) and 9 studies (n = 2380) in non-left main subgroup. In the left main subgroup, the incidence of the composite outcome was 15.3% in the no-ischemia/deferral group vs 14.3% in the ischemia/revascularization group (risk ratio [RR] = 1.13, 95% confidence interval [CI]: 0.76-1.68, P = 0.54, I(2) = 3.7%). In the non-left main subgroup, the incidence of the composite outcome was 9.2% in the no-ischemia/deferral group vs 18.8% in the ischemia/revascularization group (RR = 0.42, 95% CI: 0.34-0.52, P < 0.0001, I(2) = 20.7%). CONCLUSIONS: Patients with left main coronary disease had a relatively high incidence of adverse cardiovascular events, which was similar in both the deferral and revascularization groups. In patients with non-left main disease, ischemia was associated with worse outcomes despite revascularization.

Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies.

OBJECTIVES: This study sought to perform a systematic review and meta-analysis of studies comparing complete revascularization (CR) versus incomplete revascularization (IR) in patients with multivessel coronary artery disease. BACKGROUND: There are conflicting data regarding the benefits of CR in patients with multivessel coronary artery disease. METHODS: We identified observational studies and subgroup analysis of randomized clinical trials (RCT) published in PubMed from 1970 through September 2012 using the following keywords: "percutaneous coronary intervention" (PCI); "coronary artery bypass graft" (CABG); "complete revascularization"; and "incomplete revascularization." Main outcome measures were total mortality, myocardial infarction, and repeat revascularization procedures. RESULTS: We identified 35 studies including 89,883 patients, of whom 45,417 (50.5%) received CR and 44,466 (49.5%) received IR. IR was more common after PCI than after CABG (56% vs. 25%; p < 0.001). Relative to IR, CR was associated with lower long-term mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.65 to 0.77; p < 0.001), myocardial infarction (RR: 0.78, 95% CI: 0.68 to 0.90; p = 0.001), and repeat coronary revascularization (RR: 0.74, 95% CI: 0.65 to 0.83; p < 0.001). The mortality benefit associated with CR was consistent across studies irrespective of revascularization modality (CABG: RR: 0.70, 95% CI: 0.61 to 0.80; p < 0.001; and PCI: RR: 0.72, 95% CI: 0.64 to 0.81; p < 0.001) and definition of CR (anatomic definition: RR: 0.73, 95% CI: 0.67 to 0.79; p < 0.001; and nonanatomic definition: RR: 0.57, 95% CI: 0.36 to 0.89; p = 0.014). CONCLUSIONS: CR is achieved more commonly with CABG than with PCI. Among patients with multivessel coronary artery disease, CR may be the optimal revascularization strategy.

Cirugía de revascularización miocárdica: análisis de supervivencia a corto y largo plazo / Myocardial revascularization surgery: short and long-term survival analysis

FUNDAMENTO: Describir la supervivencia y evolución clínica de pacientes sometidos a cirugía de revascularización miocárdica, identificando los factores predictores del resultado quirúrgico a corto y largo plazo. MÉTODO: Estudio de una cohorte de 175 pacientes sometidos a cirugía de revascularización miocárdica coronaria pura o mixta en un servicio de Cirugía Cardiaca, reclutada entre 2008 y 2010 y seguida durante diez años. Se realizó análisis descriptivo, de regresión logística (OR e IC95%) y de supervivencia por (Kaplan Meier y regresión de Cox uni y multivariante (HR e IC95%) a corto (un año) y largo plazo (diez años). RESULTADOS: Cohorte con predominio masculino (85,1%), media de edad 67 años (45-84), y EuroSCORE medio de 5,3%. La mortalidad fue 6,8% al año y 26,9% a los 10 años La media de supervivencia de los fallecidos fue 40 meses (32,2-47,8). A corto plazo, un mejor grado funcional preoperatorio NYHA≤III se asoció no significativamente a menor mortalidad (OR :0,11; IC95%: 0,01-1,08; p = 0,058), mientras que el sexo femenino (OR: 2,94; IC95%: 1,01-8,57; p = 0,048) y un EuroSCORE >4% (OR: 4,94; IC95%: 1,52-16,1; p = 0,008) incrementaron el riesgo de presentar eventos cardiacos adversos. A largo plazo, mayor edad (HR: 1,06; IC95%: 1,01-1,10; p = 0,026) y menor índice de masa corporal tras el primer año postoperatorio (HR: 0,90; IC95%: 0,81-0,99; p = 0,040) fueron predictores independientes de mortalidad. CONCLUSIONES: La edad fue predictor independiente de mortalidad a largo plazo, mientras que el sexo femenino y un EuroSCORE >4% se asociaron con mayor riesgo de padecer eventos cardiovasculares a corto plazo

BACKGROUND: This study sets out to describe the survival and clinical evolution of patients who undergo myocardial revascularisation surgery, and identifies the short- and long-term predictive factors for surgical outcomes. METHODS: Study of a cohort of 175 patients undergoing pure or mixed coronary myocardial revascularisation surgery at a heart surgery unit, recruited between 2008 and 2010 and monitored for ten years. Descriptive and logistic regression (OR and 95%CI) analysis were carried out, along with an analysis of survival by Kaplan Meier and Cox uni- and multivariate regression (HR and 95%CI) in the short- (one year) and long-term (ten years). RESULTS: Predominantly male cohort (85.1%), mean age of 67 years (45-84), and mean EuroSCORE of 5.3%. Mortality was 6.8 and 26.9% at 1 and 10 years, respectively. Mean survival of deceased individuals was 40 months (32.2-47.8). In the short-term, a better NYHA ≤III preoperative functional level was not significantly associated with lower mortality (OR: 0.11; 95%CI: 0.01-1.08; p = 0.058), while being female (OR: 2.94; 95%CI: 1.01-8.57; p = 0.048) and having a EuroSCORE of >4% (OR: 4.94; 95%CI: 1.52-16.10; p = 0.008) showed an increased risk of presenting adverse cardiac events. In the long-term, greater age (HR: 1.06; 95%CI: 1.01-1.10; p = 0.026) and lower rates of body mass index after the first postoperative year (HR: 0.90; 95%CI: 0.81-0.99; p = 0.040) were independent predictors of mortality. CONCLUSION: Age was an independent predictor of long-term mortality, while being female and a EuroSCORE >4% were associated with a higher risk of suffering from short-term cardiovascular events

Diferença nas taxas de letalidade e nas principais causas de óbito, entre homens e mulheres, por revascularização miocárdica cirúrgica / Differences in lethality rates and the main causes of death among men and women, due to surgical revascularization of the myocardium

Fundamentos:Parece haver diferenças na revascularização cirúrgica do miocárdio(RVM), com pior resultados nas mulheres. Objetivo: Avaliar a diferença na letalidade e no percentual de óbitos relacionados ao aparelho circulatório, diabetes mellitus e procedimento(ApCDMC), intra-hospitalar até um 1 ano pós-alta, entre homens e mulheres, submetidos à RVM, pelo sistema único de saúde, no estado do Rio de Janeiro(ERJ), de 1999 a 2003. Métodos:Os dados sobre RVM provieram dos bancos de autorização de internação hospitalar e declaração de óbito do ERJ. O relacionamento probalístico entre foi realizado através do RecLink. Excluiram-se RVM com trocas valvares.Consideraram-se 4 períodos de tempo(em dias): intra-hospitalar, até 30, de 31-180 e de 181-365 dias pós-alta; e 3 faixas etárias (em anos):20-49, 50-69 e >=70 anos percentuais de óbitos e taxas de letalidade por: sexo, faixas etárias, causas do ApCDM e períodos. Resultados: Encontrados 5180 pacientes submetidos à RVM, sendo que 675 morreram até um ano pós-alta. A letalidade intra-hospitalar foi 9,7 por cento nas mulheres e 7,2 por cento nos homens. As letalidades nos períodos de 0-30 dias, 31-180 e 181-365 dias pós-alta foram, respectivamente, nas mulheres: 11,8 por cento, 13,9por cento e 15,5 por cento, e nos homens 9,2 por cento, 10,9 por cento e 11,8 por cento. O percentual de óbitos por causa da ApCDM foi mais frequente nos homens jovens e nas mulheres mais idosas. Conclusões: As taxas de letalidade intra-hospitalar e até um ano pós-alta nas RVM foram mais elevadas nas mulheres no período masi afastado do procedimento, enquanto os homens morreram mais precocemente por essas causas.