Percutaneous coronary intervention versus coronary artery by-pass grafting in premature coronary artery disease: What is the evidence? -A narrative review.

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.

Emergency CABG for a migrated stent in a COVID-19 positive patient.

Percutaneous coronary interventions (PCI) have become a standard of treatment worldwide. Despite high safety rates, iatrogenic complications caused by stent dislodgements do exist in 0.21% of cases and most require emergency coronary artery by-pass grafting (CABG). Here we present a case of a coronavirus disease 2019 positive 40-year-old male patient presenting with STEMI due to thrombotic lesions in his left coronary trunk. The patient is taken to PCI and stent placement. Stent dislodgement results in the need for emergency CABG and stent removal. Informed consent and ethics approval were obtained.

Sequential organ failure assessment score predicts mortality after coronary artery bypass grafting.

BACKGROUND: Mortality after coronary artery bypass grafting (CABG) is generally associated with underlying disease and surgical factors overlooked in preoperative prognostic models. Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores are widely used in intensive care units for outcome prediction. This study investigated the accuracy of these models in predicting mortality. METHODS: Between January 2010 and April 2013, 483 patients who underwent isolated CABG were enrolled. The clinical characteristics, outcomes, and prognostic model scores of the patients were collected. Discrimination was assessed using the area under the curve approach. RESULTS: Both SOFA and APACHE II scores were effective for predicting in-hospital mortality. Among the organ systems examined in the SOFA, the cardiac and renal systems were the strongest predictors of CABG mortality. Multivariate analysis identified only the SOFA score as being an independent risk factor for mortality. CONCLUSION: In summary, the SOFA score can be used to accurately identify mortality after isolated CABG.

A Complex Left Internal Mammary Artery Intervention.

There is a variety of conduits utilized as vascular grafts in coronary artery bypass grafting (CABG). Post-CABG graft rate of failure varies depending on the type of conduit used, with the highest failure rates seen in saphenous vein grafts (SVG). Patency rates of SVG are reported to be about 75% at 12-18 months. Left internal mammary artery (LIMA) grafts have shown higher long-term patency rates when compared to other arterial and venous grafts; however, LIMA occlusions occur, most commonly in the early postoperative period. Percutaneous coronary intervention (PCI) of LIMA graft can be challenging based on the location, the length of the lesion, as well as other factors such as vessel tortuosity. Here we present a case of a complex intervention for osteal and proximal LIMA chronic total occlusion (CTO) in a symptomatic patient. Long stent delivery is usually a challenge in LIMA intervention; however, it was successfully achieved here by placing two overlapping stents. This intervention was also complicated by the tortuosity of the lesion, as well as the difficult cannulation of the left subclavian artery requiring a longer sheath for guide support.

Incidental Finding of Thoracic Aortic Dissection in a Patient Post-Coronary Artery Bypass Graft Surgery.

Thoracic aortic dissection (TAD) is an uncommon but potentially fatal complication of coronary artery bypass graft (CABG). Most patients present to the emergency room with severe chest pain, shortness of breath, or after a syncopal episode. Asymptomatic patients pose a challenge to diagnosis. The authors present a case of an 82-year-old male, who was found to have an incidental finding of a 5-cm ascending aortic aneurysm with an intimal dissection flap four months after CABG. Extensive workup on possible risk factors such as underlying aortic diseases, genetic conditions, and hypertensive crisis proved noncontributory. Aggressive blood pressure control was achieved, and the patient was observed in the intensive care unit before discharge with follow-up. The purpose of this case report is to alert clinicians of TAD after CABG and highlight the importance of developing a protocol for follow-up and monitoring of patients who have undergone CABG, as complications can be asymptomatic. Early and accurate diagnosis of TAD as a complication of CABG is essential to improving survival rates.

Dyskeratosis Congenita: A Case Report of a Patient With Coronary Artery Disease.

Clinical evidence demonstrates that patients with telomere biology disorders, such as dyskeratosis congenita, are more prone to coronary artery disease. We present the case of a 43-year-old female diagnosed with dyskeratosis congenita with critical cardiovascular disease. She underwent coronary artery bypass graft (CABG) with improvement of her cardiac function. Although this is a rare genetic disease, further studies are warranted to investigate the underlying pathophysiology of cardiovascular disease in patients with dyskeratosis congenita.

Comparison of SYNTAX and Gensini Scores in the Decision of Surgery or Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease.

INTRODUCTION:  Many scoring systems have been developed to determine the extent of coronary artery disease (CAD) in patients with multi-vessel disease. The most widely used of these are Synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) and Gensini scoring. Gensini scoring system can successfully show coronary plaque burden. In our study, we aimed to test the predictive power of SYNTAX and Gensini scores for surgical or percutaneous intervention decisions made by the cardiac team in patients with three-vessel disease. METHODS: A total of 476 patients without ST-elevation myocardial infarction with the three-vessel disease were included in the study. SYNTAX and Gensini scores of the patients were calculated from their coronary angiographies. Receiver operating characteristic curve (ROC-curve) analysis was performed using both scores. RESULTS:  Both the SYNTAX score and Gensini score were able to predict heart team decisions (AUC: 0.759, 0.680; p<0.001). Diabetes and smoking were more common in patients who were decided to have surgery (p<0.001). CONCLUSION:  In the light of our study results, the decisions to be made with the SYNTAX score will be closer to the decisions of the heart team than the Gensini score.

Aortic root replacement in a patient with previous coronary artery bypass.

Acute type A thoracic aortic dissection is a life-threatening condition that requires rapid diagnosis and prompt surgical intervention. Prior cardiac surgery is recognized as a predisposing risk factor. Here, we report a rare case and successful surgical repair of a late presenting acute type A thoracic aortic dissection four years after a three-vessel coronary artery bypass grafting. Resection of the aortic valve and aneurysmal tissue was required, reconstruction was done with a composite graft, and the native coronary ostia and aorto-saphenous buttons were preserved.

DIagnostic accuracy oF electrocardiogram for acute coronary OCClUsion resuLTing in myocardial infarction (DIFOCCULT Study).

BACKGROUND: Although ST-segment elevation (STE) has been used synonymously with acute coronary occlusion (ACO), current STE criteria miss nearly one-third of ACO and result in a substantial amount of false catheterization laboratory activations. As many other electrocardiographic (ECG) findings can reliably indicate ACO, we sought whether a new ACO/non-ACO myocardial infarction (MI) paradigm would result in better identification of the patients who need acute reperfusion therapy. METHODS: A total of 3000 patients were enrolled in STEMI, non-STEMI and control groups. All ECGs were reviewed by two cardiologists, blinded to any outcomes, for the current STEMI criteria and other subtle signs. A combined ACO endpoint was composed of peak troponin level, troponin rise within the first 24 h and angiographic appearance. The dead or alive status was checked from hospital records and from the electronic national database. RESULTS: In non-STEMI group, 28.2% of the patients were re-classified by the ECG reviewers as having ACO. This subgroup had a higher frequency of ACO, myocardial damage, and both in-hospital and long-term mortality compared to non-STEMI group. A prospective ACOMI/non-ACOMI approach to the ECG had superior diagnostic accuracy compared to the STE/non-STEMI approach in the prediction of ACO and long-term mortality. In Cox-regression analysis early intervention in patients with non-ACO-predicting ECGs was associated with a higher long-term mortality. CONCLUSIONS: We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI. (DIFOCCULT study; ClinicalTrials.gov number, NCT04022668.).

Long-term follow-up of total arterial versus conventional and hybrid myocardial revascularization: A propensity score matched analysis.

PURPOSE: To evaluate the impact of the revascularization technique (by means of conventional, total arterial or hybrid myocardial revascularization) in patients with multivessel coronary artery disease. METHODS: A propensity-score analysis of patients undergoing myocardial revascularization from 1998 to 2012 was performed based on the surgical technique utilized, either total arterial (Group1, G1,n°â€¯= 89), conventional CABG(LIMA on LAD plus veins, Group2, G2,n°â€¯= 89), or hybrid revascularization (LIMA on LAD plus PTCA on non-LAD vessels, Group3, G3, n°â€¯= 89). Primary end-points were overall survival and cardiac-related death while secondary composite end-point was survival freedom from major adverse cardiac and cerebrovascular events (MACCEs) defined as myocardial infarction, cardiac death, stroke and repeated target vessel revascularization. RESULTS: Study population was mostly affected by double-vessels disease (G1 = 2.35 vs G2 = 2.3 vs G3 = 2.4, p = 0.14) with a preserved LV function(G1 = 48% vs G2 = 49% vs G3 = 50%, p = 0.12). Hospital mortality was 0% in all groups. At a mean follow-up of 6 ±â€¯2 years overall survival was significantly better in patients receiving total arterial myocardial revascularization (G1 = 90.4 ±â€¯3.5% vs G2 = 82.3 ±â€¯4.2% vs G3 = 82.1 ±â€¯5.9%, p = 0.049) as well as freedom from MACCEs (G1 = 95.2 ±â€¯2.4% vs G2 = 86.5 ±â€¯4% vs G3 = 68 ±â€¯6.9%, p = 0.001) while survival free from cardiac-related death was similar(G1 = 97.7 ±â€¯1.6% vs G2 = 95.1 ±â€¯2.4% vs G3 = 89.5 ±â€¯5.4%, p = 0.08). Conversely, at 10 years follow-up only freedom from MACCEs was significantly better in patients of Group 1(G1 = 78.9 ±â€¯8.6% vs G2 = 72.4 ±â€¯5.7% vs G3 = 52 ±â€¯8.7%, p < 0.001). CONCLUSIONS: Total arterial revascularization provides improved outcomes at mid and long term follow-up compared with conventional or hybrid revascularization. The latter technique is particularly associated with a significantly higher incidence of late myocardial infarction and repeat revascularization.

A compact and automated ex vivo vessel culture system for the pulsatile pressure conditioning of human saphenous veins.

Saphenous vein (SV) graft disease represents an unresolved problem in coronary artery bypass grafting (CABG). After CABG, a progressive remodelling of the SV wall occurs, possibly leading to occlusion of the lumen, a process termed 'intima hyperplasia' (IH). The investigation of cellular and molecular aspects of IH progression is a primary end-point toward the generation of occlusion-free vessels that may be used as 'life-long' grafts. While animal transplantation models have clarified some of the remodelling factors, the pathology of human SV is far from being understood. This is also due to the lack of devices able to reproduce the altered mechanical load encountered by the SV after CABG. This article describes the design of a novel ex vivo vein culture system (EVCS) capable of replicating the altered pressure pattern experienced by SV after CABG, and reports the results of a preliminary biomechanical conditioning experimental campaign on SV segments. The EVCS applied a CAGB-like pressure (80-120 mmHg) or a venous-like perfusion (3 ml/min, 5 mmHg) conditioning to the SVs, keeping the segments viable in a sterile environment during 7 day culture experiments. After CABG-like pressure conditioning, SVs exhibited a decay of the wall thickness, an enlargement of the luminal perimeter, a rearrangement of the muscle fibres and partial denudation of the endothelium. Considering these preliminary results, the EVCS is a suitable system to study the mechanical attributes of SV graft disease, and its use, combined with a well-designed biological protocol, may be of help in elucidating the cellular and molecular mechanisms involved in SV graft disease.

The effects of low-dose midazolam for induction of high-dose fentanyl anesthesia for coronary artery bypass graft.

A small dose of midazolam 0.06 mg/kg or diazepam 0.15 mg/kg was used for induction of high-dose fentanyl (50 µg/kg) anesthesia in patients undergoing coronary artery bypass grafting operation. Hemodynamic variables were measured 5 min after the injection of midazolam or diazepam, after the end of the fentanyl infusion, and following endotracheal intubation. Midazolam and diazepam caused a slight but significant decrease in mean arterial pressure (-9.8%) and -11.8%), respectively) and a further significant depression was observed in the diazepam group but not in the midazolam group after fentanyl. Although the cardiac index was maintained in patients who received madazolam, a significant decrease was observed in the diazepam group (-28.5%) after administration of fentanyl. Heart rate was decreased in the diazepam group but not in the midazolam group. Therefore, a small dose of midazolam may be a suitable induction agent for high-dose fentanyl anesthesia in patients with coronary artery disease.

Transoesophageal echocardiography during coronary artery bypass procedures: impact on surgical planning.

INTRODUCTION: Intraoperative transesophageal echocardiography (iTEE) is widely accepted and routinely used during heart valve surgery. However, the impact of iTEE among patients undergoing coronary artery bypass grafting (CABG) is less well documented. In this study, we aim to define the impact of iTEE in patients undergoing myocardial revascularization for severe coronary artery disease. METHODS: We analyzed clinical data and preoperative and intraoperative echocardiograms of all adults who underwent on pump coronary bypass and iTEE between January 2008 and December 2008. RESULTS: 521 patients (mean age 69±14 years) were studied. New prebypass findings were obtained in 82 (15.7%) patients: in 62 (11.9%) of these patients, this information changed the surgical plan. New postbypass findings were obtained in 8 patients (1.5%) and the surgical plan was altered in 4 patients (0.7%). CONCLUSIONS: Overall new findings were obtained in 90 patients (17.2%) and the surgical plan was altered in 66 patients (12.6%). These data support the routine use of iTEE among patients undergoing surgical myocardial revascularization.