Coronary Artery Disease/surgery

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Research Letter

Change of Strategy in Coronary Artery Bypass Graft Surgery Waiting List during the COVID-19 Pandemic: One-Year Follow-Up

Franc Jorge Sampaio Santos Pereira et al. Marília Prudente Menezes Gabriela Carolina Santamaria Naranjo José Henrique Herrmann Delamain … José Ribamar Costa Mario Issa Vivian Lerner Amato Fausto Feres Pedro Silvio Farsky

Introduction

The COVID-19 pandemic led to a significant occupation of intensive care beds, causing the suspension of elective cases of coronary artery bypass grafting (CABG).

At the same time, the evolution of techniques for the percutaneous treatment of coronary artery disease (CAD) has expanded the possibilities for this modality, and published studies have not shown a reduction in outcomes in stable patients with moderate/high ischemic burden under optimized clinical treatment (OCT).

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Editorial

PTEN in the Context of Myocardial Revascularization: The Iceberg Tip?

Leonardo Rufino Garcia et al. André Monti Garzesi Marcello Laneza Felicio Leonardo Antônio Mamede Zornoff

Cardiovascular diseases significantly contribute to morbidity and mortality in Brazil and worldwide. Within this group of diseases, coronary artery disease stands out, accounting for about 12% of total deaths in Brazil and is a leading cause of death in North America.

In addition to lifestyle changes such as smoking cessation, weight loss with regular physical activity, control of comorbidities, notably diabetes and arterial hypertension, and drug treatment with antiplatelet agents, beta-blockers, and statins, a significant number of patients require treatment aimed at myocardial revascularization. Diabetic, multivessel-diseased patients with obstructions in the left main coronary artery greater than 50% or with depressed left ventricular function benefit the most. This fact is due to different factors, including a decrease in ischemia and symptoms, an improvement in quality of life, a decrease in the occurrence of infarcts, and, above all, mortality improvement.

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Editorial

Multi-Arterial Grafting in Surgical Coronary Revascularization. The Renewed Quest for Enhanced Outcomes

Walter J. Gomes

With a large body of contemporary and historic evidence strengthening coronary artery bypass surgery (CABG) as the most effective procedure for treating advanced atherosclerotic coronary artery disease (CAD), the quest for enhanced outcomes and quality improvement is steadily underway.

Long-term graft patency is crucial for the benefits afforded by surgery, averting spontaneous myocardial infarction rate (MI) and increasing long-term survival, which is demonstrated with the employment of internal thoracic artery (ITA) conduits anastomosed to the left anterior descending coronary artery.

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Editorial

Stress CMR in the Elderly: Does It Provide the Answers?

Vera Vaz Ferreira et al. Boban Thomas

After the ISCHEMIA clinical trial, despite the ongoing debate, clinicians need to contemplate all strategies for patients with chronic stable ischemic heart disease (SIHD). The management of SIHD has two aims – improve prognosis and/or relieve symptoms. Most studies have shown that revascularisation provides greater symptom benefits than optimal medical therapy (OMT) alone, but data on hard outcomes have been elusive. Therefore, improving our clinical decision-making tools in selecting patients for revascularization is important. This becomes particularly important when we select elderly patients for revascularisation because the risk-benefit ratio is probably more tenuous than a younger cohort. The elderly present difficulties in the evaluation of SIHD due to multiple reasons. One refinement is the adequate selection of the method to evaluate SIHD. A panoply of non-invasive techniques exists for imaging, including cardiac computed tomography, echocardiography, nuclear medicine techniques and cardiac magnetic resonance (CMR). Combining the right patient and the right method of evaluation followed by the right therapeutic strategy improves outcomes. In clinical medicine, what is important is not how much we do but how well our patients do after what we do.

CMR stress perfusion is a valuable resource with a high negative predictive value in those who do not have perfusion defects irrespective of the presence or absence of coronary artery disease. Few studies exist on the prognostic value of adenosine stress perfusion CMR in elderly patients with or without established SIHD. The study by Boonyasirinant and Kaolawanich, although not the first, is a welcome addition to the repository of existing literature that provides a cogent reason for using stress CMR for the evaluation of ischemia now addressing the elderly age group. Their findings demonstrate that while clinical data were combined with information on left ventricular function, no incremental value was seen compared to clinical data alone in predicting serious cardiac events. The presence of ischemia as detected by CMR helped predict events significantly better. The predictive power was not increased with the addition of information on late gadolinium enhancement. Esteban-Fernandez et al. found that elderly patients with a moderate or severe degree of ischemia on stress CMR have a higher risk of having an event during follow-up. Taken together, these two studies provide evidence for the use of adenosine stress CMR in predicting outcomes in elderly patients. A notable feature of both studies is the absence of significant adverse events of adenosine. However, the ISCHEMIA clinical trial reflected the limited availability of both equipment and expertise, where CMR was the least chosen method to evaluate for ischemia (5%), reflecting real-world practice.

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Original Article

Patients' Preferences after Recurrent Coronary Narrowing: Discrete Choice Experiments

Carlos Alberto da Silva Magliano et al. Andrea Liborio Monteiro Amanda Rebeca de Oliveira Rebelo Giovanna Francisconi Santos … Claudia Cristina de Aguiar Pereira Nikolas Krucien Roberto Magalhães Saraiva

Abstract

Background:

Selecting the optimal treatment strategy for coronary revascularization is challenging. A crucial endpoint to be considered when making this choice is the necessity to repeat revascularization since it is much more frequent after percutaneous coronary intervention (PCI) than after coronary artery bypass grafting (CABG).

Objective:

This study intends to provide insights on patients’ preferences for revascularization, strategies in the perspective of patients who had to repeat revascularization.

Methods:

We selected a sample of patients who had undergone PCI and were hospitalized to repeat coronary revascularization and elicited their preferences for a new PCI or CABG. Perioperative death, long-term death, myocardial infarction, and repeat revascularization were used to design scenarios describing hypothetical treatments that were labeled as PCI or CABG. PCI was always presented as the option with lower perioperative death risk and a higher necessity to repeat procedure. A conditional logit model was used to analyze patients’ choices using R software. A p value < 0.05 was considered statistically significant.

Results:

A total of 144 patients participated, most of them (73.7%) preferred CABG over PCI (p < 0.001). The regression coefficients were statistically significant for PCI label, PCI long-term death, CABG perioperative death, CABG long-term death and repeat CABG. The PCI label was the most important parameter (p < 0.05).

Conclusion:

Most patients who face the necessity to repeat coronary revascularization reject a new PCI, considering realistic levels of risks and benefits. Incorporating patients’ preferences into benefit-risk calculation and treatment recommendations could enhance patient-centered care.

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Original Article

Short-Term and Mid-Term Clinical Outcomes Following Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass: A Meta-Analysis

Li Dong et al. Yi-kun Kang Xiang-guang An

Abstract

Background:

Off-pump coronary artery bypass grafting (OPCAB) is one of the standard treatments for coronary artery disease (CAD) while hybrid coronary revascularization (HCR) represents an evolving revascularization strategy. However, the difference in outcomes between them remains unclear.

Objective:

We performed a meta-analysis to compare the short-term and mid-term outcomes of HCR versus OPCAB for the treatment of multivessel or left main CAD.

Methods:

We searched the PubMed, EMBASE, Web of Science and Cochrane databases to identify related studies and a routine meta-analysis was conducted.

Results:

Nine studies with 6121 patients were included in the analysis. There was no significant difference in short-term major adverse cardiac and cerebrovascular event (MACCE) rate (RR: 0.55, 95% CI: 0.30-1.03, p = 0.06) or mortality (RR: 0.51, 95% CI: 0.17-1.48, p = 0.22). HCR required less ventilator time (SMD: -0.36, 95% CI: -0.55- -0.16, p < 0.001), ICU stay (SMD: -0.35, 95% CI: -0.58 – -0.13, p < 0.01), hospital stay (SMD: -0.29, 95% CI: -0.50- -0.07, p < 0.05) and blood transfusion rate (RR: 0.57, 95% CI: 0.49-0.67, p < 0.001), but needed more operation time (SMD: 1.29, 95% CI: 0.54-2.05, p < 0.001) and hospitalization costs (SMD: 1.06, 95% CI: 0.45-1.66, p < 0.001). The HCR group had lower mid-term MACCE rate (RR: 0.49, 95% CI: 0.26-0.92, p < 0.05) but higher rate in mid-term target vessel revascularization (TVR, RR: 2.20, 95% CI: 1.32-3.67, p < 0.01).

Conclusions:

HCR had similar short-term mortality and morbidity comparing to OPCAB. HCR decreased the ventilator time, ICU stay, hospital stay, blood transfusion rate and increased operation time and hospitalization costs. HCR has a lower mid-term MACCE rate while OPCAB shows better in mid-term TVR.

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IJCS

Original Article

Epidemiological Characteristics and Mortality Predictors in Patients Over 70 Years Submitted to Coronary Artery Bypass Grafting

Renato Kaufman et al. Vitor Manuel Pereira Azevedo Rodrigo Mazzarone Gomes de Sá Mauro Geller … Regina Maria de Aquino Xavier Rogério Brant Martins Chaves Marcia Bueno Castier

Abstract

Background:

Coronary artery disease is the leading cause of death worldwide, with age being an independent risk factor for mortality in patients submitted to surgical revascularization.

Objective:

To evaluate the mortality risk predictors in patients older than 70 years submitted to myocardial revascularization.

Methods:

This is a retrospective cohort study of a cardiac surgery database. Logistic regression was used to assess independent death predictors.

Results:

A total of 372 patients submitted to surgical revascularization from 2004 to 2012 were assessed. The main cardiovascular risk factor was hypertension, followed by diabetes mellitus. Mortality at 30 days was 19.35%. The presence of peripheral vascular disease (OR: 2,47), emergency surgery (OR: 4,86) and combined valve procedure (OR: 3,86) were independent predictors of death.

Conclusion:

The surgical procedure in elderly patients showed a higher mortality than in the general population. Peripheral vascular disease, emergency surgery and combined valve procedures increased the risk of death in these patients.

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IJCS

Original Article

Effectiveness of Medical and Revascularization Procedures as the Initial Strategy in Stable Coronary Artery Disease: A Cohort Study

Mariana Vargas Furtado et al. Gustavo Neves de Araujo Mariana Ferreira Jost Andre Dias Americo … Nicolas Peruzzo Guilherme Nasi Guilherme Heiden Telo Flavia Kessler Borges Carisi Anne Polanczyk

Abstract

Background:

Coronary artery bypass grafting surgery (CABG) and percutaneous coronary intervention (PCI) are widely-used strategies in the management of stable coronary artery disease (CAD).

Objective:

To evaluate the prognosis of patients with stable CAD initially treated by medical therapy (MT), compared to the patients who were submitted to revascularization procedures.

Methods:

We conducted a prospective cohort study of 560 patients from an outpatient clinic in a tertiary hospital, with a mean follow-up of 5 years. Patients were classified into MT (n = 288), PCI (n = 159) and CABG (n=113) groups according to their initial treatment strategy. Primary endpoints were overall mortality and combined events of death, acute coronary syndrome, and stroke.

Results:

During follow-up, death rates were 11.1% in MT, 11.9% in PCI and 15.9% in CABG patients, with no statistical difference (hazard ratio [HR] for PCI, 1.05; 95% confidence interval [95%CI], 0.59 to 1.84; and HR for CABG, 1.20; 95% CI: 0.68 to 2.15). Combined outcomes occurred more often among patients initially submitted to PCI compared to MT (HR 1.50, 95% CI 1.05 to 2.14), and did not differ between MT and CABG patients (HR 1.24, 95% CI 0.84 to 1.83). Among patients with diabetes (n=198), PCI was the only therapeutic strategy predictive of combined outcomes (HR 2.14; 95% CI 1.25 to 3.63).

Conclusion:

In this observational study of stable coronary artery disease, there was no difference in overall mortality between initial medical therapy or revascularization surgery strategies. Patients initially treated with PCI had greater chance to develop combined major cardiovascular events.

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ABC

Letter to the Editor

Prophylactic Left Internal Mammary Artery Graft In Mildly-Stenosed Coronary Lesions. Still an Open Discussion

Levent Cerit

I have read the article entitled “Prophylactic Left Internal Mammary Artery Graft in Mildly-Stenosed Coronary Lesions. Still An Open Discussion” by Evora et al.1 with great interest, recently published in Arquivos Brasileiros de Cardiologia. The investigators reported that the idea of a prophylactic left internal mammary artery (LIMA) on left anterior descending in mild-stenosed vessels is not confirmed yet by clinical evidence.

Berger at al. reported that all moderate coronary lesions should be LIMA grafted during primary coronary bypass surgery.

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Original Article

Potential Utility of the SYNTAX Score 2 in Patients Undergoing Left Main Angioplasty

Sérgio Madeira et al. Luís Raposo João Brito Ricardo Rodrigues … Pedro Gonçalves Rui Teles Henrique Gabriel Francisco Machado Manuel Almeida Miguel Mendes

Abstract

Background:

The revascularization strategy of the left main disease is determinant for clinical outcomes.

Objective:

We sought to 1) validate and compare the performance of the SYNTAX Score 1 and 2 for predicting major cardiovascular events at 4 years in patients who underwent unprotected left main angioplasty and 2) evaluate the long-term outcome according to the SYNTAX score 2-recommended revascularization strategy.

Methods:

We retrospectively studied 132 patients from a single-centre registry who underwent unprotected left main angioplasty between March 1999 and December 2010. Discrimination and calibration of both models were assessed by ROC curve analysis, calibration curves and the Hosmer-Lemeshow test.

Results:

Total event rate was 26.5% at 4 years.The AUC for the SYNTAX Score 1 and SYNTAX Score 2 for percutaneous coronary intervention, was 0.61 (95% CI: 0.49-0.73) and 0.67 (95% CI: 0.57-0.78), respectively. Despite a good overall adjustment for both models, the SYNTAX Score 2 tended to underpredict risk. In the 47 patients (36%) who should have undergone surgery according to the SYNTAX Score 2, event rate was numerically higher (30% vs. 25%; p=0.54), and for those with a higher difference between the two SYNTAX Score 2 scores (Percutaneous coronary intervention vs. Coronary artery by-pass graft risk estimation greater than 5.7%), event rate was almost double (40% vs. 22%; p=0.2).

Conclusion:

The SYNTAX Score 2 may allow a better and individualized risk stratification of patients who need revascularization of an unprotected left main coronary artery. Prospective studies are needed for further validation.

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Original Article

Investigation Route of the Coronary Patient in the Public Health System in Curitiba, São Paulo and in Incor – IMPACT Study

Juliano J. Cerci et al. Evelinda Trindade Daniel Preto Rodrigo Julio Cerci … Pedro A. Lemos Luiz Antonio Machado Cesar Luís Preto Luiz Stinghen Cátia Martinez José Claudio Meneghetti

Background:

The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization.

Objective:

To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP.

Methods:

Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies.

Results:

There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure.

Conclusion:

Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

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