David Glineur

Three Arterial Grafts Improve Late Survival: A Meta-Analysis of Propensity Matched Studies

Background: Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed. Methods: A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals. Results: Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71–1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75–0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33–0.98; P=0.04). Conclusions: The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status.

Eight-year follow-up of the Clopidogrel After Surgery for Coronary Artery Disease (CASCADE) trial

Objective In this 8 years’ follow‐up study, we evaluated the long‐term outcomes of the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting, versus aspirin plus placebo, with respect to survival, major adverse cardiac, or major cerebrovascular events, including revascularization, functional status, graft patency, and native coronary artery disease progression. Methods In the initial Clopidogrel After Surgery for Coronary Artery Disease trial, 113 patients were randomized to receive either daily clopidogrel (n = 56) or placebo (n = 57), in addition to aspirin, in a double‐blind fashion for 1 year after coronary artery bypass grafting. All patients were re‐evaluated to collect long‐term clinical data. Surviving patients with a glomerular filtration rate > 30 mL/min were asked to undergo a coronary computed tomography angiogram to evaluate the late saphenous vein graft patency and native coronary artery disease progression. Results At a median follow‐up of 7.6 years, survival rate was 85.5% ± 3.8% (P = .23 between the 2 groups). A trend toward enhanced freedom from all‐cause death or major adverse cardiac or cerebrovascular events, including revascularization, was observed in the aspirin‐clopidogrel group (P = .11). No difference in functional status or freedom from angina was observed between the 2 groups (P > .57). The long‐term patency of saphenous vein graft was 89.11% in the aspirin‐clopidogrel group versus 91.23% in the aspirin‐placebo group (P = .79). A lower incidence of moderate to severe native disease progression was observed in the aspirin‐clopidogrel group versus the aspirin‐placebo group (7 out of 122 vs 13 out of 78 coronary segments that showed progression, respectively [odds ratio, 0.3 ± 0.2; 95% confidence interval, 0.1‐0.8; P = .02]). Conclusions At 8 years’ follow‐up, the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting exhibited a lower incidence of moderate to severe progression of native coronary artery disease and a trend toward higher freedom from major adverse cardiac or cerebrovascular events, including revascularization, or death in the aspirin‐clopidogrel group. Clinical Trial Registration http://www.clinicaltrials.gov. Unique identifier: NCT00228423.

Robotic mitral valve repair: a European single-centre experience

OBJECTIVES We report the outcomes of robotic valve repair for degenerative mitral regurgitation (MR) in our Institution. METHODS Between February 2012 and July 2016, 134 patients underwent robotic mitral valve (MV) repair with the da Vinci Si system. All the operations were performed through a mini-thoracotomy in the fourth right intercostal space, cardiopulmonary bypass and mild hypothermia. The clinical and echocardiographic follow-up was 100% complete. RESULTS There was no hospital death. The mean cross-clamp and cardiopulmonary bypass time were 112±23 and 159±33 min, respectively. Pre-discharge echocardiograms showed none-to-mild residual MR in all patients. Median follow-up was 24.1 months. We observed 1 early and 4 late reoperations on the MV for an overall freedom from reoperation of 98.2% and 94.1% at 12 and 36 months, respectively. Furthermore, echocardiographic follow-up revealed freedom from recurrence of MR greater than Grade 1+ of 92.5% and 80.7% at 12 and 36 months, respectively. Nevertheless freedom from recurrence of MR greater than Grade 2+ was 97.2% at 12 and 36 months. CONCLUSIONS Robotic MV repair is a feasible and safe option for the treatment of degenerative MR in selected patients with excellent perioperative outcomes. Early and midterm results are remarkable and are associated with low risk of late recurrence of MR and reoperation. Long-term follow-up is needed to confirm the durability of valve repair.

The balance between short-term and long-term outcomes of bilateral internal thoracic artery skeletonization in coronary artery bypass surgery: a propensity-matched cohort study†

OBJECTIVES There is growing interest in the use of bilateral internal thoracic arteries (BITAs) for myocardial revascularization. This study sought to compare the balance between early benefits and long-term outcomes of skeletonized or non-skeletonized conduits and to determine whether differences in outcomes are affected by other patient risk factors. METHODS BITAs were used in 1504 cases with either SK or NSK conduits. Propensity matching was completed using 22 covariates identifying 441 pairs of patients. The primary outcomes are the sternal wound infection in the short term and the composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure. Outcomes were assessed using paired analysis techniques and Cox proportional hazards regression models stratified using the matched pairs. RESULTS Incidences of in-hospital mortality and perioperative myocardial infarction were similar in both groups. There were fewer sternal wound infections in the SK group (5.4 vs 9.1%, P = 0.033). Homogeneity testing of the relative risk estimates confirmed that there was a protective effect of skeletonization in men that was not demonstrated in women (P = 0.020). SK had a protective effect in diabetics not seen in non-diabetics (P = 0.048). The composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure at a median of 5.6 years was comparable in both groups (hazard ratio 0.81, 95% confidence interval 0.57-1.15). CONCLUSION Skeletonization results in better perioperative outcomes and comparable cardiac outcomes in patients undergoing BITA with the greatest benefit in men and patients with chronic obstructive pulmonary disease.

Implications of coronary artery bypass grafting and percutaneous coronary intervention on disease progression and the resulting changes to the physiology and pathology of the native coronary arteries

Myocardial revascularization can be achieved through 2 different methods: coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Clinical trials comparing PCI and CABG generally use the composite end points of death, stroke, myocardial infarction and target vessel revascularization to determine superiority. Other effects of these interventions, including the preservation of normal coronary physiology, the response of the coronary tree to stressors and the response of the vessel wall to the revascularization intervention, are not routinely considered, but these may have significant implications for patients in the medium and long term. For PCI, relatively small differences in clinical outcomes have been reported between bare metal and drug-eluting stents, and the latter seems to have inconsistent and somewhat unpredictable effects on the vascular biology of the coronary arteries. In coronary bypass, the use of arterial conduits is associated with superior clinical outcomes, better long-term patency and the preservation of essentially normal coronary function after intervention. This review assembles the clinical, physiological, angiographic and pathological literature currently available and attempts to provide a more complete picture of the effects of CABG and PCI on coronary arteries.