Gijong Yi

Effects of partial thrombosis on distal aorta after repair of acute DeBakey type I aortic dissection

OBJECTIVE Prognostic implications of partial thrombosis of the residual aorta after repair of acute DeBakey type I aortic dissection have not been elucidated. We sought to analyze the impact of partial thrombosis on segmental growth rates, distal aortic reprocedures, and long-term survival. METHODS A total of 118 consecutive patients (55% were male; mean age, 60 years) with acute DeBakey type I aortic dissection underwent surgical repair (1997-2007). The hospital mortality rate was 17.8%. Survivors underwent serial computed tomography scans. Segment-specific average rates of enlargement were analyzed. Distal reprocedures and patient survival were examined. RESULTS Sixty-six patients had imaging data sufficient for growth rate calculations. The median diameters within 2 weeks after repair were as follows: aortic arch, 3.5 cm; descending aorta, 3.6 cm; and abdominal aorta, 2.4 cm. Subsequent growth rates were artic arch, 0.34 mm/y, descending aorta, 0.51 mm/y, and abdominal aorta, 0.35 mm/y. Partial thrombosis of the residual aorta predicted greater growth in the distal aorta (P = .005). There were 13 distal aortic reprocedures (5 reoperations, 8 stent graft insertions) for 10 years, and reprocedure-free survival was 66%. Partial thrombosis (P = .002) predicted greater risk of aorta-related reprocedures. Cox analysis revealed that estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) (P = .030), reintubation (P = .002), and partial thrombosis (P = .023) were independent predictors for poor survival. CONCLUSION Partial thrombosis of the false lumen after repair of acute DeBakey type I aortic dissection, compared with complete patency or complete thrombosis, is a significant independent predictor of aortic enlargement, aorta-related reprocedures, and poor long-term survival.

The Radial Artery: Current Concepts on Its Use in Coronary Artery Revascularization

The radial artery (RA) can be used as part of an arterial revascularization strategy in coronary artery bypass grafting (CABG). It is easy to harvest and several randomized controlled trials and meta-analyses have reported superior long-term patency over saphenous vein grafts. However, the RA is not used as frequently as the saphenous vein and questions remain regarding its optimum use as a conduit. This article comprehensively appraises current evidence surrounding outcomes, patient selection, harvesting technique, intraoperative strategy, and graft spasm prophylaxis to provide a contemporary review of the use of the RA as a conduit in CABG.

Comparison of Off-pump Coronary Artery Bypass Grafting With Percutaneous Coronary Intervention Versus Drug-Eluting Stents for Three-Vessel Coronary Artery Disease

BACKGROUND Drug-eluting stents (DESs) have challenged coronary bypass grafting as the gold standard for 3-vessel coronary artery disease. This study compared the clinical results between percutaneous intervention with DESs vs off-pump coronary bypass surgery (OPCAB). METHODS The study included 388 matched patients with 3-vessel coronary artery diseases who were treated either with DESs or OPCAB. We compared 30-day, 12-month, and cumulative major adverse cardiac and cerebrovascular events (MACCE) during the follow-up. RESULTS The overall follow-up was 98.5%. Follow-up duration was 621.1 +/- 259.9 days (range, 13 to 1117 days). The rates of MAACE in the DES and OPCAB group were, respectively, 1.5% at 30 days (p = 0.315) and 9.8% and 3.6% at 12 months (p = 0.015). During follow-up, five deaths occurred in the DES group and one in OPCAB group (p = 0.1). Three-year survival rate was 95.1% +/- 2.9% in DES group and 99.5% +/- 0.5% in OPCAB group (p = 0.075). Survival free from MACCE at 3 years was 73.3% +/- 5.3% in DES group and 91.3% +/- 2.9% in OPCAB group (p < 0.001). The major event for the differences between the groups was target vessel revascularization (p < 0.001): 21 DES patients (10.8%) vs 6 OPCAB patients (3.1%). CONCLUSIONS OPCAB showed better clinical outcome in 12-month and cumulative MACCE rate in 3-vessel coronary artery diseases. The major factor for the difference was target vessel revascularization. Longer follow-up is needed to clarify the differences between the two groups.

Comparison of Long-Term Outcome of Off-Pump Coronary Artery Bypass Grafting Versus Drug-Eluting Stents in Triple-Vessel Coronary Artery Disease

After the introduction of drug-eluting stents (DESs), percutaneous coronary intervention with DESs has challenged coronary artery bypass grafting as the gold standard for the treatment of 3-vessel coronary artery disease. The purpose of this study was to compare the long-term clinical results between percutaneous coronary intervention with DESs and off-pump coronary artery bypass grafting (OPCAB) in 3-vessel coronary artery disease. Two hundred ninety propensity-score matched patients with 3-vessel coronary artery disease treated by DESs or OPCAB were included. Mean follow-up duration was 58.8 ± 11.5 months (2 to 73) and follow-up rate was 97.9%. Five-year survival rates were 94.8 ± 2.1% in the DES group and 96.5 ± 1.5% in the OPCAB group (p = 0.658). Five-year rates of freedom from major adverse cardiac and cerebrovascular event were 71.6 ± 4.1% in the DES group and 89.6 ± 2.5% in the OPCAB group (p < 0.001). Freedom from nonfatal myocardial infarction and target vessel revascularization rates were the determining factors between the 2 groups (p = 0.018 and p < 0.001, respectively). The OPCAB group showed better clinical outcomes compared to the DES group in 3-vessel coronary artery disease after 5-year follow-up. Freedom from major adverse cardiac and cerebrovascular event rate was significantly higher in the OPCAB group mainly because of the lower incidence of target vessel revascularization and nonfatal myocardial infarction. Longer follow-up with randomization will clarify our present conclusions.

Midterm Outcome of Off-Pump Bypass Procedures Versus Drug-Eluting Stent for Unprotected Left Main Coronary Artery Disease

BACKGROUND Although surgical revascularization is recommended for the treatment of left main coronary artery (LMCA) disease, percutaneous coronary intervention (PCI) attempts have increased, especially after the introduction of the drug-eluting stent. The goal of this study was to compare the midterm outcomes between drug-eluting stenting and off-pump coronary artery bypass (OPCAB) grafting in LMCA disease. METHODS Five hundred twelve consecutive patients with unprotected LMCA disease who underwent OPCAB (N = 269) or drug-eluting stenting (N = 243) were enrolled. We compared major cardiac and cerebrovascular events (MACCEs) in a real-world cohort and in a matching patient cohort (N = 256). The duration of mean follow-up was 38 ± 20 months, and the follow-up rate was 97.7%. RESULTS In a real-world comparison, the OPCAB group showed better 5-year freedom from MACCEs compared with the stenting group (71.5% ± 4.4% versus 67.6% ± 4.0%; p = 0.031), despite worse patient characteristics. After patient matching, the OPCAB group showed more distinct benefit in 5-year freedom from MACCEs (75.3% ± 6.6% versus 62.8% ± 5.4; p < 0.001), including a significantly lower target vessel revascularization (TVR) rate (p < 0.001). In a subgroup analysis, the benefit of OPCAB regarding 5-year freedom from MACCEs was more clearly defined for lesions of the distal LCMA and in LMCA lesions with multivessel disease (p = 0.015, p = 0.004, respectively). CONCLUSIONS Patients with LMCA disease who were treated with OPCAB showed better 5-year freedom from MACCEs in a real-world practice and in a patient matching cohort compared with the drug-eluting stenting group. TVR was the main factor that made the difference. The benefit of OPCAB was more prominent in distal LMCA lesions and in LMCA lesions with multivessel involvement.

Stent Versus Off-Pump Coronary Bypass Grafting in the Second-Generation Drug-Eluting Stent Era

BACKGROUND Second-generation drug-eluting stents (DESs) are known to have better safety and clinical outcomes compared with the first-generation DESs. We compared the clinical results of off-pump coronary artery bypass grafting (OPCAB) with percutaneous coronary intervention (PCI) using second-generation DESs. METHODS The study enrolled 1,821 patients with triple-vessel or left main coronary disease, or both, who underwent OPCAB or PCI with second-generation DESs from 2008 to 2011. Major adverse cardiac and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and target vessel revascularization, were retrospectively compared between the two groups in a real-world and in a matched population (n = 1,294). Follow-up duration was 23.0 ± 13.0 months (range, 0 to 56 months). RESULTS The postprocedural mortality rate was comparable between the two groups (p = 0.384). The overall rate of MAACEs was 7.3% in the PCI group and 3.8% in the OPCAB group (p = 0.001). The 3-year rate of freedom from MACCEs was 88.4% ± 1.5% in the PCI group and 94.9% ± 1.0% in the OPCAB group (p < 0.001). In a matched population comparison, the 3-year rate of freedom from a MACCE was 87.5% ± 2.0% in the PCI group and 95.3% ± 1.2% in the OPCAB group (p = 0.001). The determining factors were nonfatal myocardial infarction and target vessel revascularization. The OPCAB group showed a superior rate of freedom from MACCEs in the triple-vessel (p = 0.008) and left main subset analysis (p = 0.001). CONCLUSIONS The OPCAB showed superior outcomes in triple-vessel or left main disease, or both, compared with PCI in the second-generation DES era after 23 months of follow-up. Nonfatal myocardial infarction and target vessel revascularization were the determining factors. Longer follow-up with randomization will clarify our results.

The effect of milrinone on the right ventriclular function in patients with reduced right ventricular function undergoing off-pump coronary artery bypass graft surgery

This investigation evaluated the effect of continuous milrinone infusion on right ventriclular (RV) function during off-pump coronary artery bypass graft (OPCAB) surgery in patients with reduced RV function. Fifty patients scheduled for OPCAB, with thermodilution RV ejection fraction (RVEF) <35% after anesthesia induction, were randomly allocated to either milrinone (0.5 µg/kg/min) or control (saline) group. Hemodynamic variables and RV volumetric data measured by thermodilution method were collected as follows: after anesthesia induction (T1); 10 min after heart displacement for obtuse marginal artery anastomosis (T2); after pericardial closure (T3). Cardiac index and heart rate increased and systemic vascular resistance significantly decreased in milrinone group at T2. Initially lower RVEF of milrinone group was eventually comparable to control group after milrinone infusion. RVEF did not significantly change at T2 and T3 in both groups. RV end-diastolic volume in milrinone group consistently decreased from the baseline at T2 and T3. Continuous infusion of milrinone without a bolus demonstrated potentially beneficial effect on cardiac output and RV afterload in patients with reduced RV function during OPCAB. However, aggressive augmentation of intravascular volume seems to be necessary to maximize the effect of the milrinone in these patients.

Open Pulmonary Thromboembolectomy in Patients with Major Pulmonary Thromboembolism

Purpose We retrospectively analyzed open pulmonary thromboembolectomy in patients with acute and chronic pulmonary thromboembolism. Materials and Methods Between August 1990 and May 2005, 12 consecutive patients with acute and chronic pulmonary thromboembolism underwent open pulmonary thromboembolectomy at Yonsei Cardiovascular Center. Their mean age was 47.5 years, and 7 of the patients were female. Among 12 patients, 5 had acute onset, and 7 had chronic disease, and 9 patients were associated with deep venous thrombosis. Extent of pulmonary embolism was massive in 3 patients with hemodynamic instability, and submassive in 8 patients. Preoperative echocardiogram revealed elevated right ventricular pressure in all patients, and 7 patients were in NYHA functional class III or IV. Pulmonary thromboembolectomy was performed in all patients under total circulatory arrest. Results There were 2 hospital deaths (16.7%). Among the patients who survived, mean right ventricular pressure was decreased significantly from 64.3 mmHg to 34.0 mmHg with improvement of NYHA functional class. Conclusion Open pulmonary thromboembolectomy is thought to be an immediate and definitive treatment for massive pulmonary embolism with optimal results. Even though operative mortality is still high, early diagnosis and immediate surgical intervention in highly selective patients may improve the clinical outcome.

Off-Pump Right Coronary Artery Bypass With Saphaneous Vein or In-Situ Right Internal Thoracic Artery

BACKGROUND The ideal conduit for the right coronary artery (RCA) is yet to be determined. The purpose of this study was to compare the clinical results between the right internal thoracic artery (RITA) in situ with free saphenous vein (SV) graft for RCA in off-pump coronary artery bypass graft surgery (OPCABG). METHODS Three hundred and fifty-eight patients who underwent isolated OPCABG with RCA anastomosis either by RITA in situ (n = 199) or free SV graft (n = 159) were included. We evaluated the graft patency and the incidence of RCA reintervention considering the degree of native RCA stenosis. The follow-up rate was 97.8%, and the mean follow-up duration was 57.6 months. RESULTS The overall mortality and the incidence of major cardiac and cerebrovascular event showed no difference between the two groups (p = 0.495 and p = 0.338, respectively). The 5-year freedom from graft occlusion rate was 87.4% +/- 3.2% in the RITA group and 94.3% +/- 2.0% in the SV group (p = 0.011), with a statistically significant difference only in the moderate stenosis (< 75%) group (p = 0.020). The 5-year freedom from RCA reintervention rate was 95.7% +/- 1.6% in the RITA group and 99.3% +/- 0.7% in the SV group (p = 0.055). CONCLUSIONS Both RITA and SV showed favorable graft patency for the RCA system in OPCABG. The SV graft showed better patency in patients with moderate stenosis of RCA compared with RITA in situ. A longer follow-up period is necessary to clarify our current results.

Association of incomplete revascularization with long-term survival after off-pump coronary artery bypass grafting.

BACKGROUND We evaluated the effect of incomplete revascularization (IR) on the long-term outcomes after off-pump coronary artery bypass grafting. MATERIALS AND METHODS Of 1553 patients with triple-vessel disease who had undergone consecutive off-pump coronary artery bypass grafting, 1351 (87.0%) had complete revascularization (CR) and 202 had IR (13.0%). After propensity score patient matching, we had 200 patients in each group. Cardiac survival and major adverse cardiac and cerebrovascular events (MACCE) were assessed before and after patient matching. Subgroup analysis was performed to evaluate the interaction between the left ventricular ejection fraction (LVEF) and the completeness of revascularization. The follow-up duration was 60 mo. RESULTS In the all-patient analysis, the CR group had a lower incidence of in-hospital mortality, cardiac mortality, and MACCE (P = 0.033, P < 0.001, and P = 0.003, respectively). The 5-year cardiac survival was 96.5% ± 0.6% in the CR group and 88.9% ± 2.5% in the IR group (P < 0.001), with a freedom from MACCE rate of 85.4% ± 1.2% and 78.8% ± 3.4%, respectively (P = 0.015). After patient matching, the CR group showed superior 5-year cardiac survival compared with the IR group (96.2% ± 1.4% versus 88.8% ± 2.5%, P = 0.022), with a similar freedom from MACCE rate. IR was identified as an independent predictor of cardiac death (hazard ratio 2.76, 95% confidence interval 1.62-4.70; P < 0.001). IR predicted cardiac death more distinctly in patients with a low LVEF (hazard ratio 5.29, 95% confidence interval 1.71-16.39; P = 0.004) than in those with a preserved LVEF (hazard ratio 2.04, 95% confidence interval 1.02-4.08; P = 0.045). CONCLUSIONS CR in off-pump coronary artery bypass grafting was related to superior cardiac survival after 5 years of follow-up compared with IR. The benefit of CR was more distinct in those with a low LVEF. CR should be achieved whenever possible, especially in patients with a low LVEF.