Suk-Jung Choo

Long-Term Outcomes After Stenting Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Disease: 10-Year Results of Bare-Metal Stents and 5-Year Results of Drug-Eluting Stents From the ASAN–MAIN (ASAN Medical Center–Left MAIN Revascularization) Registry

OBJECTIVESnThis study sought to evaluate the long-term safety and effectiveness of percutaneous coronary intervention (PCI), as compared with coronary artery bypass grafting (CABG), for unprotected left main coronary artery (LMCA) disease.nnnBACKGROUNDnData on the long-term (beyond 5-year) comparative results of treatment of unprotected LMCA disease with stent implantation or CABG are limited.nnnMETHODSnWe performed a 10-year clinical follow-up of 350 patients with unprotected LMCA disease who underwent PCI with bare-metal stents (BMS) (n = 100) or CABG (n = 250) from January 1995 to April 1999, and 5-year clinical follow-up of 395 patients with unprotected LMCA disease who underwent PCI with drug-eluting stents (DES) (n = 176) or CABG (n = 219) from January 2003 to May 2004. The primary safety end points were all-cause mortality and the composite of death, Q-wave myocardial infarction (MI), or stroke, and the primary efficacy end point was target vessel revascularization (TVR).nnnRESULTSnIn the 10-year follow-up cohort of BMS and concurrent CABG, the adjusted risks of death (hazard ratio [HR]: 0.81; 95% confidence interval [CI]: 0.44 to 1.50; p = 0.50) and the composite of death, Q-wave MI, or stroke (HR: 0.92; 95% CI: 0.55 to 1.53; p = 0.74) were similar between the 2 groups. The rate of TVR was significantly higher in the group that received BMS (HR: 10.34; 95% CI: 4.61 to 23.18; p < 0.001). In the 5-year follow-up cohort of DES and concurrent CABG, there was no significant difference in the adjusted risk of death (HR: 0.83; 95% CI: 0.34 to 2.07; p = 0.70) or the risk of the composite outcome (HR: 0.91; 95% CI: 0.45 to 1.83; p = 0.79). The rates of TVR were also higher in the DES group than the CABG group (HR: 6.22; 95% CI: 2.26 to 17.14; p < 0.001).nnnCONCLUSIONSnFor the treatment of unprotected LMCA disease, PCI with stent implantation showed similar long-term mortality and rates of death, Q-wave MI, or stroke. However, stenting, even with DES, was associated with higher rates of repeat revascularization than was CABG.

Long-Term Comparison of Drug-Eluting Stents and Coronary Artery Bypass Grafting for Multivessel Coronary Revascularization 5-Year Outcomes From the Asan Medical Center- Multivessel Revascularization Registry

OBJECTIVESnWe performed the long-term (5-year) follow-up of a large cohort of patients who underwent drug-eluting stent (DES) or coronary artery bypass graft (CABG) surgery for multivessel revascularization.nnnBACKGROUNDnLimited information is available on very long-term outcomes after multivessel DES treatment relative to CABG.nnnMETHODSnWe evaluated 3,042 patients with multivessel disease who received DES (n = 1,547) or underwent CABG (n = 1,495) between January 2003 and December 2005, and for whom complete follow-up data were available for a median 5.6 years (interquartile range: 4.6 to 6.3 years). We compared adverse outcomes (death; a composite outcome of death, myocardial infarction, or stroke; and repeat revascularization).nnnRESULTSnAfter adjustment for differences in baseline risk factors, 5-year risk of death (hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.76 to 1.32, p = 0.99) and the combined risk of death, myocardial infarction, or stroke (HR: 0.97; 95% CI: 0.76 to 1.24, p = 0.81) were similar between the DES group and the CABG group. However, the rates of revascularization were significantly higher in the DES group (HR: 2.93; 95% CI: 2.20 to 3.90, p < 0.001). Similar results were obtained in comparisons of DES with CABG for high-risk clinical and anatomic subgroups with diabetes mellitus, abnormal ventricular function, age 65 years or more, and 3-vessel and left main disease. However, mortality benefit with DES implantation relative to CABG was noted in patients with 2-vessel disease (HR: 0.57; 95% CI: 0.36 to 0.92, p = 0.02).nnnCONCLUSIONSnFor patients with multivessel disease, DES treatment, compared with CABG, showed similar rates of mortality and of the composite safety outcomes, but higher rates of revascularization up to 5 years.

Stroke Risk After Coronary Artery Bypass Graft Surgery and Extent of Cerebral Artery Atherosclerosis

OBJECTIVESnWe aimed to define the relationship between cerebral atherosclerosis and stroke after coronary artery bypass grafting (CABG).nnnBACKGROUNDnAlthough cerebral atherosclerosis may play a crucial role in the advent of post-CABG stroke, only extracranial carotid artery disease has been extensively studied, and the effects of atherosclerosis on the mechanisms underlying post-CABG stroke remain unclear.nnnMETHODSnPre-operative magnetic resonance angiography was performed on 1,367 consecutive CABG patients to assess intracranial and extracranial cerebral atherosclerosis. Disease severity was evaluated by atherosclerosis score, as determined by the number of steno-occlusions of cerebral arteries and the degree thereof. Post-CABG strokes (within 14 days) were classified as atherosclerotic (strokes attributable to pre-defined atherosclerosis) or other (strokes caused by other mechanisms). Associations between post-CABG stroke and each type of atherosclerotic disease (extracranial carotid artery disease, intracranial, extracranial, or extracranial and/or intracranial cerebral atherosclerosis), differentiated according to the involved arteries, were analyzed.nnnRESULTSnStroke occurred in 33 patients, and the atherosclerosis score was independently associated with stroke development (odds ratio: 1.35; 95% confidence interval: 1.16 to 1.56). Atherosclerotic stroke was defined in 15 (45%), and constituted >40% of both immediate (within 24 h) and delayed strokes. Intracranial, extracranial, and extracranial and/or intracranial cerebral atherosclerosis were significantly associated with stroke.nnnCONCLUSIONSnCerebral atherosclerosis was closely related to the occurrence of post-CABG stroke, being both an independent risk factor for and the cause of a significant proportion of strokes. Pre-operative evaluation of intracranial and extracranial cerebral arteries, apart from the extracranial carotid artery, may be useful to predict the likelihood of post-CABG stroke.

New Cerebral Lesions on T2*-Weighted Gradient-Echo Imaging after Cardiac Valve Surgery

Background: It is well known that silent ischemic brain lesions on diffusion-weighted imaging (DWI) commonly occur after various interventional procedures or surgeries. However, to our knowledge, postoperative new lesions on T2*-weighted gradient-echo imaging (GRE) have never been explored. Methods: This prospective observational study enrolled 19 consecutive patients undergoing cardiac valve surgery. Preoperative and postoperative (within 7 days) GRE and DWI were performed. New GRE lesions were defined as signal loss lesions on postoperative GRE which were not observed on preoperative GRE. Long-term follow-up GRE was performed in a limited number of cases. Results: Twelve patients developed 26 small (<10 mm) new GRE lesions. Of these patients, 1 had a generalized seizure accompanied by confusion and facial weakness with DWI lesions, and 1 showed confusion of short duration without DWI lesions. Long-term follow-up GRE was performed 3 years after surgery in 4 patients. Of the 12 new GRE lesions in these 4 patients, 11 lesions were still observable on long-term follow-up GRE. Conclusions: New cerebral lesions on GRE after cardiac valve surgery are common and are presumed to be rapidly developed microbleeds and mostly asymptomatic. Further studies are needed to investigate the precise nature and clinical implications of new GRE lesions.

Effect of Exogenous Albumin on the Incidence of Postoperative Acute Kidney Injury in Patients Undergoing Off-pump Coronary Artery Bypass Surgery with a Preoperative Albumin Level of Less Than 4.0 g/dl.

Background:Hypoalbuminemia may increase the risk of acute kidney injury (AKI). The authors investigated whether the immediate preoperative administration of 20% albumin solution affects the incidence of AKI after off-pump coronary artery bypass surgery. Methods:In this prospective, single-center, randomized, parallel-arm double-blind trial, 220 patients with preoperative serum albumin levels less than 4.0 g/dl were administered 100, 200, or 300 ml of 20% human albumin according to the preoperative serum albumin level (3.5 to 3.9, 3.0 to 3.4, or less than 3.0 g/dl, respectively) or with an equal volume of saline before surgery. The primary outcome measure was AKI incidence after surgery. Postoperative AKI was defined by maximal AKI Network criteria based on creatinine changes. Results:Patient characteristics and perioperative data except urine output during surgery were similar between the two groups studied, the albumin group and the control group. Urine output (median [interquartile range]) during surgery was higher in the albumin group (550 ml [315 to 980]) than in the control group (370 ml [230 to 670]; P = 0.006). The incidence of postoperative AKI in the albumin group was lower than that in the control group (14 [13.7%] vs. 26 [25.7%]; P = 0.048). There were no significant between-group differences in severe AKI, including renal replacement therapy, 30-day mortality, and other clinical outcomes. There were no significant adverse events. Conclusion:Administration of 20% exogenous albumin immediately before surgery increases urine output during surgery and reduces the risk of AKI after off-pump coronary artery bypass surgery in patients with a preoperative serum albumin level of less than 4.0 g/dl.

Postoperative Hypoalbuminemia Is Associated With Outcome in Patients Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

OBJECTIVEnThe authors aimed to investigate whether immediate postoperative hypoalbuminemia could be associated with outcomes after off-pump coronary artery bypass graft (OPCAB) surgery.nnnDESIGNnA retrospective analysis of the medical data.nnnSETTINGnCardiac operating room and adult cardiovascular intensive care unit at a single institution.nnnPARTICIPANTSnSix hundred ninety adult patients underwent elective OPCAB surgery over a 30-month period.nnnINTERVENTIONSnNone.nnnMEASUREMENTS AND MAIN RESULTSnTo evaluate the clinical relevance of immediate postoperative hypoalbuminemia, the lowest serum albumin level measured over the first 12 hours postoperatively was recorded. A cutoff point was calculated by the area under the curve in the receiver operating characteristic plot for 30-day adverse events including death. Patients were classified according to the cutoff value, and outcomes were compared between groups using propensity score-matching analysis. The impact of immediate postoperative hypoalbuminemia on OPCAB outcome was investigated using multivariate analysis. The cutoff value for immediate postoperative albumin concentration for predicting 30-day adverse events was 2.3 g/dL. Immediate postoperative hypoalbuminemia (<2.3 g/dL) was associated independently with postoperative respiratory failure (odds ratio [OR] = 8.85, p = 0.04), wound infection (OR = 4.44, p = 0.04), the need for an intra-aortic balloon pump after the operation (OR = 13.7, p = 0.02), renal failure (OR = 7.98, p = 0.01), reoperation for bleeding (OR = 4.33, p = 0.05), and the need for inotropes in the intensive care unit (OR = 1.79, p = 0.02).nnnCONCLUSIONSnImmediate postoperative hypoalbuminemia was associated with poorer outcomes in OPCAB patients. Monitoring of albumin levels after OPCAB could identify patients at risk for short-term adverse events.

Management of concomitant mild to moderate functional mitral regurgitation during aortic valve surgery for severe aortic insufficiency.

OBJECTIVESnThe optimal management of mild to moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) for severe aortic insufficiency (AI) is poorly defined. We aimed to investigate the fate of FMR after AVR with or without concomitant mitral annuloplasty (MAP) and to identify the risk factors and clinical implications of persistent FMR.nnnMETHODSnBetween June 1996 and August 2011, 155 patients with mild to moderate FMR undergoing AVR for severe AI were reviewed. The preoperative MR grade was mild in 101 patients (65%) and moderate in 54xa0patients (35%). Persistent FMR was defined as MR grade remaining the same or increased on the last follow-up echocardiogram.nnnRESULTSnThe mean follow-up duration was 4.5 ± 3.9 years. FMR improved in 88% of the patients. Onxa0multivariate analysis, left ventricular end-diastolic dimension (LVEDD) reduction after AVR was identified as the only predictor for FMR improvement (Pxa0=xa0.004; hazard ratio, 0.927; confidence interval, 0.881 to 0.977). Concomitant MAP did not show additional benefit in preventing persistent FMR (Pxa0=xa0.35). Although no survival difference was observed between the patients with and without persistent FMR (Pxa0=xa0.78), persistent FMR was associated with greater heart failure events (Pxa0<xa0.001).nnnCONCLUSIONSnMild to moderate FMR as a result of severe AI improved with AVR in most patients with or withoutxa0concomitant MAP. Poor postoperative LVEDD reduction was the only risk factor for persistent FMR.xa0Becausexa0persistent FMR tended to be associated with heart failure events, close echocardiographic monitoringxa0and proactive medical management are recommended in patients showing poor LVEDD reduction after AVR.

Refractory Coronary Artery Spasm after Minimally Invasive Direct Coronary Artery Bypass Grafting

Postoperative coronary arterial spasm is a rare but potentially fatal complication. A 51-year-old male patient with a history of a reactive ergonovine stress test coronary angiogram developed refractory coronary artery spasm after undergoing minimally invasive direct coronary artery bypass grafting of the left anterior descending coronary artery. The patient was successfully managed with rapid implementation of intra-aortic balloon-pump counter pulsation and extracorporeal membrane oxygenation.