YunQing Shi

Prophylactic Application of an Intra-Aortic Balloon Pump in High-Risk Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Background: An intra-aortic balloon pump (IABP) is the most commonly used circulatory assist device in cardiac surgery. We hypothesized that prophylactic application of an IABP improves early clinical outcome of high-risk patients undergoing scheduled off-pump coronary artery bypass grafting (OPCABG). Methods: From January 2010 to December 2013, hemodynamically stable, high-risk patients undergoing scheduled OPCABG with preincision use of an IABP were recruited to the IABP group. Using the propensity score-matching method, every patient in the IABP group was matched with another patient (the control group) with a similar propensity score who received an IABP on an as-needed basis during or after OPCABG. Surgical mortality and major morbidity rates were compared between groups. Results: A total of 116 patient pairs were included in this study. In patients in the IABP group, postoperative low cardiac output and respiratory as well as renal failure were less frequent, intensive care unit stay was shorter, and surgical mortality was lower compared to patients in the control group. In multivariate logistic regression, timing of IABP implantation, as an independent risk factor, was associated with postoperative low cardiac output (OR = 2.02, 95% CI 1.28-5.76), respiratory failure (OR = 1.86, 95% CI 1.19-4.27), renal failure (OR = 2.96, 95% CI 1.51-6.63) and surgical mortality (OR = 2.45, 95% CI 1.42-6.07). Conclusions: Prophylactic application of an IABP improves postoperative cardiac performance, reduces respiratory and renal complications, and consequently lowers surgical mortality in high-risk patients undergoing scheduled OPCABG.

Incidence of Deep Sternal Wound Infection in Diabetic Patients Undergoing Off-Pump Skeletonized Internal Thoracic Artery Grafting

Objectives: To evaluate the impact of skeletonized bilateral or single internal thoracic artery (ITA) grafting on the risk of deep sternal wound infection (DSWI) in diabetic patients undergoing off-pump coronary artery bypass grafting (OPCAB). Materials and Methods: A total of 803 diabetic patients undergoing OPCAB surgery from January 2010 to December 2014 were enrolled into this study and assigned to the pSITA group (patients undergoing pedicled single ITA grafting, n = 362), the sSITA group (skeletonized single ITA grafting, n = 295), or the sBITA group (skeletonized bilateral ITA grafting, n = 146). The primary end point was the diagnosis of a DSWI. Results: Eighteen patients developed postoperative DSWI, with an incidence of 2.2%. Patients in the sSITA group had a significantly lower incidence of DSWI than those in the pSITA group (1.0 vs. 3.6%, p = 0.0408). In multivariate logistic regression analysis, the risk of DSWI in the sSITA group was 0.41 times that in the pSITA group. Conclusions: sSITA grafting lowered the risk of DSWI in diabetic patients undergoing OPCAB surgery compared to pSITA grafting. Multicenter clinical trials involving larger sample sizes are needed to determine the merit of pSITA grafting in reducing the risk of DSWI following OPCAB surgery.

Secondhand Smoking and Matrix Metalloproteinase-2 and -9 Gene Expression in Saphenous Veins of Women Nonsmokers

BACKGROUND Active smoking upregulated matrix metalloproteinase-2 (MMP-2) and MMP-9 gene expression in saphenous veins (SVs) before coronary operation. However, little is known about the effects of secondhand smoke (SHS), a smoking status that is more widely harmful to the general population, on MMP gene expression in SVs. Health effects of SHS were investigated mainly in nonsmokers married to smokers. Because the vast majority of women are nonsmokers in China, we had an opportunity to evaluate the relations between SHS and MMP gene expression in SVs of women patients before operation. METHODS A total of 258 woman patients were divided into three groups: control group, nonsmokers; SHS group, patients exposed to SHS until operation; active smoking group, patients who smoked a minimum of 1 package of cigarettes every day for more than 20 years. Messenger RNA and protein levels of MMP-2 and MMP-9 were analyzed. Saphenous vein graft patency after coronary operation was evaluated. RESULTS The clinical backgrounds in the three groups were comparable. Compared with the control group, MMP-2 and MMP-9 gene expression was significantly increased in the SHS and active smoking groups (p<0.05). The degree of MMP gene expression changed by SHS or active smoking was comparable. A significant difference of SV graft patency was found among the three groups. An association of increased MMP gene expression with lowered SV graft patency was found in follow-up. CONCLUSIONS Our data revealed that SHS had similar power as active smoking to affect MMP gene expression in SVs before operation and SV graft patency after coronary operation in women nonsmokers.

Preoperative glucose level has different effects on the endogenous extracellular matrix-related gene expression in saphenous vein of type 2 diabetic patients undergoing coronary surgery

Background: Type 2 diabetes mellitus (DM) severely reduces the benefits of coronary artery bypass grafting (CABG). However, few studies investigated the correlation between preoperative glucose level and endogenous extracellular matrix (ECM)-related gene expression of saphenous vein (SV) conduits in diabetic patients. Methods: A total of 130 patients were divided into high-glucose (HG), low-glucose (LG) and control group according to the preoperative level of blood glucose. The expression of ECM-related genes was analysed by microarray. Results: Compared with control group, 30 genes showed at least a threefold change in expression in HG group; up-regulation was observed in 24 genes. However, there were only 21 ECM-related genes showed at least a threefold change in expression between the LG and control group. Compared with HG group, matrix metalloproteinases’ (MMPs) expression was significantly decreased in LG and control groups. In contrast to the decrease in MMPs’ expression, expression of tissue inhibitors of metalloproteinases (TIMPs) was increased. Conclusion: This study suggested that different preoperative diabetic status affected the expression of ECM-related genes in SV. ECM-related genes were more significantly imbalanced in diabetic patients with uncontrolled preoperative blood glucose than those with well-controlled preoperative blood glucose.

In Situ Skeletonized Right Internal Mammary Artery Bypass Grafting to Left Anterior Descending Artery: Feasibility, Mid-Term Efficacy, and Risk Factors for Graft Failure

This study aimed to evaluate the feasibility and the mid-term efficacy of an in situ skeletonized right internal mammary artery (IMA) bypass grafting to a left anterior descending artery (LAD), and to determine risk factors for IMA graft failure in a single-center study.From January 2012 to December 2015, 189 patients (173 males, 50.6 ± 6.0 years old) undergoing first isolated coronary artery bypass grafting surgery with the in situ skeletonized right IMA grafting to the LAD were included in this study. Baseline characteristics, peroperative data, and follow-up outcomes were investigated and analyzed.The length of the in situ skeletonized right IMA grafts was 18.6 ± 1.2 cm (17.0-22.0 cm). Intraoperative graft flow of the in situ skeletonized right IMA grafting to LAD was 42 ± 9 mL/minute (18-72 mL/minute) associated with measured pulsatility index of 0.8-4.3. In-hospital mortality was 0.5%. Postoperative morbidity included acute myocardial infarction (0.5%), stroke (0.5%), and deep sternal wound infections (1.1%). The mid-term survival was 97.2% and the incidence of repeat revascularization was 0.6%. The patency rate of the in situ skeletonized right IMA grafting to the LAD was 97.1% by computed tomography angiography examination during the follow-up period of 23.2 ± 9.7 months. Additionally, logistic regression analysis showed that intraoperative graft flow had an independent influence on the risk of the mid-term right IMA graft failure.The strategy of the in situ skeletonized right IMA grafting to the LAD is feasible and effective. Intraoperative graft flow was an independent risk factor for the mid-term right IMA graft failure.

Sequential Saphenous Vein Coronary Bypass Grafting: Does the Number of Distal Anastomoses per Single Vein Affect the Graft Patency?

The enormous majority of previous reports focused on evaluating the safety and efficacy of sequential saphenous vein (SV) coronary bypass grafting; however, no reports to date have revealed concern regarding the impacts of the number of distal anastomoses of sequential SV grafting on graft patency after coronary artery bypass grafting (CABG). This single-center retrospective study aimed to evaluate the impacts of three versus two distal anastomoses per single SV conduit on SV graft patency after off-pump CABG, and to determine the independent risk factors for sequential SV graft failure.From January 2011 to December 2014, 1320 eligible patients were assigned to either a triple group (three distal anastomoses of sequential SV grafting, n = 758) or a double group (two distal anastomoses of sequential SV grafting, n = 562). The primary endpoint was over a 2-year follow-up SV graft failure after off-pump CABG.The triple and double group received a similar total patency rate of sequential SV conduits (86.5% versus 87.1%, P = 0.757). The number of distal anastomoses of sequential SV grafting (three versus two) was not a predictive factor for the follow-up graft failure of sequential SV conduits (HR = 0.91, 95% CI: 0.66-2.29, P = 0.137). Moreover, the two groups received a similar follow-up survival freedom from repeat revascularization (χ2 = 1.881, log-rank P = 0.170).Three versus two distal anastomoses per single SV conduit received a similar SV graft patency. The number of distal anastomoses of sequential SV grafting was not an independent risk factor for graft failure.

Sequential Grafting of in Situ Skeletonized Left Internal Mammary Artery to the Left Coronary System: A Single-Center Retrospective Study

Sequential grafting may be an effective way to maximize the benefits of the left internal mammary artery (LIMA) conduit. Despite increasing clinical application, the strategy of sequential LIMA grafting has not been proven its superiority. This single-center retrospective study aimed to evaluate the in-hospital and mid-term outcomes of sequential grafting of in situ skeletonized LIMA to the left coronary system.According to the use of sequential or separate LIMA grafting, 1505 eligible patients were assigned to a sequential group (n = 230) and a control group (n = 1275). According to sequential LIMA graft configurations, patients with sequential LIMA grafting were divided into a DOM subgroup (n = 113) and a DLAD subgroup (n = 117). The clinical outcomes and LIMA graft patency were investigated and compared.Sequential LIMA grafting compared with separate LIMA grafting was not an independent predictor either of in-hospital adverse events or follow-up survival free from repeat revascularization during the follow-up period of 32.4 ± 8.5 months. Sequential LIMA grafting had similar LIMA graft patency with separate LIMA grafting (99.5% of 1st sequential sites and 97.7% of 2nd sites versus 98.2% of LIMA-LAD grafts) at 32.3 ± 8.5 months after coronary artery bypass grafting (CABG) surgery. Additionally, the two subgroups received similar mid-term clinical outcomes and graft patency of LIMA segments.Sequential grafting of in situ skeletonized LIMA to the left coronary system resulted in excellent clinical outcomes and graft patency. The two sequential LIMA graft configurations received similar clinical outcomes and graft patency.

Revascularization of Left Coronary System Using a Skeletonized Left Internal Mammary Artery ― Sequential vs. Separate Grafting ―

BACKGROUND To evaluate in-hospital and mid-term outcomes of sequential vs. separate grafting of in situ skeletonized left internal mammary artery (LIMA) to the left coronary system in a single-center, propensity-matched study.Methods and Results:After propensity score-matching, 120 pairs of patients undergoing first scheduled isolated coronary artery bypass grafting (CABG) with in situ skeletonized LIMA grafting to the left anterior descending artery (LAD) territory were entered into a sequential group (sequential grafting of LIMA to the diagonal artery and then to the LAD) or a control group (separate grafting of LIMA to the LAD). The in-hospital and follow-up clinical outcomes and follow-up LIMA graft patency were compared. Both propensity score-matched groups had similar in-hospital and follow-up clinical outcomes. Sequential LIMA grafting was not found to be an independent predictor of adverse events. During a follow-up period of 27.0±7.3 months, 99.1% patency for the diagonal site and 98.3% for the LAD site were determined by coronary computed tomographic angiography after sequential LIMA grafting, both of which were similar with graft patency of separate grafting of in situ skeletonized LIMA to the LAD. CONCLUSIONS Revascularization of the left coronary system using a skeletonized LIMA resulted in excellent in-hospital and mid-term clinical outcomes and graft patency using sequential grafting.