Effect of complete revascularization in acute coronary syndrome after 75 years old:insights from the BleeMACS registry

BACKGROUND The prognostic benefit of complete revascularization in elderly patients(aged over 75 years)with multi-vessel disease and acute coronary syndrome(ACS)is currently unclear.This study aimed to determine the long-term prognostic impact of complete revascularization in this population.METHODS We conducted this study using data obtained from the BleeMACS(Bleeding complications in a Multicenter registry of patients discharged after an Acute Coronary Syndrome)registry,which was carried out from 2003 to 2014.The objective was to categorize older patients diagnosed with ACS into two groups:those who underwent complete revascularization and those who did not.Propensity score matching and the Kaplan-Meier analysis were employed to examine differences in one-year clinical outcomes.The primary endpoint was major adverse cardiovascular event(MACE),which encompassed a combination of all-cause mortality and myocardial infarction.RESULTS Out of 1263 patients evaluated,445 patients(35.2%)received complete revascularization.Patients who underwent complete revascularization had a higher prevalence of hypertension and prior percutaneous coronary intervention compared to those who did not.During the one-year follow-up period,complete revascularization was associated with a significantly decreased risk of MACE[13.7%vs.20.5%,hazard ratio(HR)=0.63,95%CI:0.45–0.88,P=0.007]and a lower risk of myocardial infarction(5.9%vs.9.9%,HR=0.55,95%CI:0.33–0.92,P=0.02).However,it was not linked to a lower risk of all-cause death(9.5%vs.13.5%,HR=0.68,95%CI:0.45–1.02,P=0.06).Similar results were observed in the subgroup analysis.CONCLUSIONS Long-term clinical improvements were observed in ACS patients aged over 75 years with multi-vessel disease who achieved complete revascularization.Therefore,adhering to guidelines for complete revascularization should be recommended for elderly patients.

益气破血化痰方对冠心病血运重建术后心绞痛患者CRP、Hcy及血管内皮功能的影响

目的 分析益气破血化痰方对冠心病血运重建术后心绞痛患者C-反应蛋白(CRP)、同型半胱氨酸(Hcy)及血管内皮功能的影响。方法 选取2019年10月到2023年1月河南省中西医结合医院收治的82例冠心病血运重建术后心绞痛患者为研究对象,采用随机数字表法将患者分为对照组(常规西医治疗)41例和观察组(常规西医+益气破血化痰方治疗)41例。比较两组治疗效果、CRP、Hcy及血管内皮功能,并统计比较两组治疗安全性。结果 观察组临床总有效率(87.80%)显著高于对照组(60.98%),差异有统计学意义(P<0.05);治疗后两组CRP、Hcy水平均显著降低,且观察组显著低于对照组,差异有统计学意义(P<0.05);治疗后,两组中医证候积分均降低,FMD值均上升,且观察组中医证候积分低于对照组,FMD值高于对照组,差异有统计学意义(P<0.05);观察组治疗安全性显著高于对照组,差异有统计学意义(P<0.05)。结论 益气破血化痰方可明显降低冠心病血运重建术后心绞痛患者CRP、Hcy水平,能更好地改善患者血管内皮功能及中医证候,临床疗效更佳,且具有一定安全性。

Impact of gout on in-hospital outcomes of acute coronary syndrome-related hospitalizations and revascularizations: Insights from the national inpatient sample

BACKGROUND Previous studies have established a role of gout in predicting risk and prognosis of cardiovascular diseases. However, large-scale data on the impact of gout on inpatient outcomes of acute coronary syndrome (ACS)-related hospitalizations and post-revascularization is inadequate. AIM To evaluate the impact of gout on in-hospital outcomes of ACS hospitalizations, subsequent healthcare burden and predictors of post-revascularization inpatient mortality. METHODS We used the national inpatient sample (2010-2014) to identify the ACS and goutrelated hospitalizations, relevant comorbidities, revascularization and postrevascularization outcomes using the ICD-9 CM codes. A multivariable analysis was performed to evaluate the predictors of post-revascularization in-hospital mortality. RESULTS We identified 3144744 ACS-related hospitalizations, of which 105198 (3.35%) also had gout. The ACS-gout cohort were more often older white males with a higher prevalence of comorbidities. Coronary artery bypass grafting was required more often in the ACS-gout cohort. Post-revascularization complications including cardiac (3.2% vs 2.9%), respiratory (3.5% vs 2.9%), and hemorrhage (3.1% vs 2.7%) were higher whereas all-cause mortality was lower (2.2% vs 3.0%) in the ACSgout cohort (P < 0.001). An older age (OR 15.63, CI: 5.51-44.39), non-elective admissions (OR 2.00, CI: 1.44-2.79), lower household income (OR 1.44, CI: 1.17- 1.78), and comorbid conditions predicted higher mortality in ACS-gout cohort undergoing revascularization (P < 0.001). Odds of post-revascularization inhospital mortality were lower in Hispanics (OR 0.45, CI: 0.31-0.67) and Asians (OR 0.65, CI: 0.45-0.94) as compared to white (P < 0.001). However, postoperative complications significantly raised mortality odds. Mean length of stay, transfer to other facilities, and hospital charges were higher in the ACS-gout cohort. CONCLUSION Although gout was not independently associated with an increased risk of postrevascularization in-hospital mortality in ACS, it did increase postrevascularization complications.

Coronary angiography in the very old: impact of diabetes on long-term revascularization and mortality

Background Diabetes is often associated with coronary artery disease,leading to adverse clinical outcomes.Real-world data is limited regarding the impact of diabetes in very old patients undergoing coronary angiography on the risk for late or repeated coronary revascularization and mortality.Methods Retrospective analysis of 1,353 consecutive patients>80 years who were admitted to the cardiac unit and further underwent coronary angiography.Subsequent revascularization procedures and all-cause mortality were recorded over a median fbllow-up of 47 months and their relation to diabetic status and presentation with acute coronary syndrome(ACS)was studied.Results Diabetes was present in 31%of the patients undergoing coronary angiography,and was associated with higher rates of obesity,hypertension,hyperlipidemia,chronic kidney disease and female gender.ACS was the presenting diagnosis in 71%of the patients and was associated with worse survival(1-year mortality 20%in ACS vs.6.2%in non-ACS patients,P<0.0001).Increase in long-term mortality rates was seen in diabetic subjects compared to non-diabetic subjects presenting with ACS(log-rank P=0.005),but not in the non-ACS setting(P=0」99).In a multivariable model,additionally adjusting for acuity of presentation,the presence of diabetes was associated with an adjusted hazard ratio of 1.60(95%confidence interval:12-2.28),P=0.011,for the need of late or repeat coronary revascularization and 1.48(1.26-1.74),P<0.0001 for all-cause mortality,during long-term follow-up.Conclusions In very old patients undergoing coronary angiography,presentation with ACS was associated with worse survival.Diabetes was an independent predictor of late or repeated revascularization and long-term mortality.

Off-pump coronary artery bypass grafting versus optimal medical therapy alone：effectiveness of incomplete revascularization in high risk patients

BackgroundGeriatric patients with multivessel coronary artery disease （CAD） are a challenging group to treat; these cases elicit dis-cussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass （OPCAB） provides good quality graft on left anterior descending （LAD） without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy.MethodsWe retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included： 42 were treated with incomplete off-pump revascularization using left internal mammary artery （LIMA） on LAD; 41 were discharged in optimal medical therapy （OMT）, having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events （MACEs）.ResultsDuring follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those dis-charged in OMT （Log Rank ＆lt; 0.001）, and OMT group carries a propensity score-adjusted hazard ratio of 3.862 （P ＆lt; 0.001）. With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT （Log Rank = 0.002）, and OMT group carries a propensity score-adjusted hazard ratio of 3.663 （P = 0.010）. There is no statistically significant difference concerning freedom from MACEs （Log Rank = 0.273）.ConclusionsFor high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.

Redo Coronary Artery Bypass Grafting: On-Pump and Off-Pump Coronary Artery Bypass Grafting Revascularization Techniques

Objective To analyze the short-term outcomes of redo coronary artery bypass grafting(CABG) using on-pump and off-pump CABG techniques. Methods From January 2003 to August 2013, non-randomized 80 patients were treated with redo CABG in the Department of Cardiac Surgery, Peking University Third Hospital. Among these patients, 40 underwent on-pump CABG technique(redo-ONCAB group) and 40 underwent off-pump CABG technique(redo-OPCAB group). Furthermore, transmyocardial laser revascularization was performed in high-risk patients who were not suitable to conventional grafting. Clinical data of the two groups were recorded and analyzed including operation time, coronary grafts, incomplete revascularization, postoperative ventilation, perioperative stroke, and low output syndrome, etc. Results There were no significantly differences in age, gender distribution, incidences of hypertension, stroke, and other clinical characteristics between redo-OPCAB group and redo-ONCAB group(all P>0.05), except for incidences of renal dysfunction and pulmonary disease(all P<0.05). The number of grafting vessels in the redo-ONCAB and redo-OPCAB groups was 2.1 ± 0.74 and 1.4 ±0.52 respectively. There was significant difference between the two groups(P=0.0243). Compared with the redo-ONCAB group, there was shorter operation time(P=0.0045), postoperative ventilation(P=0.0211) and intensive care unit stay(P=0.0400), as well as fewer use of platelet(P=0.0338) and blood transfusion(P=0.0034) in the redo-OPCAB group. The incidence of incomplete revascularization(P=0.0253) and the use of transmyocardial laser revascularization(P=0.0052) were higher in the redo-OPCAB group than those in the redo-ONCAB group(all P<0.05). However, no significant differences were showed for the incidence of the use of intra aortic balloon pump and continuous renal replacement therapy, perioperative stroke, low output syndrome, and in-hospital mortality between the two groups(all P>0.05). Conclusion Redo CABG is the safety and efficacy surgical procedure, and redo-OPCAB technique with better outcomes is commended especially in high-risk patients.

Hybrid coronary revascularization vs. percutaneous coronary interventions for multivessel coronary artery disease

OBJECTIVE Hybrid coronary revascularization(HCR)combines a minimally invasive surgical approach to the left anterior descending(LAD)artery with percutaneous coronary intervention(PCI)for non-LAD diseased coronary arteries.It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery,but there is little information comparing it to isolated PCI for multivessel disease.Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease.METHODS This cohort study used data from New York’s cardiac surgery and PCI registries in 2010−2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI.Cox proportional hazards methods were used to reduce selection bias.Patients were followed for a median of four years.RESULTS There was a total of 335 HCR patients(1.2%)and 25,557 PCI patients(98.8%)after exclusions.There was no difference in 6-year risk adjusted survival between HCR and PCI patients 83.17%vs.81.65%,adjusted hazard ratio(aHR)=0.90(95%CI:0.67−1.20).However,HCR patients were more likely to be free from repeat revascularization in the LAD artery(91.13%vs.83.59%,aHR=0.51(95%CI:0.34−0.77)).CONCLUSIONS For patients with multi-vessel coronary artery disease,HCR is rarely performed.There are no differences in mortality rates after four years,but HCR is associated with lower repeat revascularization rates in the LAD artery,presumably due to better longevity in left arterial mammary grafts.

Risk or Beneficial Factors Associated with Unplanned Revascularization Risk Following Percutaneous Coronary Intervention: A Large Single-Center Data

Objective To analyze factors associated with unplanned revascularization(UR) risk in patients with coronary artery disease(CAD) who underwent percutaneous coronary intervention(PCI).Methods A total of 10,640 cases with CAD who underwent PCI were analyzed. Multivariate COX regressions and competing risk regressions were applied.Results The patients who underwent UR following PCI in 30 days, 1, and 2 years accounted for 0.3%,6.5%, and 8.7%, respectively. After multivariate adjustment, the number of target lesions [hazard ratio(HR) = 2.320;95% confidence interval(CI): 1.643–3.277;P < 0.001], time of procedure(HR = 1.006;95%CI: 1.001–1.010;P = 0.014), body mass index(HR = 1.104;95% CI: 1.006–1.210;P = 0.036), incomplete revascularization(ICR)(HR = 2.476;95% CI: 1.030–5.952;P = 0.043), and age(HR = 1.037;95% CI:1.000–1.075;P = 0.048) were determined as independent risk factors of 30-day UR. Factors, including low-molecular-weight heparin or fondaparinux(HR = 0.618;95% CI: 0.531–0.719;P < 0.001), secondgeneration durable polymer drug-eluting stent(HR = 0.713;95% CI: 0.624–0.814;P < 0.001), left anterior descending artery involvement(HR = 0.654;95% CI: 0.530–0.807;P < 0.001), and age(HR = 0.992;95%CI: 0.985–0.998;P = 0.014), were independently associated with decreased two-year UR risk. While,Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score(HR =1.024;95% CI: 1.014–1.033;P < 0.001) and ICR(HR = 1.549;95% CI: 1.290–1.860;P < 0.001) were negatively associated with two-year UR risk.Conclusion Specific factors were positively or negatively associated with short-and medium-long-term UR following PCI.

Minimally invasive surgical techniques in the era of hybrid coronary revascularization： additional benefits for the elderly patients？

Geriatric patients affected by stable multi-vessel coronary artery disease （CAD） are at the crossroad： they can live with the risks of acute coronary syndrome, malignant arrhythmias or heart failure, or they can undergo a rapid evaluation for myocardial revascularization.

Long-term outcomes of high-risk elderly male patients with multivessel coronary disease： optimal medical therapy versus revascularization

Background Many studies have indicated that medical therapy and percutaneous coronary intervention have similar effects in terms of the long-term prognosis of patients with stable coronary artery disease. This study investigated the effects of optimal medical therapy （OMT） and revascularization-plus-OMT in elderly patients with high-risk angina. Methods In this prospective non-randomized study, 241 consecutive high-risk elderly male patients （65-92 years of age） with angiographically confirmed multivessel disease were enrolled in the registry from January 2004 to April 2005. Of these, 98 patients underwent OMT and 143 underwent revascularization therapy plus OMT. Results After 6.5 years of follow-up, we found that the rate of long-term cardiac mortality was significantly higher in patients who under- went OMT than in those who underwent revascularization （6.5-year unadjusted mortality rate, 14.3% for OMT vs. 7.0% for revascularization patients; log-rank P = 0.04）. However, the overall risks of major adverse cardiac cerebrovascular events （MACCE） were similar among all patients （6.5-year unadjusted mortality rate, 29.6% for OMT vs. 27.3% for revascularization patients; log-rank P = 0.67）. Conclusions OMT was associated with an increase in cardiac death but a similar 6.5-year risk of MACCE compared with revascularization in high-risk elderly male patients with coronary multivessel disease.

Application of SYNTAX and its Derivative Scores in the Selection of Revascularization Strategies for Complex Coronary Heart Disease

Complex coronary heart disease(CHD)has become a hot spot in medicine due to its complex coronary anatomy,variable clinical factors,difficult hemodynamic reconstruction,and limited effect of conservative drug treatment.Identifying complex CHD and selecting optimal treatment methods have become more scientific as revascularization technology has improved,and coronary risk stratification scores have been introduced.SYNTAX and its derivative scores are decision-making tools that quantitatively describe the characteristics of coronary lesions in patients based on their complexity and severity.The SYNTAX and its derivative scores could assist clinicians in rationalizing the selection of hemodynamic reconstruction treatment strategies,and have demon-strated outstanding value in evaluating the prognosis of patients with complex CHD undergoing revascularization treatment.The authors in this article summary the practical application of SYNTAX and its derivative scores in complex CHD in order to deepen the understanding of the relationship between the choice of different revascularization strategies and SYNTAX and its derived scores in complex CHD and provide a further reference for clinical treatment of complex CHD.

Impact of Baseline LDL-C and Lp(a) Elevation on Coronary Revascularization in Patients with Acute Coronary Syndrome One-Year after First Percutaneous Coronary Intervention

Objective: The aim of this study was to investigate the effect of Lipoprotein-a [Lp(a)] on Coronary Revascularizaton (CR) on one year follow up in patients with Acute Coronary Syndrome (ACS) after the first Percutaneous Coronary Intervention (PCI). Method: A retrospective study was designed. A total of 475 patients that underwent their first PCI treatment due to ACS between January 2016 and December 2017 were recruited and followed for one year at the Zhongda Hospital, China. The clinical end point after first PCI was prevalence of Major Adverse Cardiovascular Events (MACE) including nonfatal Myocardial Infarction (MI), cardiovascular death, ischemic stroke and Coronary Revascularization (CR). According to the cut point of Lp(a), participants were divided into low Lp(a) subgroup (Lp(a) mg/L) and high Lp(a) subgroup (Lp(a) ≥ 300 mg/L). Furthermore, based on baseline Low Density Lipoprotein Cholesterol (LDL-C) level, participants were divided into low LDL-C (LDL-C mmol/L) and high LDL-C (LDL-C ≥ 1.8 mmol/L) subgroups. Results: The number of prevalence of CR was higher with elevated serum Lp(a) in both low LDL-C subgroup and high LDL-C subgroup, and was significantly different in both the low LDL-C subgroup and high LDL-C subgroup (p = 0.009 and p = 0.006, respectively). Multivariate Cox-hazard regression analysis for CR showed increase in serum LDL-C and Lp(a) increased prevalence of CR by 1.514 and 1.002 folds respectively. Furthermore, Kaplan-Meier cumulative survival curves showed that increased prevalence of CR within one year after first PCI in patients with high Lp(a) [log rank p = 0.000]. Conclusion: Baseline increase of serum LDL-C and Lp(a) significantly increases the prevalence of CR after first PCI within one year. It indicates that after PCI treatment, in patient with serum LDL-C and Lp(a) elevation, treatment with high-dose statin therapy or PCSK9 inhibitors may alleviate the adverse effects imposed by Lp(a) elevation.

Effect of coronary artery revascularization on in-hospital outcomes and long-term prognoses in acute myocardial infarction patients with prior ischemic stroke

Objective To investigate whether coronary artery revascularization therapies （CART）, including percutaneous coronary intervention （PCI） and coronary artery bypass grafting （CABG）, can improve the in-hospital and long-term outcomes for acute myocardial infarction （AMI） patients with prior ischemic stroke （IS）. Methods A total of 387 AMI patients with prior IS were enrolled consecutively from January 15, 2005 to December 24, 2011 in this cohort study. All patients were categorized into the CART group （n = 204） or the conservative medications （CM） group （n = 183）. In-hospital cardiocerebral events and long-term mortality of the two groups after an average follow-up of 36 months were recorded by Kaplan-Meier survival curves and compared by Logistic regression and the Cox regression model. Results The CART patients were younger （66.5 ± 9.7 years vs. 71.7 ± 9.7 years, P 〈 0.01）, had less non-ST segment elevation myocardial infarction （11.8% vs. 20.8%, P = 0.016） and more multiple-vascular coronary lesions （50% vs. 69.4%, P = 0.031）. The hospitalization incidence of cardiocerebral events in the CART group was 9.3% while 26.2% in the CM group （P 〈 0.01）. CART significantly reduced the risk of in-hospital cardiocerebral events by 65% [adjusted odds ratio （OR） = 0.35, 95% CI： 0.13-0.92]. By the end of follow-up, 57 cases （41.6%） died in CM group （n = 137） and 24 cases （12.2%） died in CART group （n = 197）. Cox regression indicated that CART decreased the long-term mortality by 72% [adjusted hazard ratio （HR） = 0.28, 95% CI： 0.064）.46], while categorical analysis indicated no s{gnificant dif- ference between PCI and CABG. Conclusions CART has a significant effect on improving the in-hospital and long-term prognoses for AMI patients with prior IS.

Meta-analysis on Efficacy of Yiqi Huoxue Chinese Drugs in the Treatment of Coronary Heart Disease after Coronary Revascularization

[Objectives] To make a systematic evaluation on the therapeutic efficacy and safety of Yiqi Huoxue traditional Chinese drugs combined with western medicine in treatment of coronary heart disease( CHD) after coronary revascularization. [Methods] The literatures were retrieved from China Knowledge Infrastructure( CNKI),Chinese science and technology journal full-text database( VIP database,VIP),Wanfang Data,the Chinese biomedical Database,Pub Med,Embase,and the Cochrane Library. The retrieval time was set to the creation of the database to January 2017. The randomized controlled trial( RCT) was conducted on the comparison between Yiqi Huoxue Chinese drugs combined with western medicine and the western medicine alone in the treatment of CHD after coronary revascularization. The literature information was extracted and the methodological quality of the included literature was evaluated according to the bias risk assessment tool developed by the Cochrane Collaboration. Meta-analysis was performed with the aid of Rev Man 5. 3 software. Coronary artery restenosis rate,angina pectoris treatment efficiency,left ventricular ejection fraction( LVEF),left ventricular end-diastolic volume( LVEDV),B-type natriuretic peptide( BNP),6-minute walk test( 6 MWT),and adverse reactions were analyzed. [Results] A total of 29 articles were included,a total of2 518 patients,the literature quality was low. Meta-analysis results showed that compared with the treatment by western medicine alone,Yiqi Huoxue Chinese drugs combined with western medicine could further reduce coronary restenosis rate[RR = 0. 45,95% CI( 0. 34,0. 60),P <0. 000 01],improve the angina pectoris treatment efficiency[RR = 1. 13,95% CI( 1. 05,1. 21),P = 0. 000 5],raise LVEF[WMD = 4. 25,95% CI( 3. 46,5. 04),P < 0. 000 01],reduce LVEDV[WMD =-10. 41,95% CI(-17. 88,-2. 95),P = 0. 006],decrease the plasma BNP level[WMD =-32. 32,95% CI(-44. 92,-19. 72),P < 0. 000 01],and increase 6 MWT distance(WMD = 62. 25,95% CI( 21. 71,102. 78),P = 0. 003)[Conclusions]Yiqi Huoxue Chinese drugs combined with western medicine can alleviate the symptoms of angina pectoris,reduce the rate of coronary restenosis,improve heart function and improve exercise capacity,thereby improving clinical efficacy in patients with CHD after coronary revascularization.

Review: Outcomes of Revascularization Strategies for Coronary Artery Disease

The optimal revascularization strategy for patients with coronary artery disease is influenced by the continuous improvement in medical therapy and the improved designs of the new generation of coronary stents allowing them to be increasingly applied in patients with complex coronary anatomy, including those with left main stem disease. On the other hand, surgical results are also improved as a result of the increased experience over years and the improvement of myocardial protection techniques. This will make the comparison of percutaneous coronary interventions and coronary artery bypass surgery a moving target. In this paper, we reviewed the recent randomized controlled trials and important registries emphasizing the benefits and the results of each therapy in different patient subsets. A heart team of both cardiologists and cardiac surgeons is of paramount importance in choosing the optimal revascularization strategy.

Review: Do We Still Need a Viability Study before Considering Revascularization in Patient with Stable Coronary Artery Disease and Significant Left Ventricular Systolic Dysfunction?

Patients with ischemic cardiomyopathy constitute a heterogeneous group of patients with an extremely complex condition in which many factors play an important prognostic role. So it is difficult and probably unrealistic to expect that a single feature like presence of viable myocardium would provide an unequivocal answer to a critical question of revasculrization or not for all patients. Opposite to the hopes of investigators and physicians involved in the care of these patients, the findings of prospective studies with the use of different viability testing methods did not help in the decision-making process regarding CABG in ischemic cardiomyopathy. Instead, they left us with the same dilemma. The implication of most of these trials is that in patients with CAD and significant LV dysfunction, assessment of myocardial viability does not identify patients who will have the greatest survival benefit from adding CABG to aggressive medical therapy. In the clinical practice, these observations remind physicians to consider the multiplicity of factors involved in the decision-making process for patients with such a complex disease.

Physiology of in-situ arterial revascularization in coronary artery bypass grafting: Preoperative,intraoperative and postoperative factors and influences

Surgical revascularization with coronary artery bypass grafting(CABG) has become established as the most effective interventional therapy for patients with moderately severe and severe stable ischemic heart disease(SIHD). This recommendation is based on traditional 5-year outcomes of mortality and avoidance of myocardial infarction leading to reintervention and/or cardiac death. However, these results are confounded in that they challenge the traditional CABG surgical tenets of completeness of anatomic revascularization, the impact of arterial revascularization on late survival, and the lesser impact of secondary prevention following CABG on late outcomes. Moreover, the emergence of physiologic-based revascularization with percutaneous cardiovascular intervention as an alternative strategy for revascularization in SIHD raises the question of whether there are similar physiologic effects in CABG. Finally, the ongoing ISCHEMIA trial is specifically addressing the importance of the physiology of moderate or severe ischemia in optimizing therapeutic interventions in SIHD. So it is time to address the role that physiology plays in surgical revascularization. The long-standing anatomic framework for surgical revascularization is no longer sufficient to explain the mechanisms for short-term and long-term outcomes in CABG. Novel intraoperative imaging technologies have generated important new data on the physiologic blood flow and myocardial perfusion responses to revascularization on an individual graft and global basis. Long-standing assumptions about technical issues such as competitive flow are brought into question by real-time visualization of the physiology of revascularization. Our underestimation of the impact of Guideline Directed Medical Therapy, or Optimal Medical Therapy, on the physiology of preoperative SIHD, and the full impact of secondary prevention on post-intervention SIHD, must be better understood. In this review, these issues are addressed through the perspective of multi-arterial revascularization in CABG, which is emerging(after 30 years) as the "standard of care" for CABG. In fact, it is the physiology of these arterial grafts that is the mechanism for their impact on long-term outcomes in CABG. Moreover, a better understanding of all of these preoperative, intraoperative and postoperative components of the physiology of revascularization that will generate the next, more granular body of knowledge about CABG, and enable surgeons to design and execute a better surgical revascularization procedure for patients in the future.

Complete revascularization reduces adverse outcomes in patients with multivessel coronary artery disease

AIM To investigate the infuence of complete and incomplete revascularization （ICR） in patients with multivessel coro-nary artery disease undergoing coronary artery bypass or percutaneous coronary intervention.METHODS We searched PubMed using the keywords “complete revascularization”, “incomplete revascularization”, “cor-onary artery bypass”, and “percutaneous coronary intervention”. We selected randomized controlled studies （RCT） and observational studies only for review. The main outcomes of interest were mortality, myocardial infarction （MI） and repeat revascularization. We identified further studies by hand searching relevant publications and included those that met with the inclusion criteria in our fnal analysis and performed a systematic review.RESULTSTen studies were identified, including 13327 patients of whom, 8053 received complete revascularization and 5274 received ICR. Relative to ICR, CR was associated with lower mortality （RR： 0.755, 95%CI： 0.66 to 0.864, P = 0.765, I2 = 0.0%）, lower rates of MI （RR： 0.759, 95%CI： 0.615 to 0.937, P = 0.091, I2 = 45.1%）, lower rates of MACCE （RR： 0.731, 95%CI： 0.668 to 0.8, P = 0.453, I2 = 0.0%） and reduced rates of repeat coronary revascularization （RR： 0.691, 95%CI： 0.541 to 0.883, P = 0.0, I2 = 88.3%）.CONCLUSIONCR is associated with lower rates of adverse outcomes. CR can be used as a standard in the choice of any particular revascularization strategy.

Coronary Embolization and Myocardial Microinfarction: MR Imaging and Histopathologic Characterization

Magnetic resonance imaging (MRI) has been proven to reliably assess regional perfusion and left ventricular (LV) function of microembolized myocardium. The visibility of microinfarct on delayed enhancement MRI (DE-MRI) is limited and dependent on technical and biological issues. Furthermore, MRI underestimates total microinfarct size compared with microscopy. MRI studies revealed that the presence of microemboli in pre-existing acute infarct delays infarct healing and magnifies LV remodeling. Discrimination of acute from chronic microinfarct is based on presence of inflammatory cells, edema and scar tissue, respectively. These noninvasive findings highlight the importance of prognostic utility of MRI and warrant larger clinical studies or registries to evaluate the significance of presence of focal microinfarct. Serial microscopic studies revealed that intravascular microemboli migrate into the extravascular space and this migration process is a function of time. This phenomenon may limit the use of microemboli therapy in occluding hemorrhagic blood vessels or treating tumors. Despite current standard of care, existing methods and therapies do not prevent coronary embolization nor reverse their deleterious effects.

Off-Pump Complete Coronary Revascularization with 860 cases andtwo year experience

Background Cardiopulmonary bypass (CPB) produces a well documented diffuse inflammatory response that affects multiple organ systems. To avoid the deleterious effects of cardiopulmonary bypass, off pump coronary artery bypass grafting is becoming increasingly popular world wide. We reviewed our experience of complete coronary artery revascularization on the beating heart without CPB. Methods From Aug 1998 to Aug 2000, 860 off pump revascularizations (99%since January 1999) were performed at Manipal Hospital Heart Foundation. The patients consist of males 757(88%), females 103(12%). Averaged age 64.2±15 years. All surgeries were performed through a median sternotomy. Exposure techniques are tailored to individual vessels and cardiac regions. Local immobilization is performed with octopus. Vascular control is achieved with occluders and shunts. Results Among 860 off pump CABG patients. Single graft 72 (8.3%), two grafts 208 (24.2%), three grafts 469 (54.5%), four grafts 101 (11.8%), five graft 10 (1.2%). The average number of grafts per patient was 2.72±0.32. Operative mortality was 0.69%(6 patients). Anesthetic time 3.9±1.2hours, extubation time 6±2.5 hours, Blood requirement 360±90 ml, Preoperative LVEF 60.2±8.5%, Post LVEF 64.1±14%Low cardiac output 48 patients (5.6%), IABP requirement: 25 patients(2.9%), 25 patients converted to CPB during OP CAB(2.9%)and 20 of them were done with on pump beating heart. 25 patients showed myocardial ischemic and 16 patients showed perioperative myocardial infarction. ICU stay 1.1±0.8 days, hospital stay 6.2±1.1 days. Conclusion Off-pump coronary artery bypass in complete revascularization is a safe, effective technique and suitable.