Objective To systematically review randomized controlled trials to compare myocardial protection profiles of sevoflurane with propofol in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods Ele...Objective To systematically review randomized controlled trials to compare myocardial protection profiles of sevoflurane with propofol in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods Electronic databases were searched to identify all randomized controlled trials comparing sevoflurane with propofol for protecting myocardium in adult patients undergoing CABG surgery. Two authors independently extracted patients' perioperative data, including patients' baseline characteristics, surgical variables, and outcome data. For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio (OR) and 95% CI. Each outcome was tested for heterogeneity, and randomized-effects or fixed-effects model was used in the presence or absence of significant heterogeneity (Q test P<0.05). Sensitivity analyses were done by examining the influence of statistical model on estimated treatment effects. Publication bias was explored through visual inspection of funnel plots of the outcomes. Statistical significance was defined as P<0.05. Results Our search yielded 13 studies including 696 patients, and 402 patients were allocated into sevoflurane group and 294 into propofol group. There was no significant difference in postoperative mechanical ventilation time, inotropic support, mortality, myocardial infarction, and atrial fibrillation between the two groups (all P>0.05). Patients randomized into sevoflurane group had higher post-bypass cardiac index (WMD=0.39, 95% CI: 0.18 to 0.60, P=0.0003), lower troponin I level (WMD=-0.82, 95% CI:-0.87 to-0.85, P=0.0002), lower incidence of myocardial ischemia (OR=0.37, 95% CI: 0.16 to 0.83, P=0.02), shorter ICU and hospital stay length (WMD=-10.99, 95% CI:-12.97 to-9.01, P<0.00001; WMD=-0.78, 95% CI:-1.00 to-0.56, P<0.00001, respectively). Conclusion This meta-analysis has found some evidence showing that sevoflurane has better myocardial protection than propofol in CABG surgery.展开更多
Objective:To evaluate the clinical efficacy of intravenous recombinant human brain natriuretic peptide(rhBNP)in patients with acute myocardial infarction after on-pump coronary artery bypass grafting(CABG).Methods:40 ...Objective:To evaluate the clinical efficacy of intravenous recombinant human brain natriuretic peptide(rhBNP)in patients with acute myocardial infarction after on-pump coronary artery bypass grafting(CABG).Methods:40 cases of coronary heart disease,left ventricular ejection fraction<50%and(plasma brain natriuretic peptide in type N terminal)NT-proBNP>300 pg/ml underwent on-pump coronary artery bypass surgery with cardiopulmonary bypass were enrolled and randomly divided into two groups,experimental group of 20 patients after operation on the basis of conventional therapy plus recombinant human brain natriuretic peptide treatment(first loading dose of 1.5μg/kg intravenously,to maintain dose of 0.01μg/kg/min continuous infusion of 72h),20 cases of the control group was given routine treatment,observe two groups of patients before and after treatment of blood pressure,heart rate,urine volume,blood creatinine and NT-proBNP,and to observe the left ventricular ejection fraction(LVEF),echocardiography and the length of time the index.Results:the experimental group after treatment,urine volume,left ventricular ejection fraction(LVEF),cardiac index(CI)was significantly higher than that before treatment,the serum creatinine,plasma N-terminal pro brain natriuretic peptide(NTproBNP),the content of serum troponin T peptide(cT nT),creatine kinase isoenzyme(CK MB)was significantly lower than before treatment.Conclusion:Recombinant human brain natriuretic peptide can improve cardiac and renal function in patients with acute period of acute myocardial infarction underwent coronary artery bypass surgery,shorten the hospitalization time,and it is safe and feasible.展开更多
Coronary artery bypass grafting(CABG) continues to be one of the most commonly performed cardiac surgical procedures worldwide. Conventional CABG performed on cardiopulmonary bypass termed on-pump CABG is regarded as ...Coronary artery bypass grafting(CABG) continues to be one of the most commonly performed cardiac surgical procedures worldwide. Conventional CABG performed on cardiopulmonary bypass termed on-pump CABG is regarded as the gold standard. However, on-pump CABG results in several physiologic derangements including but not limited to thrombocytopenia, activation of complement factors, immune suppression, and inflammatory responses leading to organ dysfunction.Furthermore, manipulating an atherosclerotic ascending aorta during cannulation and cross-clamping can predispose to embolization and stroke risk. Recognition of these detrimental effects of on-pump CABG resulted in resurgence of off-pump CABG nearly two decades ago.Off-pump CABG since its resurgence has been a subject of intensive scrutiny and speculation. Despite numerous retrospective nonrandomized studies, prospective randomized trials, and meta-analyses validating the safety and efficacy of off-pump CABG, opponents of the technique have persistently demanded abandonment of off-pump CABG. Several misconceptions and misperceptions are used as an excuse for such demands. This review article examines published scientific evidence to evaluate these misperceptions and misconceptions about off-pump CABG.展开更多
New surgical techniques for coronary artery bypass graft (CABG) have been explored in order to minimize disfiguring scars, avoid cardiopulmonary bypass and decrease hospital residence and costs etc. Improved surgica...New surgical techniques for coronary artery bypass graft (CABG) have been explored in order to minimize disfiguring scars, avoid cardiopulmonary bypass and decrease hospital residence and costs etc. Improved surgical expense can perform the procedures in some high-risk patients such as poor left ventricular function, redo CABG, advanced age and renal dysfunction etc. Intraoperatively there is an obligatory period of myocardial ischemia, which may lead to significant hemodynamic consequences. It is a quite challenge to anesthetist in managing the intraoperative patient.展开更多
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(SI...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.展开更多
Coronary bypass graft surgery (CABG) is a revascularization procedure which reduces myocardial ischemia and cardiovascular morbidity and mortality in selected patients;however, up to 40% of saphanous vein grafts may d...Coronary bypass graft surgery (CABG) is a revascularization procedure which reduces myocardial ischemia and cardiovascular morbidity and mortality in selected patients;however, up to 40% of saphanous vein grafts may degenerate over 10 years. Although coronary angiography is the gold standard to detect graft patency and native vessel disease, sometimes it is difficult to locate the grafts resulting in increased exposure to radiation and contrast administration. This case highlights the utility of cardiac computerized tomography and magnetic resonance imaging to provide comprehensive noninvasive assessment in a patient post CABG.(J Geriatr Cardiol 2007;4:244-247.)展开更多
AIM: To investigate potential gender differences in the prevalence of cardiovascular risk factors, cardiovascular disease (CVD) management, and prognosis in acute coronary syndrome (ACS). METHODS: A systematic literat...AIM: To investigate potential gender differences in the prevalence of cardiovascular risk factors, cardiovascular disease (CVD) management, and prognosis in acute coronary syndrome (ACS). METHODS: A systematic literature search was performed through Medline using pre-specified key words . An additional search was performed, focusing specifically on randomized controlled clinical trials in relation to therapeutic intervention and prognosis. In total, 92 relevant articles were found. RESULTS: Women with CVD tended to have more hypertension and diabetes at the time of presentation, whereas men were more likely to smoke. Coronary angiography and revascularization by percutaneous coronary intervention were performed more often in men. Women were at a greater risk of short-term mortality and complications after revascularization. Interestingly, women under 40 years presenting with ACS were athighest risk of cardiovascular death compared with men of the same age, irrespective of risk factors. This disadvantage disappeared in older age. The long-term mortality risk of ACS was similar in men and women, and even in favor of women. CONCLUSION: Mortality rates are higher among young women with ACS, but this difference tends to disappear with age, and long-term prognosis is even better among older women.展开更多
Background Myocardial protection during off-pump coronary artery bypass grafting (OPCABG) is a multifactorial problem in which maintaining stable systemic hemodynamics is very important. In this study passive graft ...Background Myocardial protection during off-pump coronary artery bypass grafting (OPCABG) is a multifactorial problem in which maintaining stable systemic hemodynamics is very important. In this study passive graft perfusion (PGP) was applied to investigate the effect during and after OPCABG as evaluated by cardiac troponin I (CTnl) and hemodynamic indexes. Methods Thirty first-time patients underwent OPCABG under one surgeon. They were randomly divided into two groups: The passive graft perfusion group (PGP, n=15) received distal coronary perfusion during the anastomosis and immediate graft perfusion after the distal anastomosis. The control group, no graft perfusion group, (NGP, n=15) received no graft perfusion after the distal anastomosis. The results of the two protocols were evaluated by concentration of CTnl and hemodynamic indexes before induction and after operation. Results There were no statistically significant differences between these two groups in their perioperation parameters. The level of CTnl increased postoperatively, reached its peak at 6 hours (P〈0.05) and recovered by the 6 days postoperative. Compared with the control group the concentration of CTnl in the PGP group was significantly lower at 6 and 24 hours (P〈0.01). Compared with the NGP group, cardiac index (CI) in the PGP group was higher at 12 and 24 hours after operation (P〈0.05). The period of mechanical ventilation was significantly shorter in the PGP group than in the NGP group (P〈0.05). Conclusion PGP can increase the flow to the myocardium and shorten the heart ischemia time, thus maintain stable systemic hemodynamics, supply a satisfactory CI after surgery and improve surgery outcome.展开更多
Background Kawasaki disease (KD) is the leading cause of pediatric ischemic heart disease. The incidence of serious coronary sequelae is low and about 2%-3% of patients with KD, but once myocardial infarction occurs...Background Kawasaki disease (KD) is the leading cause of pediatric ischemic heart disease. The incidence of serious coronary sequelae is low and about 2%-3% of patients with KD, but once myocardial infarction occurs in children, the mortality is quite high and 22% at the first infarction.This study aimed to evaluate the efficacy of coronary artery bypass grafting (CABG) in patients with KD. Methods Eight patients with a history of KD underwent CABG between October 1997 and July 2005. The number of bypass grafts placed was 2 to 4 per patient (mean 2.5±0.8). Various bypass grafts were used in patients, i.e. the left internal mammary artery (LIMA) in 3 patients, bilateral internal mammary artery (IMA) in 2 patients, LIMA plus gastroepiploic artery (GEA) in 1 patient and total saphenous vein grafts (SVGs) in 2 patients. The combined procedures included ventricular aneurysmectomy in 1 patient, mitral valve plasty in 1 and right coronary aneurysmectomy in 1. One patient was not able to wean from cardiopulmonary bypass (CPB), after being supported with intra-aortic balloon pump (IABP), the patient was weaned from CPB successfully. Results One patient died of low cardiac output syndrome and acute renal failure 19 days after operation. Other patients recovered and were discharged uneventfully. During the follow-up that ranged from 3 to 57 months (mean 27 months), clincal angina disappeared or improved. Cardiac function was in Class I-II (NYHA).Conclusion CABG is a safe and effective procedure for Kawasaki coronary artery disease. However long-term results need to be followed up.展开更多
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...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.展开更多
Background Patients with prior coronary artery bypass graft (CABG) have a poor outcome after acute myocardial infarction (AMI).Little is known about the treatment strategy and outcome of percutaneous coronary inte...Background Patients with prior coronary artery bypass graft (CABG) have a poor outcome after acute myocardial infarction (AMI).Little is known about the treatment strategy and outcome of percutaneous coronary intervention (PCI) in these patients.The purpose of this study was to investigate the impact of graft versus native artery PCI on the outcomes of prior CABG patients with AMI.Methods Between September 2005 and October 2011,a total of 140 consecutive patients with previous CABG undergoing PCI for the treatment of AMI were included.Clinical/procedural characteristics and long-term clinical outcomes were compared between graft and native artery PCI patients.Results The mean time interval to prior CABG was (5.6±4.2) years.Thirty patients received graft PCI,success rate being 90%.One hundred and ten patients received native artery PCI,success rate being 90.7% (P 〉0.05).There were no significant differences in the basic characteristics between the two groups.All patients received drug eluting stents (DESs).Three patients died during hospitalization in the graft-PCI group (10% vs.native PCI 0,P 〈0.05).After a median followup of two years,major adverse cardiac events (MACE) (myocardial infarction,target vessel revascularization,total death) were 20% with no significant difference between the two groups.Cox regression analysis showed that both diabetes mellitus (DM,HR 3.57,95% CI 1.03-5.75,P 〈0.05) and primary PCI (HR 5.932,95% Cl 1.91-18.4,P 〈0.05) were independent predictors of MACE.Conclusions More patients with prior CABG underwent native artery PCI for AMI.PCI to culprit graft vessels had higher in-hospital mortality.DM and primary PCI,but not graft PCI,were predictors for adverse long-term outcome.展开更多
AIM: To identify the typical shape of the rise and fall curve of troponin(Tn) following the different types of myocardial infarction(MI). METHODS: We conducted a systematic search in PubM ed and Embase including all s...AIM: To identify the typical shape of the rise and fall curve of troponin(Tn) following the different types of myocardial infarction(MI). METHODS: We conducted a systematic search in PubM ed and Embase including all studies which focused on the kinetics of Tn in MI type 1, type 4 and type 5. Tn levels were standardized using the 99 th percentile, a pooled mean with 95%CI was calculated from the weighted means for each time point until 72 h. RESULTS: A total of 34 of the 2528 studies identified in the systematic search were included. The maximum peak level of the Tn was seen after 6 h after successful reperfusion of an acute MI, after 12 h for type 1 MI and after 72 h for type 5 MI. In type 1 MI there were additional smaller peaks at 1 h and at 24 h. After successful reperfusion of an acute MI there was a second peak at 24 h. There was not enough data available to analyze the Tn release after MI associated with percutaneous coronary intervention(type 4).CONCLUSION: The typical rise and fall of Tn is different for type 1 MI, successful reperfusion of an acute MI and type 5 MI, with different timing of the peak levels and different slopes of the fall phase.展开更多
The current practice of myocardial revascularization for acute myocardial infarction (MI) is primary percutaneous intervention (PCI). Surgical revascularization (“bypass”) is reserved for patients unsuitable for PCI...The current practice of myocardial revascularization for acute myocardial infarction (MI) is primary percutaneous intervention (PCI). Surgical revascularization (“bypass”) is reserved for patients unsuitable for PCI. The purpose of this report is to describe the long-term outcome of acute MI patients who underwent left-sided arterial revascularization (left anterior descending and circumflex arteries) before PCI was adopted as the preferred treatment for this subset of patients. Between 1996 and 2002, 434 consecutive patients in our center underwent myocardial revascularization for recent MI using the composite T-graft technique (381 bilateral internal thoracic arteries and 53 single internal thoracic artery and radial arteries). Two-hundred and seventy-six patients were operated on within seven days of an acute MI (Group A) and the remaining 158 patients were operated on after the 7th day since an acute MI (Group B). Group A had significantly increased operative mortality (6.5% vs 1.3% for Group B, P = 0.012). Surgery performed within the first week of an acute MI was also found to be a significant predictor of early mortality in multivariate logistic regression analysis (O.R. 10.31;95% C.I. 1.32-83.30, P = 0.026). The mean follow-up was 10.6 ± 5.2 years. The Kaplan Meier 10-year survival of the two groups, however, was similar (65.6 ± 2.9 Group A vs 64.6 ± 3.8 Group B, P = 0.953), and assignment to Group A was not an independent predictor of decreased survival (P = 0.395, Cox model). When using arterial grafts for myocardial revascularization, the long-term outcome of patients operated on during the first 7 days of acute MI is not worse than that of patients operated on after more than 7 days, despite their increased operative mortality.展开更多
文摘Objective To systematically review randomized controlled trials to compare myocardial protection profiles of sevoflurane with propofol in patients undergoing coronary artery bypass grafting (CABG) surgery. Methods Electronic databases were searched to identify all randomized controlled trials comparing sevoflurane with propofol for protecting myocardium in adult patients undergoing CABG surgery. Two authors independently extracted patients' perioperative data, including patients' baseline characteristics, surgical variables, and outcome data. For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio (OR) and 95% CI. Each outcome was tested for heterogeneity, and randomized-effects or fixed-effects model was used in the presence or absence of significant heterogeneity (Q test P<0.05). Sensitivity analyses were done by examining the influence of statistical model on estimated treatment effects. Publication bias was explored through visual inspection of funnel plots of the outcomes. Statistical significance was defined as P<0.05. Results Our search yielded 13 studies including 696 patients, and 402 patients were allocated into sevoflurane group and 294 into propofol group. There was no significant difference in postoperative mechanical ventilation time, inotropic support, mortality, myocardial infarction, and atrial fibrillation between the two groups (all P>0.05). Patients randomized into sevoflurane group had higher post-bypass cardiac index (WMD=0.39, 95% CI: 0.18 to 0.60, P=0.0003), lower troponin I level (WMD=-0.82, 95% CI:-0.87 to-0.85, P=0.0002), lower incidence of myocardial ischemia (OR=0.37, 95% CI: 0.16 to 0.83, P=0.02), shorter ICU and hospital stay length (WMD=-10.99, 95% CI:-12.97 to-9.01, P<0.00001; WMD=-0.78, 95% CI:-1.00 to-0.56, P<0.00001, respectively). Conclusion This meta-analysis has found some evidence showing that sevoflurane has better myocardial protection than propofol in CABG surgery.
文摘Objective:To evaluate the clinical efficacy of intravenous recombinant human brain natriuretic peptide(rhBNP)in patients with acute myocardial infarction after on-pump coronary artery bypass grafting(CABG).Methods:40 cases of coronary heart disease,left ventricular ejection fraction<50%and(plasma brain natriuretic peptide in type N terminal)NT-proBNP>300 pg/ml underwent on-pump coronary artery bypass surgery with cardiopulmonary bypass were enrolled and randomly divided into two groups,experimental group of 20 patients after operation on the basis of conventional therapy plus recombinant human brain natriuretic peptide treatment(first loading dose of 1.5μg/kg intravenously,to maintain dose of 0.01μg/kg/min continuous infusion of 72h),20 cases of the control group was given routine treatment,observe two groups of patients before and after treatment of blood pressure,heart rate,urine volume,blood creatinine and NT-proBNP,and to observe the left ventricular ejection fraction(LVEF),echocardiography and the length of time the index.Results:the experimental group after treatment,urine volume,left ventricular ejection fraction(LVEF),cardiac index(CI)was significantly higher than that before treatment,the serum creatinine,plasma N-terminal pro brain natriuretic peptide(NTproBNP),the content of serum troponin T peptide(cT nT),creatine kinase isoenzyme(CK MB)was significantly lower than before treatment.Conclusion:Recombinant human brain natriuretic peptide can improve cardiac and renal function in patients with acute period of acute myocardial infarction underwent coronary artery bypass surgery,shorten the hospitalization time,and it is safe and feasible.
文摘Coronary artery bypass grafting(CABG) continues to be one of the most commonly performed cardiac surgical procedures worldwide. Conventional CABG performed on cardiopulmonary bypass termed on-pump CABG is regarded as the gold standard. However, on-pump CABG results in several physiologic derangements including but not limited to thrombocytopenia, activation of complement factors, immune suppression, and inflammatory responses leading to organ dysfunction.Furthermore, manipulating an atherosclerotic ascending aorta during cannulation and cross-clamping can predispose to embolization and stroke risk. Recognition of these detrimental effects of on-pump CABG resulted in resurgence of off-pump CABG nearly two decades ago.Off-pump CABG since its resurgence has been a subject of intensive scrutiny and speculation. Despite numerous retrospective nonrandomized studies, prospective randomized trials, and meta-analyses validating the safety and efficacy of off-pump CABG, opponents of the technique have persistently demanded abandonment of off-pump CABG. Several misconceptions and misperceptions are used as an excuse for such demands. This review article examines published scientific evidence to evaluate these misperceptions and misconceptions about off-pump CABG.
文摘New surgical techniques for coronary artery bypass graft (CABG) have been explored in order to minimize disfiguring scars, avoid cardiopulmonary bypass and decrease hospital residence and costs etc. Improved surgical expense can perform the procedures in some high-risk patients such as poor left ventricular function, redo CABG, advanced age and renal dysfunction etc. Intraoperatively there is an obligatory period of myocardial ischemia, which may lead to significant hemodynamic consequences. It is a quite challenge to anesthetist in managing the intraoperative patient.
基金supported by a Sponsored Research Agreement between ECU and Novadaq Technologies,Inc.,Toronto,Ontario,Canada
文摘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.
基金This study was supported by the National Natural Science Foundation of China (81470491). We thank all the staff of the Department of Cardiology in Xuanwu Hospital affilitated to the Capital Medical University for their contribution to this study.
文摘Coronary bypass graft surgery (CABG) is a revascularization procedure which reduces myocardial ischemia and cardiovascular morbidity and mortality in selected patients;however, up to 40% of saphanous vein grafts may degenerate over 10 years. Although coronary angiography is the gold standard to detect graft patency and native vessel disease, sometimes it is difficult to locate the grafts resulting in increased exposure to radiation and contrast administration. This case highlights the utility of cardiac computerized tomography and magnetic resonance imaging to provide comprehensive noninvasive assessment in a patient post CABG.(J Geriatr Cardiol 2007;4:244-247.)
基金Supported by A clinical fellowship from the Netherlands Organisation for Health Research and Development to Folkert W Asselbergs,No.90700342
文摘AIM: To investigate potential gender differences in the prevalence of cardiovascular risk factors, cardiovascular disease (CVD) management, and prognosis in acute coronary syndrome (ACS). METHODS: A systematic literature search was performed through Medline using pre-specified key words . An additional search was performed, focusing specifically on randomized controlled clinical trials in relation to therapeutic intervention and prognosis. In total, 92 relevant articles were found. RESULTS: Women with CVD tended to have more hypertension and diabetes at the time of presentation, whereas men were more likely to smoke. Coronary angiography and revascularization by percutaneous coronary intervention were performed more often in men. Women were at a greater risk of short-term mortality and complications after revascularization. Interestingly, women under 40 years presenting with ACS were athighest risk of cardiovascular death compared with men of the same age, irrespective of risk factors. This disadvantage disappeared in older age. The long-term mortality risk of ACS was similar in men and women, and even in favor of women. CONCLUSION: Mortality rates are higher among young women with ACS, but this difference tends to disappear with age, and long-term prognosis is even better among older women.
文摘Background Myocardial protection during off-pump coronary artery bypass grafting (OPCABG) is a multifactorial problem in which maintaining stable systemic hemodynamics is very important. In this study passive graft perfusion (PGP) was applied to investigate the effect during and after OPCABG as evaluated by cardiac troponin I (CTnl) and hemodynamic indexes. Methods Thirty first-time patients underwent OPCABG under one surgeon. They were randomly divided into two groups: The passive graft perfusion group (PGP, n=15) received distal coronary perfusion during the anastomosis and immediate graft perfusion after the distal anastomosis. The control group, no graft perfusion group, (NGP, n=15) received no graft perfusion after the distal anastomosis. The results of the two protocols were evaluated by concentration of CTnl and hemodynamic indexes before induction and after operation. Results There were no statistically significant differences between these two groups in their perioperation parameters. The level of CTnl increased postoperatively, reached its peak at 6 hours (P〈0.05) and recovered by the 6 days postoperative. Compared with the control group the concentration of CTnl in the PGP group was significantly lower at 6 and 24 hours (P〈0.01). Compared with the NGP group, cardiac index (CI) in the PGP group was higher at 12 and 24 hours after operation (P〈0.05). The period of mechanical ventilation was significantly shorter in the PGP group than in the NGP group (P〈0.05). Conclusion PGP can increase the flow to the myocardium and shorten the heart ischemia time, thus maintain stable systemic hemodynamics, supply a satisfactory CI after surgery and improve surgery outcome.
文摘Background Kawasaki disease (KD) is the leading cause of pediatric ischemic heart disease. The incidence of serious coronary sequelae is low and about 2%-3% of patients with KD, but once myocardial infarction occurs in children, the mortality is quite high and 22% at the first infarction.This study aimed to evaluate the efficacy of coronary artery bypass grafting (CABG) in patients with KD. Methods Eight patients with a history of KD underwent CABG between October 1997 and July 2005. The number of bypass grafts placed was 2 to 4 per patient (mean 2.5±0.8). Various bypass grafts were used in patients, i.e. the left internal mammary artery (LIMA) in 3 patients, bilateral internal mammary artery (IMA) in 2 patients, LIMA plus gastroepiploic artery (GEA) in 1 patient and total saphenous vein grafts (SVGs) in 2 patients. The combined procedures included ventricular aneurysmectomy in 1 patient, mitral valve plasty in 1 and right coronary aneurysmectomy in 1. One patient was not able to wean from cardiopulmonary bypass (CPB), after being supported with intra-aortic balloon pump (IABP), the patient was weaned from CPB successfully. Results One patient died of low cardiac output syndrome and acute renal failure 19 days after operation. Other patients recovered and were discharged uneventfully. During the follow-up that ranged from 3 to 57 months (mean 27 months), clincal angina disappeared or improved. Cardiac function was in Class I-II (NYHA).Conclusion CABG is a safe and effective procedure for Kawasaki coronary artery disease. However long-term results need to be followed up.
文摘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.
文摘Background Patients with prior coronary artery bypass graft (CABG) have a poor outcome after acute myocardial infarction (AMI).Little is known about the treatment strategy and outcome of percutaneous coronary intervention (PCI) in these patients.The purpose of this study was to investigate the impact of graft versus native artery PCI on the outcomes of prior CABG patients with AMI.Methods Between September 2005 and October 2011,a total of 140 consecutive patients with previous CABG undergoing PCI for the treatment of AMI were included.Clinical/procedural characteristics and long-term clinical outcomes were compared between graft and native artery PCI patients.Results The mean time interval to prior CABG was (5.6±4.2) years.Thirty patients received graft PCI,success rate being 90%.One hundred and ten patients received native artery PCI,success rate being 90.7% (P 〉0.05).There were no significant differences in the basic characteristics between the two groups.All patients received drug eluting stents (DESs).Three patients died during hospitalization in the graft-PCI group (10% vs.native PCI 0,P 〈0.05).After a median followup of two years,major adverse cardiac events (MACE) (myocardial infarction,target vessel revascularization,total death) were 20% with no significant difference between the two groups.Cox regression analysis showed that both diabetes mellitus (DM,HR 3.57,95% CI 1.03-5.75,P 〈0.05) and primary PCI (HR 5.932,95% Cl 1.91-18.4,P 〈0.05) were independent predictors of MACE.Conclusions More patients with prior CABG underwent native artery PCI for AMI.PCI to culprit graft vessels had higher in-hospital mortality.DM and primary PCI,but not graft PCI,were predictors for adverse long-term outcome.
文摘AIM: To identify the typical shape of the rise and fall curve of troponin(Tn) following the different types of myocardial infarction(MI). METHODS: We conducted a systematic search in PubM ed and Embase including all studies which focused on the kinetics of Tn in MI type 1, type 4 and type 5. Tn levels were standardized using the 99 th percentile, a pooled mean with 95%CI was calculated from the weighted means for each time point until 72 h. RESULTS: A total of 34 of the 2528 studies identified in the systematic search were included. The maximum peak level of the Tn was seen after 6 h after successful reperfusion of an acute MI, after 12 h for type 1 MI and after 72 h for type 5 MI. In type 1 MI there were additional smaller peaks at 1 h and at 24 h. After successful reperfusion of an acute MI there was a second peak at 24 h. There was not enough data available to analyze the Tn release after MI associated with percutaneous coronary intervention(type 4).CONCLUSION: The typical rise and fall of Tn is different for type 1 MI, successful reperfusion of an acute MI and type 5 MI, with different timing of the peak levels and different slopes of the fall phase.
文摘The current practice of myocardial revascularization for acute myocardial infarction (MI) is primary percutaneous intervention (PCI). Surgical revascularization (“bypass”) is reserved for patients unsuitable for PCI. The purpose of this report is to describe the long-term outcome of acute MI patients who underwent left-sided arterial revascularization (left anterior descending and circumflex arteries) before PCI was adopted as the preferred treatment for this subset of patients. Between 1996 and 2002, 434 consecutive patients in our center underwent myocardial revascularization for recent MI using the composite T-graft technique (381 bilateral internal thoracic arteries and 53 single internal thoracic artery and radial arteries). Two-hundred and seventy-six patients were operated on within seven days of an acute MI (Group A) and the remaining 158 patients were operated on after the 7th day since an acute MI (Group B). Group A had significantly increased operative mortality (6.5% vs 1.3% for Group B, P = 0.012). Surgery performed within the first week of an acute MI was also found to be a significant predictor of early mortality in multivariate logistic regression analysis (O.R. 10.31;95% C.I. 1.32-83.30, P = 0.026). The mean follow-up was 10.6 ± 5.2 years. The Kaplan Meier 10-year survival of the two groups, however, was similar (65.6 ± 2.9 Group A vs 64.6 ± 3.8 Group B, P = 0.953), and assignment to Group A was not an independent predictor of decreased survival (P = 0.395, Cox model). When using arterial grafts for myocardial revascularization, the long-term outcome of patients operated on during the first 7 days of acute MI is not worse than that of patients operated on after more than 7 days, despite their increased operative mortality.