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The ROMA trial is a large randomized clinical trial comparing single arterial grafting (SAG) and multiple arterial grafting (MAG) in coronary artery bypass surgery (CABG). The trial began in 2017 and is expected to conclude in 2023. It was initiated due to the inconclusive results of a previous trial. Challenges faced by the ROMA trial include high crossover rates and the impact of the COVID-19 pandemic. The trial's results are still pending but are anticipated to provide valuable insights into the effectiveness of MAG in CABG procedures. The success of the ROMA trial has led to the establishment of the ROMA network, which conducts other cardiac surgery trials. The trial involves multiple participating centers across different continents, including hospitals in Asia such as Jilin Heart Hospital, Fuwai Hospital, Teda Hospital, National Taiwan University Hospital, and Ruijin Hospital Shanghai Jiao Tong USM. The document also provides a list of hospitals and medical institutions from various countries involved in the trial. The ROMA trial is funded by the National Institutes of Health and the Canadian Institutes of Health and Research. [Extracted from the article]

Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials. [ABSTRACT FROM AUTHOR]

As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines. [Display omitted] • Expanded use of cardiac imaging has resulted in the identification of a greater number of adults with AAOCA, which encompasses a wide range of anomalies and associated symptoms. • This variability makes general recommendations difficult to apply, so using a structured Delphi process, an expert panel agreed on recommendations that complement clinical practice guidelines. • Individualized implementation requires understanding of the mechanisms of ischemia in patients with AAOCA, the approach to symptoms, the role of imaging, clinical risk assessment, and options for revascularization. [ABSTRACT FROM AUTHOR]

BACKGROUND: Graft patency is the postulated mechanism for the benefits of coronary artery bypass grafting (CABG). However, systematic graft imaging assessment after CABG is rare, and there is a lack of contemporary data on the factors associated with graft failure and on the association between graft failure and clinical events after CABG. METHODS: We pooled individual patient data from randomized clinical trials with systematic CABG graft imaging to assess the incidence of graft failure and its association with clinical risk factors. The primary outcome was the composite of myocardial infarction or repeat revascularization occurring after CABG and before imaging. A 2-stage meta-analytic approach was used to evaluate the association between graft failure and the primary outcome. We also assessed the association between graft failure and myocardial infarction, repeat revascularization, or all-cause death occurring after imaging. RESULTS: Seven trials were included comprising 4413 patients (mean age, 64.4±9.1 years; 777 [17.6%] women; 3636 [82.4%] men) and 13 163 grafts (8740 saphenous vein grafts and 4423 arterial grafts). The median time to imaging was 1.02 years (interquartile range [IQR], 1.00-1.03). Graft failure occurred in 1487 (33.7%) patients and in 2190 (16.6%) grafts. Age (adjusted odds ratio [aOR], 1.08 [per 10-year increment] [95% CI, 1.01-1.15]; P=0.03), female sex (aOR, 1.27 [95% CI, 1.08-1.50]; P=0.004), and smoking (aOR, 1.20 [95% CI, 1.04-1.38]; P=0.01) were independently associated with graft failure, whereas statins were associated with a protective effect (aOR, 0.74 [95% CI, 0.63-0.88]; P<0.001). Graft failure was associated with an increased risk of myocardial infarction or repeat revascularization occurring between CABG and imaging assessment (8.0% in patients with graft failure versus 1.7% in patients without graft failure; aOR, 3.98 [95% CI, 3.54-4.47]; P<0.001). Graft failure was also associated with an increased risk of myocardial infarction or repeat revascularization occurring after imaging (7.8% versus 2.0%; aOR, 2.59 [95% CI, 1.86-3.62]; P<0.001). All-cause death after imaging occurred more frequently in patients with graft failure compared with patients without graft failure (11.0% versus 2.1%; aOR, 2.79 [95% CI, 2.01-3.89]; P<0.001). CONCLUSIONS: In contemporary practice, graft failure remains common among patients undergoing CABG and is strongly associated with adverse cardiac events. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Preamble The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS). [ABSTRACT FROM AUTHOR]

Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance. [ABSTRACT FROM AUTHOR]

Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed. [ABSTRACT FROM AUTHOR]

Keywords: Coronary artery bypass grafting; Arterial grafting; Radial artery; Internal thoracic artery; Bilateral internal thoracic artery; Meta-analysis EN Coronary artery bypass grafting Arterial grafting Radial artery Internal thoracic artery Bilateral internal thoracic artery Meta-analysis 1 5 5 03/02/23 20230201 NES 230201 We are grateful for the opportunity to reply and comment on the Taggart I et al. i [[1]] and Freemantle I et al. i [[2]] pieces. Taggart I et al. i [[1]] raise the following points in their commentary: The mean age of the left internal thoracic artery (LITA) and radial artery (RA) group was younger than the other groups: this is incorrect. Apparent exclusion of the Radial Artery Patency and Clinical Outcomes (RAPCO) trial: RAPCO patients were excluded from the propensity score-matched analysis due to the high rate of missing baseline data which would have not allowed the application of a non-parsimonious model to calculate the propensity score. However, the RA effect is qualitatively consistent with the 30% mortality reduction with RA versus BITA at 15 years recently reported by the RAPCO trial and, despite all the described limitations, cannot be ignored or dismissed as implausible. [Extracted from the article]

Cardiac surgery presents specific methodological challenges in the design, implementation, and analysis of randomized controlled trials. The purposes of this scientific statement are to review key standards in cardiac surgery randomized trial design and implementation, and to provide recommendations for conducting and interpreting cardiac surgery trials. Recommendations include a careful evaluation of the suitability of the research question for a clinical trial, assessment of clinical equipoise, feasibility of enrolling a representative patient cohort, impact of practice variations on the safety and efficacy of the study intervention, likelihood and impact of crossover, and duration of follow-up. Trial interventions and study end points should be predefined, and appropriate strategies must be used to ensure adequate deliverability of the trial interventions. Every effort must be made to ensure a high completeness of follow-up; trial design and analytic techniques must be tailored to the specific research question and trial setting. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES We used individual patient data from 4 of the largest contemporary coronary bypass surgery trials to evaluate differences in long-term outcomes when radial artery (RA), right internal thoracic artery (RITA) or saphenous vein graft (SVG) are used to complement the left internal thoracic artery-to-left anterior descending graft. METHODS Primary outcome was all-cause mortality. Secondary outcome was a composite of major adverse cardiac and cerebrovascular events (all-cause mortality, myocardial infarction and stroke). Propensity score matching and Cox regression were used to reduce the effect of treatment selection bias and confounders. RESULTS A total of 10 256 patients (1510 RITA; 1385 RA; 7361 SVG) were included. The matched population consisted of 1776 propensity score-matched triplets. The mean follow-up was 7.9 ± 0.1, 7.8 ± 0.1 and 7.8 ± 0.1 years in the RITA, RA and SVG cohorts respectively. All-cause mortality was significantly lower in the RA versus the SVG [hazard ratio (HR) 0.62, 95% confidence interval (CI): 0.51–0.76, P  = 0.003] and the RITA group (HR 0.59, 95% CI 0.48–0.71, P  = 0.001). Major adverse cardiac and cerebrovascular event rate was also lower in the RA group versus the SVG (HR 0.78, 95% CI 0.67–0.90, P  = 0.04) and the RITA group (HR 0.75, 95% CI 0.65–0.86, P  = 0.02). Results were consistent in the Cox-adjusted analysis and solid to hidden confounders. CONCLUSIONS In this pooled analysis of 4 large coronary bypass surgery trials, the use of the RA was associated with better clinical outcomes when compared to SVG and RITA. [ABSTRACT FROM AUTHOR]

Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Patients who develop POAF are more likely to experience adverse outcomes, including increased rates of death, stroke, heart failure, and hospitalizations, and higher hospital costs. Understanding the mechanisms underlying POAF is important to improve patients' outcome and optimize health systems' efficiency. Beyond classic pathogenic hypotheses, emerging evidence suggests that postoperative pericardial effusion and localized pericardial inflammation may trigger POAF. This hypothesis is supported by data from nonhuman animal models and a growing body of evidence showing that reducing postoperative pericardial effusion might reduce POAF incidence. In this review, we summarize the classic pathophysiology theories of POAF following cardiac surgery and discuss new etiologic mechanisms with a specific focus on the role of pericardial effusion and inflammation. [ABSTRACT FROM AUTHOR]

Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery. [ABSTRACT FROM AUTHOR]

The fragility index is a clinically meaningful metric based on modifying patient outcomes that is increasingly used to interpret the robustness of clinical trial results. The fragility index relies on a concept that explores alternative realizations of the same clinical trial by modifying patient measurements. In this article, we propose to generalize the fragility index to a family of fragility indices called the incidence fragility indices that permit only outcome modifications that are sufficiently likely and provide an exact algorithm to calculate the incidence fragility indices. Additionally, we introduce a far-reaching generalization of the fragility index to any data type and explain how to permit only sufficiently likely modifications for nondichotomous outcomes. All of the proposed methodologies follow the fragility index concept. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery.Methods: In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible patients were randomly assigned (1:1), stratified by CHA2DS2-VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population. Safety was assessed in the as-treated population. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete.Findings: Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0-70·0), 102 (24%) patients were female, and 318 (76%) were male, with a median CHA2DS2-VASc score of 2·0 (IQR 1·0-3·0). The two groups were balanced with respect to clinical and surgical characteristics. No patients were lost to follow-up and data completeness was 100%. Three patients in the posterior left pericardiotomy group did not receive the intervention. In the ITT population, the incidence of postoperative atrial fibrillation was significantly lower in the posterior left pericardiotomy group than in the no intervention group (37 [17%] of 212 vs 66 [32%] of 208 [p=0·0007]; odds ratio adjusted for the stratification variable 0·44 [95% CI 0·27-0·70; p=0·0005]). Two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group died within 30 days after hospital discharge. The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 [12%] of 209 vs 45 [21%] of 211; relative risk 0·58 [95% CI 0·37-0·91]). Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) in the no intervention group. No posterior left pericardiotomy related complications were seen.Interpretation: Posterior left pericardiotomy is highly effective in reducing the incidence of atrial fibrillation after surgery on the coronary arteries, aortic valve, or ascending aorta, or a combination of these without additional risk of postoperative complications.Funding: None. [ABSTRACT FROM AUTHOR]

Transit time flow measurement (TTFM) allows quality control in coronary artery bypass grafting but remains largely underused, probably because of limited information and the lack of standardization. We performed a systematic review of the evidence on TTFM and other methods for quality control in coronary artery bypass grafting following PRISMA standards and elaborated expert recommendations by using a structured process. A panel of 19 experts took part in the consensus process using a 3-step modified Delphi method that consisted of 2 rounds of electronic voting and a final face-to-face virtual meeting. Eighty percent agreement was required for acceptance of the statements. A 2-level scale (strong, moderate) was used to grade the statements based on the perceived likelihood of a clinical benefit. The existing evidence supports an association between TTFM readings and graft patency and postoperative clinical outcomes, although there is high methodological heterogeneity among the published series. The evidence is more robust for arterial, rather than venous, grafts and for grafts to the left anterior descending artery. Although TTFM use increases the duration and the cost of surgery, there are no data to quantify this effect. Based on the systematic review, 10 expert statements for TTFM use in clinical practice were formulated. Six were approved at the first round of voting, 3 at the second round, and 1 at the virtual meeting. In conclusion, although TTFM use may increase the costs and duration of the procedure and requires a learning curve, its cost/benefit ratio seems largely favorable, in view of the potential clinical consequences of graft dysfunction. These consensus statements will help to standardize the use of TTFM in clinical practice and provide guidance in clinical decision-making. [ABSTRACT FROM AUTHOR]

Hence, Carpentier restarted the RA use, but this time using a calcium-channel blocker (CB), during and after the operation.2 Finally, in 1992, he published a paper titled: "Revival of the radial artery for coronary artery bypass grafting", where significantly improved patency was reported.4 It seemed that the "key" for preserving RA patency perhaps was the use of CB as the very early start of the harvesting and the prescription as chronic antispastic agents. Keywords: calcium-channel blockers; radial artery EN calcium-channel blockers radial artery 1827 1831 5 05/11/21 20210601 NES 210601 INTRODUCTION The first use of the radial artery (RA) as a conduit for coronary artery bypass grafting is dated back in 1973 when Carpentier and colleagues published a case series of 30 patients1; he explored the RA potential due to the larger diameter, ease of dissection, and generally more suitability for suturing. Cameron et al.20 performed an angiogram 5 years post-RA grafting in 50 patients; 37 of these patients received CB. 17 Gaudino M, Glieca F, Luciani N, Alessandrini F, Possati G. Clinical and angiographic effects of chronic calcium channel blocker therapy continued beyond first postoperative year in patients with radial artery grafts: results of a prospective randomized investigation. [Extracted from the article]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The optimal revascularization strategy for patients with ischaemic left ventricular systolic dysfunction (iLVSD) remains controversial. We aimed to compare percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT) in a network meta-analysis. METHODS All randomized controlled trials and observational studies comparing any combination of PCI, CABG and MT in patients with iLVSD were analysed in a frequentist network meta-analysis (generic inverse variance method). Primary outcome was mortality at longest available follow-up. Secondary outcomes were cardiac death, stroke, myocardial infarction (MI) and repeat revascularization (RR). RESULTS Twenty-three studies were included (n  = 23 633; 4 randomized controlled trials). Compared to CABG, PCI was associated with higher mortality [incidence rate ratio (IRR) 1.32, 95% confidence interval (CI) 1.13–1.53], cardiac death (IRR 1.65, 95% CI 1.18–2.33), MI (IRR 2.18, 95% CI 1.70–2.80) and RR (IRR 3.75, 95% CI 2.89–4.85). Compared to CABG, MT was associated with higher mortality (IRR 1.52, 95% CI 1.26–1.84), cardiac death (IRR 3.83, 95% CI 2.12–6.91), MI (IRR 3.22, 95% CI 1.52–6.79) and RR (IRR 3.37, 95% CI 1.67–6.79). Compared to MT, PCI was associated with lower cardiac death (IRR 0.43, 95% CI 0.24–0.78). CABG ranked as the best revascularization strategy for mortality, cardiac death, MI and RR; MT ranked as the strategy associated with the lowest incidence of stroke. Left ventricular ejection fraction, year of study, use of drug-eluting stents did not affect relative treatment effects. CONCLUSIONS CABG appears to be the best therapy for iLVSD, although mainly based on observational data. Definitive randomized controlled trials comparing CABG and PCI in iLVSD are required. PROSPERO registration ID 132414. [ABSTRACT FROM AUTHOR]

Introduction: Post‐infarction left ventricular remodeling is associated with increased mortality in patients with ischemic heart disease. Surgical ventricular reconstruction (SVR) in addition to coronary artery bypass grafting (CABG) has been proposed to reduce left ventricular volume and improve clinical outcomes. The Surgical Treatment for Ischemic Heart Failure (STICH) trial found that the addition of SVR to CABG did not reduce the rates of death or rehospitalization in the 5 years after surgery compared to CABG alone. Like all randomized trials, STICH has limitations and it has been hypothesized that it may have underestimated the treatment effect of SVR. The aim of this study is to evaluate the results of SVR in one of the largest contemporary single‐center series and to compare the results with those of the STICH trial using individual patient's data. Methods and Analysis: Individual data of patients who underwent SVR with or without CABG will be obtained from San Donato University Hospital in Milan. Using multivariable Cox regression analysis, significant prognostic indicators in this cohort will be identified. We will then compare the San Donato cohort to individual patient's data from the SVR arm of Hypothesis 2 of the STICH trial and from both arms of the STICH Extended Study (STICHES). To reduce confounders, propensity score adjustment will be used for this comparison. The primary endpoint will be all‐cause mortality. Data will be merged and analyzed independently at Weill Cornell Medicine in New York. [ABSTRACT FROM AUTHOR]

Indeed, the majority of contemporary randomized trials that included imaging follow-up at 1 year have failed to demonstrate a significant benefit of intensified antithrombotic therapy including oral anticoagulation on SVG patency over aspirin5,6,12-14 (Figure 1). Keywords: coronary artery disease; patency; saphenous vein graft; ticagrelor EN coronary artery disease patency saphenous vein graft ticagrelor 1087 1089 3 03/02/22 20220401 NES 220401 Saphenous vein grafts (SVGs) remain the most commonly used conduits in coronary artery bypass grafting (CABG) despite greater rates of both early and late occlusion compared to arterial grafts. In a recent meta-analysis based on aggregate data from 48 studies including 41,530 grafts, the pooled incidence of SVG occlusion within the first year after CABG was estimated at 11%.1 The role of aspirin in the prevention of SVG failure has been firmly established. [Extracted from the article]

Background: The association of age with the outcomes of bilateral internal thoracic arteries (BITAs) versus single internal thoracic arteries (SITAs) for coronary bypass grafting (CABG) remains to be determined.Objectives: The purpose of this study was to evaluate the association between age and BITA versus SITA outcomes in the Arterial Revascularization Trial.Methods: The primary endpoints were all-cause mortality and a composite of major adverse events, including all-cause mortality, myocardial infarction, or stroke. Secondary endpoints were bleeding complications and sternal wound complications up to 6 months after surgery. Multivariable fractional polynomials analysis and log-rank tests were used.Results: Age did not affect any of the explored outcomes in the overall BITA versus SITA comparison in the intention-to-treat analysis and in the analysis based on the number of arterial grafts received. However, when the intention-to-treat analysis was restricted to the populations of patients between age 50 and 70 years, younger patients in the BITA arm had a significantly lower incidence of major adverse events (p = 0.03).Conclusions: Our results suggest that BITA may improve long-term outcome in younger patients, although more randomized data are needed to confirm this hypothesis. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide Observational evidence shows that the use of multiple arterial grafts (MAG) is associated with longer postoperative survival and improved clinical outcomes. The current European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommend the use of MAG in appropriate patients. However, a significant volume-to-outcome relationship exists for MAG, and lack of sufficient experience is associated with increased operative risk. A stepwise approach to building experience with MAG allows successful implementation of this technique into routine coronary surgery practice. [ABSTRACT FROM AUTHOR]

Perioperative stroke is one of the most severe and feared complications of cardiac surgery. Based on the timing of onset and detection, perioperative stroke can be classified as intraoperative or postoperative. The pathogenesis of perioperative stroke is multifactorial, which makes prediction and prevention challenging. However, information on its incidence, mechanisms, diagnosis, and treatment can be helpful in minimizing the perioperative neurological risk for individual patients. We herein provide suggestions on preoperative, intraoperative, and postoperative strategies aimed at reducing the risk of perioperative stroke and at improving the outcomes of patients who experience a perioperative stroke. [ABSTRACT FROM AUTHOR]

Background: Postoperative atrial fibrillation (pAF) after coronary artery bypass grafting is a common complication. Whether pAF is associated with an increased risk of cerebrovascular accident (CVA) remains uncertain. We investigated the association between pAF and long-term risk of CVA by performing a post hoc analysis of 10-year outcomes of the ART (Arterial Revascularization Trial).Methods: For the present analysis, among patients enrolled in the ART (n=3102), we excluded those who did not undergo surgery (n=25), had a history of atrial fibrillation (n=45), or had no information on the incidence of pAF (n=9). The final population consisted of 3023 patients, of whom 734 (24.3%) developed pAF with the remaining 2289 maintaining sinus rhythm. Competing risk and Cox regression analyses were used to investigate the association between pAF and the risk of CVA.Results: At 10 years, the cumulative incidence of CVA was 6.3% (4.6%-8.1%) versus 3.7% (2.9%-4.5%) in patients with pAF and sinus rhythm, respectively. pAF was an independent predictor of CVA at 10 years (hazard ratio, 1.53 [95% CI, 1.06-2.23]; P=0.025) even when CVAs that occurred during the index admission were excluded from the analysis (hazard ratio, 1.47 [95% 1.02-2.11]; P=0.04).Conclusions: Patients with pAF after coronary artery bypass grafting are at higher risk of CVA. These findings challenge the notion that pAF is a benign complication. [ABSTRACT FROM AUTHOR]

Introduction: The impact of sex on the outcomes after coronary artery bypass grafting (CABG) is controversial. The majority of CABG studies are retrospectively collected clinical or registry data, women comprise only a minority, and the reported findings represent the male predominated cohort. This individual patient meta-analysis is aimed at evaluating sex-related differences in outcomes after CABG using high quality data from randomized controlled trials (RCTs).Methods and Analysis: A systematic literature search will be performed to identify all CABG RCTs (minimum follow-up: 5 years). Detailed specification for the minimum deidentified patient records' data requirements will be provided to RCT primary contact to request their deidentified data for pooling. The pooled analysis will follow the prospective register of systematic reviews (PROSPERO) and the preferred reporting items for systematic reviews and meta-analyses for individual patient data systematic reviews (PRISMA-IPD) recommendations and will compare sex-related outcomes after CABG. The main hypothesis is that outcomes after CABG are worse in women than in men. We will also test whether treatment effects for off-pump and the use of multiple arterial grafts are present within each sex, and also, whether there are differential treatment effects between sexes. The primary endpoint will be a composite of all-cause mortality, myocardial infarction, stroke, and repeat revascularization at long-term follow up.Ethics and Dissemination: Ethics approval and participant consent for the study will be obtained locally by each study team if needed. Data will be disseminated and submitted to peer-reviewed scientific journals and meetings irrespective of study outcome. [ABSTRACT FROM AUTHOR]

Importance: Observational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials.Objective: To compare clinical outcomes between patients receiving radial artery vs saphenous vein grafts for coronary artery bypass grafting after long-term follow-up.Design, Setting, and Participants: Patient-level pooled analysis comparing radial artery vs saphenous vein graft in adult patients undergoing isolated coronary artery bypass grafting from 5 countries (Australia, Italy, Serbia, South Korea, and the United Kingdom), with enrollment from 1997 to 2009 and follow-up completed in 2019.Interventions: Patients were randomized to undergo either radial artery (n = 534) or saphenous vein (n = 502) grafts for coronary artery bypass grafting.Main Outcomes and Measures: The primary outcome was a composite of death, myocardial infarction, or repeat revascularization and the secondary outcome was a composite of death or myocardial infarction.Results: A total of 1036 patients were randomized (mean age, 66.6 years in the radial artery group vs 67.1 years in the saphenous vein group; 376 [70.4%] men in the radial artery group vs 351 [69.9%] in the saphenous vein group); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 in the radial artery group). At a median (interquartile range) follow-up of 10 (10-11) years, the use of the radial artery, compared with the saphenous vein, in coronary artery bypass grafting was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction, or repeat revascularization (220 vs 237 total events; 41 vs 47 events per 1000 patient-years; hazard ratio, 0.73 [95% CI, 0.61-0.88]; P < .001) and of the composite of death or myocardial infarction (188 vs 193 total events; 35 vs 38 events per 1000 patient-years; hazard ratio, 0.77 [95% CI, 0.63-0.94]; P = .01).Conclusions and Relevance: In this individual participant data meta-analysis with a median follow-up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with the saphenous vein was associated with a lower risk of a composite of cardiovascular outcomes. [ABSTRACT FROM AUTHOR]

Compared with randomized controlled trials (RCTs) in medical specialties, RCTs in cardiac surgery face specific issues. Individual and collective equipoise, rapid evolution of the surgical techniques, as well as difficulties in obtaining funding, and limited education in clinical epidemiology in the surgical community are among the most important challenges in the design phase of the trial. Use of complex interventions and learning curve effect, differences in individual operators' expertise, difficulties in blinding, and slow recruitment make the successful completion of cardiac surgery RCTs particularly challenging. In fact, over the course of the last 20 years, the number of cardiac surgery RCTs has declined significantly. In this review, a team of surgeons, trialists, and epidemiologists discusses the most important challenges faced by RCTs in cardiac surgery and provides a list of suggestions for the successful design and completion of cardiac surgery RCTs. [ABSTRACT FROM AUTHOR]

Whether hemodiafiltration (HDF) is better than conventional hemodialysis (HD) in improving left ventricular hypertrophy (LVH), defined as reduction of the left ventricular mass index (LVMi) and increasing the ejection fraction (EF), is unclear. A systematic literature search was performed. Primary outcome was the mean difference between pre- and post-procedural LVMi. Secondary outcome was the mean difference in EF. Seven studies with a total of 845 patients were included. The pooled mean difference between pre-and post-procedural LVMi was -8.0 g/m2 (95% confidence interval [CI] -13.1, -2.8). On subgroup analysis, the mean differences between pre- and post-procedural LVMi for HD and HDF were -6.7 g/m2 (95% CI -14.5, 1.1) and -9.3 g/m2 (95% CI -16.3, -2.3), respectively (P for subgroups = .62). Pooled mean difference between pre- and post-procedural EF was 2.4% (95% CI -1.8, 6.5). On subgroup analysis, the mean differences between pre- and post-procedural EF for HD and HDF were 3.6% (95% CI -2.7, 9.8) and 2.0% (95% CI 2.9, 6.8), respectively (P for subgroups = .68). On meta-regression, age (Beta -0.35 ± 0.05, P < .001) and longer dialysis duration (Beta -0.12 ± 0.02, P < .001) were associated with lower mean difference between pre-and post-procedural EF. No significant effects on changes in LVMi and EF were observed with HDF compared with conventional HD. [ABSTRACT FROM AUTHOR]

It is generally accepted that radial artery (RA) grafts have better mid-term patency rate compared to saphenous vein grafts. However, the clinical correlates of the improved patency rate are still debated. Observational studies have suggested increased survival and event-free survival for patients who receive an RA rather than a saphenous vein, but they are open to bias and confounders. The only evidence based on randomized data is a pooled meta-analysis of 6 randomized controlled trial comparing the RA and the saphenous vein published by the RADial artery International Alliance (RADIAL). In the RADIAL database, improved freedom from follow-up cardiac events (death, myocardial infarction and repeat revascularization) was found at 5-year follow-up in the RA arm. The most important limitation of the RADIAL analysis is that most of the included trials had an angiographic follow-up in the first 5 years and it is unclear whether the rate of repeat revascularization (the main driver of the composite outcome) was clinically indicated due to per-protocol angiographies. Here, we present the protocol for the long-term analysis of the RADIAL database. By extending the follow-up beyond the 5th postoperative year (all trials except 1 did not have angiographic follow-up beyond 5 years), we aim to provide data on the role of RA in coronary artery bypass surgery with respect to long-term outcomes. [ABSTRACT FROM AUTHOR]

Given the lack of established benefit, routine P2Y12 receptor inhibitor pretreatment in NSTE-ACS is not recommended in patients in whom the coronary anatomy is not known and early invasive management is planned, although it may be considered for patients with delayed invasive management.3 However, P2Y12 receptor inhibitor pretreatment may increase bleeding risk and delay surgery after diagnostic angiography in patients for whom CABG is indicated. In addition, in studies investigating the association of P2Y12 receptor inhibitors and perioperative bleeding risk a surgical bleeding site was identified in up to 55% of patients undergoing reoperation for bleeding,5,14 potentially confounding reports of increased bleeding with ticagrelor. Hansson et al.10 studied the incidence of CABG-related bleeding using the Bleeding Academic Research Consortium (BARC) classification11 in relation to P2Y12 receptor inhibitor discontinuation periods in a retrospective analysis of 2244 ACS patients referred for CABG on DAPT with either ticagrelor or clopidogrel. [Extracted from the article]

Observational and randomized evidence shows that arterial grafts have better patency rates than saphenous vein grafts (SVGs) in coronary artery bypass grafting. Observational studies suggest that the use of multiple arterial grafts is associated with longer postoperative survival, but this must be interpreted in the context of treatment allocation bias and hidden confounders intrinsic to the study designs. Recently, a pooled analysis of 6 randomized trials comparing the radial artery with the SVG as the second conduit and the largest randomized trial comparing the use of single and bilateral internal thoracic arteries have provided apparently divergent results about a clinical benefit with the use of >1 arterial conduit. However, both analyses have methodological limitations that may have influenced their results. At present, it is unclear whether the well-documented increased patency rate of arterial grafts translates into clinical benefits in the majority of patients undergoing coronary artery bypass grafting. A large randomized trial testing the arterial grafts hypothesis (ROMA [Randomized Comparison of the Clinical Outcome of Single Versus Multiple Arterial Grafts]) is underway and will report the results in a few years. [ABSTRACT FROM AUTHOR]

Background: Few studies have evaluated the effect of chronic calcium-channel blocker therapy (CCB) on the angiographic and clinical outcome of radial artery (RA) grafts used for coronary bypass surgery.Objectives: The purpose of this study was to evaluate if CCB influences midterm clinical and angiographic outcomes of RA grafts.Methods: Patient-level data of 6 angiographic randomized trials evaluating RA graft status at midterm follow-up were joined in this observational analysis. Cox regression and propensity score methods were used to evaluate the effect of CCB on the incidence of a composite of major adverse cardiac events (MACE) (death, myocardial infarction, and repeat revascularization) and graft occlusion.Results: The study population included 732 patients (502 on CCB). The median clinical follow-up was 60 months. The cumulative incidence of MACE at 36, 72, and 108 months was 3.7% vs. 9.3%, 13.4% vs. 17.6%, and 16.8% vs. 20.5% in the CCB and no CCB groups, respectively (log-rank p = 0.003). Protocol-driven angiographic follow-up was available in 243 patients in the CCB group and 200 in the no CCB group. The median angiographic follow-up was 55 months. The cumulative incidence of RA occlusion at 36, 72, and 108 months was 0.9% vs. 8.6%, 9.6% vs. 21.4%, and 14.3% vs. 38.9% in the CCB and no CCB groups, respectively (log-rank p < 0.001). After controlling for known confounding, CCB therapy was found to be consistently associated with a significantly lower risk of MACE (multivariate Cox hazard ratio: 0.52; 95% confidence interval: 0.31 to 0.89; p = 0.02) and RA graft occlusion (multivariate Cox hazard ratio: 0.20; 95% confidence interval: 0.08 to 0.49; p < 0.001).Conclusions: In patients with RA grafts CCB is associated with significantly better midterm clinical and angiographic RA outcomes. [ABSTRACT FROM AUTHOR]

Keywords: Editorials; coronary artery bypass; coronary artery bypass, off-pump; myocardial revascularization; randomized controlled trial; treatment outcome It is critically important that we continuously refine our techniques for surgical coronary revascularization, both on-pump and off-pump, to better serve these patients with complex comorbidities. Five-year outcomes after on-pump and off-pump coronary-artery bypass. Editorials, coronary artery bypass, coronary artery bypass, off-pump, myocardial revascularization, randomized controlled trial, treatment outcome. [Extracted from the article]

Abstract After more than thirty years, a hundred randomized studies and dozens of meta-analyses, there is still controversy on the results and benefits of off-pump coronary artery bypass grafting. The present review summarizes the most relevant evidence, the relation of outcomes with surgeon's and institution's experience, addresses regional variations in popularity of the technique, and the need for structural training. Highlights • The benefits of off-pump coronary artery bypass grafting (OPCAB) are still matter of debate • The prevalence of OPCAB varies greatly among countries • OPCAB reduces short-term morbidity at the expense of a higher rate of incomplete revascularization • Results of OPCAB improve sensibly with the surgeon's and centre's experience • Dedicated "OPCAB teams" might guarantee the best possible outcomes [ABSTRACT FROM AUTHOR]

An editorial is presented which discusses use of radial artery (RA) as a conduct for coronary artery bypass grafting (CABG). It mentions that 2018 European Society of Cardiology-European Association of Cardiothoracic Surgery (ESC/EACTS) guidelines on myocardial revascularization issued stated that additional arterial graft should be considered in appropriate patients (IIaB) and that the use of the RA is recommended over saphenous vein (SV) in patients with high-grade coronary artery stenosis.

We summarize the evidence on the new strategies for coronary artery bypass grafting (CABG). Hybrid CABG implies surgical grafting of the left anterior descending artery and percutaneous treatment of the other target vessels, with the promise of combining the durable benefits of surgery with the less invasive approach of percutaneous coronary interventions. Robotic CABG and minimally invasive CABG are performed through minimal incision or port access with dedicated equipment and instruments. Anaortic coronary artery bypass refers to off-pump CABG using only in-situ grafts. The use of multiple arterial grafts has been shown to improve patency and is potentially associated with better clinical outcomes. All these techniques require dedicated training and are more complex than conventional CABG but can significantly improve the results of surgery. Validation of the results of these new approaches in large randomized trials is a priority for the surgical community. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Since 2000, we anastomosed the saphenous vein graft to the right coronary artery system using the stump of the right internal thoracic artery as inflow. The long-term results of patients where the right coronary artery was grafted with the right internal thoracic artery or the ascending aorta as saphenous vein inflow has not been reported. METHODS From 2000 to 2018, 699 consecutive patients had right internal thoracic artery elongated with saphenous vein (I-graft group, n  = 358, 51.2%) or saphenous vein from the aorta (Ao-graft group, n  = 341, 48.8%) on right coronary artery system. Inclusion criteria were age ≤75 years, bilateral internal thoracic arteries as a Y graft on the left system (three-vessel disease, n  = 603, 86.3%) or as a left internal thoracic artery on left anterior descending and right internal thoracic artery elongated with saphenous vein on the right coronary artery system (two-vessel disease, n  = 96, 13.7%), only 1 saphenous vein per patient. Propensity-matching identified 272 patients per group. One-hundred and twenty-two patients underwent coronary computed tomographic angiography to asses grafts patency after a median follow-up of 88 (65–93) months. RESULTS In the paired samples, there was no difference in the early outcome. Ten-year survival and freedom from death, non-fatal acute myocardial infarction and repeat revascularization were higher in I-graft group: 90.6 [standard error (SE): 2.0] vs 78.2 (SE: 5.3), P  = 0.0266, and 85.2 (SE: 2.4) vs 69.9 (SE: 5.3), P  = 0.0179. Saphenous vein graft, at a long-time follow-up, showed a higher patency rate (81.6% (SE: 7.0) vs 50.7% (SE: 7.9), P  < 0.0001) and a smaller internal lumen diameter (2.7, standard deviation: 0.4 vs 3.4, standard deviation: 0.6 mm, P  < 0.0001) when right internal thoracic artery was the inflow. CONCLUSIONS Grafting the right coronary artery with saphenous vein may entail higher patency rate and better outcome when the inflow is the right internal thoracic artery than when is the ascending aorta. Prospective randomized data are needed to test this hypothesis. [ABSTRACT FROM AUTHOR]

Background and Aim: To evaluate the publication rate of articles related to cardiac surgery in the four main cardiovascular journals over the last 5 years. Methods: A bibliometric review of all full‐length articles published between January 2014 and March 2020 in the top four cardiovascular journals (Circulation, European Heart Journal (EHJ), Journal of the American College of Cardiology (JACC), and JAMA Cardiology) was conducted. For each eligible article in the four journals, the journal of publication, study design, area of interest, country of origin, and type of intervention tested (for cardiac surgery and interventional cardiology studies) were extracted. The affiliations of all editorial board members were identified from journal websites or from online searches and recorded as from cardiac surgery, cardiology, or another discipline. Correlations between variables were evaluated. Results: A total of 4835 articles were reviewed. Cardiac surgery studies amounted to 6.2% (104) of total research publications in JACC, 4.4% (74) in Circulation, 3.6% (13) in JAMA Cardiology, and 2.0% (22) in EHJ (P <.001). The percentage of cardiac surgery publications was significantly less than interventional cardiology publications (P <.001). Conclusions: Cardiac surgery studies represent only a small minority of the articles published in the top cardiovascular journals over the last 5 years, with significant differences between individual journals. Cardiac surgery studies were more often observational and this may constitute one important reason for their under‐representation. [ABSTRACT FROM AUTHOR]

Keywords: cardiac surgery; COVID-19 EN cardiac surgery COVID-19 300 302 3 07/23/20 20200721 NES 200721 The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented global effect on health care. Status of Responding Centers During the COVID-19 Pandemic This survey of 60 cardiac surgery centers (comprising 618 cardiac surgeons) across 19 countries provides a unique description of the cardiac surgery response to the COVID-19 pandemic worldwide. The widespread interruption in cardiac surgery described herein adds to the concerning observation that excess mortality not related to COVID-19 infections may now surpass mortality directly related to COVID-19 infections. [Extracted from the article]

OBJECTIVES Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting. METHODS The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients. RESULTS After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety. CONCLUSIONS In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA. [ABSTRACT FROM AUTHOR]

Background: The use of radial-artery grafts for coronary-artery bypass grafting (CABG) may result in better postoperative outcomes than the use of saphenous-vein grafts. However, randomized, controlled trials comparing radial-artery grafts and saphenous-vein grafts have been individually underpowered to detect differences in clinical outcomes. We performed a patient-level combined analysis of randomized, controlled trials to compare radial-artery grafts and saphenous-vein grafts for CABG.Methods: Six trials were identified. The primary outcome was a composite of death, myocardial infarction, or repeat revascularization. The secondary outcome was graft patency on follow-up angiography. Mixed-effects Cox regression models were used to estimate the treatment effect on the outcomes.Results: A total of 1036 patients were included in the analysis (534 patients with radial-artery grafts and 502 patients with saphenous-vein grafts). After a mean (±SD) follow-up time of 60±30 months, the incidence of adverse cardiac events was significantly lower in association with radial-artery grafts than with saphenous-vein grafts (hazard ratio, 0.67; 95% confidence interval [CI], 0.49 to 0.90; P=0.01). At follow-up angiography (mean follow-up, 50±30 months), the use of radial-artery grafts was also associated with a significantly lower risk of occlusion (hazard ratio, 0.44; 95% CI, 0.28 to 0.70; P<0.001). As compared with the use of saphenous-vein grafts, the use of radial-artery grafts was associated with a nominally lower incidence of myocardial infarction (hazard ratio, 0.72; 95% CI, 0.53 to 0.99; P=0.04) and a lower incidence of repeat revascularization (hazard ratio, 0.50; 95% CI, 0.40 to 0.63; P<0.001) but not a lower incidence of death from any cause (hazard ratio, 0.90; 95% CI, 0.59 to 1.41; P=0.68).Conclusions: As compared with the use of saphenous-vein grafts, the use of radial-artery grafts for CABG resulted in a lower rate of adverse cardiac events and a higher rate of patency at 5 years of follow-up. (Funded by Weill Cornell Medicine and others.). [ABSTRACT FROM AUTHOR]

The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting. [ABSTRACT FROM AUTHOR]

This article summarizes the current research on the benefits of using the transradial approach for percutaneous procedures and the radial artery as a conduit for coronary artery bypass surgery. Based on the available evidence, the authors provide recommendations for the use of the radial artery in patients undergoing percutaneous or surgical coronary procedures. [ABSTRACT FROM AUTHOR]

We investigated whether/how cardiac surgeons can be productive both academically and clinically. Using online resources (New York State Adult Cardiac Surgery database, SCOPUS), we collected individual clinical volumes (operations performed/year), academic metrics (ongoing publications, role as author), practice setting, and seniority for all cardiac surgeons in the State of New York from 1994 to 2011. Over time, individual clinical volumes decreased (median operations/year: 193 in 1995 vs 126 in 2010; P < 0.001), whereas academic productivity remained unchanged (median publications/year: 0.7 vs 0.3; P = 0.55). There was no correlation (Spearman's correlation coefficient: -0.061; P = 0.08) between the number of new publications and operations/year for the whole population. More operations/year (median: 155 vs 144; P = 0.03) were performed by surgeons without versus with publications during that same year. Who published more worked at hospitals with higher clinical volumes (Spearman's correlation coefficient: 0.16; P < 0.001) and was more likely affiliated with thoracic surgery fellowship programs (median publications/year: 1.7 for affiliated vs 0 for nonaffiliated surgeons; P < 0.001). Cardiac surgeons could be classified into four categories: ∼40 per cent clinically busy, but not publishing at all; ∼45 per cent operating less, but publishing a little; ∼15 per cent clinically very productive (operating as much as the nonpublishers) and publishing a lot; and ∼1 per cent operating the least, but publishing the most. [ABSTRACT FROM AUTHOR]