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Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Objective: Patient characteristics, risks, and outcomes associated with reoperative multivalve cardiac surgery are poorly characterized. Effect of patient variables and surgical components of each reoperation were evaluated with regard to operative mortality., Methods: From January 2008 to January 2022, 2324 patients with previous cardiac surgery underwent 2352 reoperations involving repair or replacement of multiple cardiac valves at Cleveland Clinic. Mean age was 66 ± 14 years. Number of surgical components representing surgical complexity (valve procedures, aortic surgery, coronary artery bypass grafting, and atrial fibrillation procedures) ranged from 2 to 6. Random forest for imbalanced data was used to identify risk factors for operative mortality., Results: Surgery was elective in 1327 (56%), urgent in 1006 (43%), and emergency in 19 (0.8%). First-time reoperations were performed in 1796 (76%) and 556 (24%) had 2 or more previous operations. Isolated multivalve operations comprised 54% (1265) of cases; 1087 incorporated additional surgical components. Two valves were operated on in 80% (1889) of cases, 3 in 20% (461), and 4 in 0.09% (2). Operative mortality was 4.2% (98 out of 2352), with 1.7% (12 out of 704) for elective, isolated multivalve reoperations. For each added surgical component, operative mortality incrementally increased, from 2.4% for 2 components (24 out of 1009) to 17% for ≥5 (5 out of 30). Predictors of operative mortality included coronary artery bypass grafting, surgical urgency, cardiac, renal dysfunction, peripheral artery disease, New York Heart Association functional class, and anemia., Conclusions: Elective, isolated reoperative multivalve surgery can be performed with low mortality. Surgical complexity coupled with key physiologic factors can be used to inform surgical risk and decision making., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Purpose of Review: Redo coronary artery bypass grafting (CABG) remains technically challenging with significant procedural risk but may be the best option for patients in whom repeat revascularization is indicated. This review summarizes the latest data regarding risk of redo CABG, who should receive this surgery, and how to achieve best outcomes., Recent Findings: Over the past two decades, the risk of performing redo CABG has declined and is approaching that of primary CABG in the hands of experienced surgeons. Nonetheless, patients for whom redo CABG is indicated tend to be older and have more complex medical comorbidities. Preoperative imaging is paramount in guiding sternal re-entry and mediastinal dissection, and in how to best employ rescue strategies when needed., Summary: Patients with complex, progressive coronary disease with unprotected left anterior descending (LAD) coronary artery disease and prior coronary bypass may benefit from the durable, complete revascularization that redo CABG can offer with internal thoracic artery bypass to the LAD and, when possible, arterial inflow to other important coronary targets. Preoperative imaging, careful planning, meticulous surgical technique, myocardial protection, and an experienced surgical team are critical for optimal outcomes., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To identify preoperative predictors of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy and evaluate trajectory of postoperative ventricular function., Methods: From January 2017 to January 2020, 238 patients with ejection fraction <30% (206/238) or 30% to 34% with at least moderately severe mitral regurgitation (32/238) underwent conventional cardiac surgery at Cleveland Clinic, 125 with ischemic and 113 with nonischemic cardiomyopathy. Preoperative ejection fraction was 25 ± 4.5%. The primary outcome was postcardiotomy cardiogenic shock, defined as need for microaxial temporary left ventricular assist device, extracorporeal membrane oxygenation, or vasoactive-inotropic score >25. RandomForestSRC was used to identify its predictors., Results: Postcardiotomy cardiogenic shock occurred in 27% (65/238). Pulmonary artery pulsatility index <3.5 and pulmonary capillary wedge pressure >19 mm Hg were the most important factors predictive of postcardiotomy cardiogenic shock in ischemic cardiomyopathy. Cardiac index <2.2 L·min -1  m -2 and pulmonary capillary wedge pressure >21 mm Hg were the most important predictive factors in nonischemic cardiomyopathy. Operative mortality was 1.7%. Ejection fraction at 12 months after surgery increased to 39% (confidence interval, 35-40%) in the ischemic group and 37% (confidence interval, 35-38%) in the nonischemic cardiomyopathy group., Conclusions: Predictors of postcardiotomy cardiogenic shock were different in ischemic and nonischemic cardiomyopathy. Right heart dysfunction, indicated by low pulmonary artery pulsatility index, was the most important predictor in ischemic cardiomyopathy, whereas greater degree of cardiac decompensation was the most important in nonischemic cardiomyopathy. Therefore, preoperative right heart catheterization will help identify patients with low ejection fraction who are at greater risk of postcardiotomy cardiogenic shock., Competing Interests: Conflict of Interest Statement M.T. reported consulting and speaking honorarium with Abbott and Abiomed. E.S. receives honoraria from Abiomed, AtriCure, and Abbott. E.B. reported noncompensated statistical consultant for Abiomed and Edwards Lifesciences. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Survivors of post-myocardial infarction (MI) ventricular septal rupture (VSR) repair may require reintervention if initial repairs are incomplete or fail. We assessed patients undergoing post-MI VSR re-repair., Methods: Between January 1976 and July 2023, 38 consecutive patients underwent re-repair of post-MI VSR at Cleveland Clinic. Preoperative characteristics, operative details, and postoperative outcomes were obtained through medical records review, and patients were followed for survival., Results: Thirty-two (84%) re-repairs were elective/urgent, and 6 (16%) were emergencies. Preoperative temporary mechanical circulatory support was used in 14 (37%), with 12 isolated intra-aortic balloon pumps. Indications for re-repair were recurrent VSR detected during postoperative surveillance (n = 25; 66%) and residual VSR after incomplete initial repair (n = 13; 34%). The median time from initial repair to re-repair was 55 days (15th/85th percentiles: 5-331 days). Two patients (5.3%) had residual or recurrent VSR after re-repair but received no intervention due to hemodynamic insignificance. Postoperative complications included sepsis (n = 7; 18%), stroke (n = 6; 16%), and new-onset dialysis (n = 6; 16%). Operative mortality was 32% (n = 12), with differences between patients who underwent surgery before January 2001 (n = 10/18; 56%) and those who did so after January 2001 (n = 2/20; 10%), as well as between patients who received preoperative temporary mechanical circulatory support (n = 8/14; 57%) and those who did not (n = 4/24; 17%)., Conclusions: Patients with failed or incomplete initial post-MI VSR repairs may be considered for re-repair, as modern-day improvements in perioperative care may be associated with more favorable outcomes. Referral to an expert tertiary center should be considered owing to the surgical complexity of re-repair., Competing Interests: Dr Soltesz reports honoraria from Abbott, Abiomed, AtriCure, and Dilon. Dr Tong reports honoraria from Abbott and Abiomed. Dr Roselli serves as a speaker, consultant, and advisory board member for Artivion, Cook Medical, Edwards Lifesciences, W.L. Gore & Associates, Medtronic, and Terumo Aortic. Dr Gillinov serves as a consultant for Edwards, Medtronic, Abbott, Artivion, AtriCure, ClearFlow, and Johnson & Johnson. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

Objective: To evaluate whether multiarterial grafting provides an incremental benefit above single arterial grafting in isolated redo coronary artery bypass grafting (CABG)., Methods: From January 1980 to July 2020, 6559 adults underwent a total of 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity score-matched with those undergoing single arterial grafting with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. The median follow-up was 10 years, with 25% of patients followed for >17 years. Multivariable multiphase hazard models and nonparametric random survival forest models for survival were used to identify patients for whom multiarterial grafting was most beneficial., Results: Among propensity score-matched patients, postoperative complications in multiarterial versus single arterial grafting included any reoperation (50 [2.5%] vs 65 [3.2%]); renal failure (73 [3.6%] vs 55 [2.7%]), stroke (44 [2.2%] vs 38 [1.9%]), and deep sternal infection (36 [1.8%] vs 25 [1.2%]). In-hospital mortality was 1.7% (n = 35) in multiarterial grafting versus 2.8% (n = 56) in single arterial grafting (P = .03). Comparing multiarterial to single arterial grafting, overall survival was 95% versus 94% at 1 year, 92% versus 88% at 3 years, 87% versus 82% at 5 years, 49% versus 42% at 15 years, and 31% versus 25% at 20 years. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P < .0001)., Conclusions: Redo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Surgical coronary bypass has evolved continually, and most analyses currently favor performing coronary grafts with autologous living arterial conduits to obtain better long-term patencies and clinical outcomes. With bilateral internal mammary artery grafts and both radial arteries, 4 excellent arterial conduits exist for creating "all-arterial" revascularization in the majority of multivessel disease patients, including those with valve disorders. Using contemporary surgical techniques, it is possible to obtain greater than 95% overall early graft patencies that translate into better late outcomes, including improved survival, freedom from myocardial infarction, fewer percutaneous coronary interventions, and redo coronary bypass procedures. The overall goal is to revascularize the 2 most important coronary systems with internal mammary artery grafts, and the rest with radial arteries, depending on the anatomy, experience, and choice of the surgeon. Using highly validated management strategies, early postoperative complications, including the incidence of sternal infections, are extremely uncommon, and in many practices, multi-arterial grafts currently are used in the majority of multivessel patients, including those with concomitant valve disease. Because patencies and outcomes are significantly better than with saphenous vein bypass or percutaneous coronary interventions, referring physicians frequently favor multi-arterial bypass procedures as the primary therapy for patients with prognostically serious multivessel disease. Thus, coronary bypass using predominantly autologous arterial conduits should play an increasingly important role in the future management of severe coronary atherosclerosis., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To characterize the clinical courses and outcomes of patients presenting with post-myocardial infarction (MI) ventricular septal rupture (VSR) receiving temporary microaxial transvalvular left ventricular assist device (tVAD) support., Methods: Between December 2019 and July 2023, 10 consecutive patients presented with a post-MI VSR. All 10 patients received a tVAD. Patient characteristics, hemodynamics, intraoperative details, and postoperative outcomes were reviewed., Results: Eight patients underwent VSR repair (7 open, 1 percutaneous), and 2 patients died while on tVAD before being treated. Among the 7 patients who underwent open repair, 6 received preoperative tVAD support and 1 required intraoperative tVAD insertion during emergency right ventricular rupture repair. In the 6 patients receiving preoperative tVAD support, improvements from insertion to repair were observed in shunt fraction (from 2.6 [range, 2.3-3.3] to 1.8 (range, 1.5-3.3]), cardiac index (from 1.5 [range, 1.5-6.2] L·min -1  m -2 to 3.1 [range, 2.2-6.9] L·min -1  m -2 ), pulmonary capillary wedge pressure (from 25 [range, 14-35] mm Hg to 16 [range, 14-18] mm Hg), central venous pressure (from 14 [range, 7-26] mm Hg to 12 [range, 1-26] mm Hg), creatinine (from 1.5 [range, 1.1-1.8] mg/dL to 1.2 [range, 0.9-1.5] mg/dL) and lactate (from 1.3 [1-1.7] mmol/L to 0.7 [range, 0.4-1.2] mmol/L). The median time from post-MI VSR diagnosis to repair was 15 (range, 13-18) days. Surgical repair was approached via right atriotomy in 4 patients, via left ventriculotomy in 2 patients, and via right ventricular defect in 1 patient, with no residual shunts or operative mortalities., Conclusions: Perioperative tVAD support for post-MI VSR acutely stabilizes hemodynamics and end-organ function, facilitating delayed intervention with reduced operative risk while also preventing futile interventions. This paradigm shift in management of post-MI VSR from emergency to urgent operations may be associated with improved outcomes., Competing Interests: Dr Soltesz reports honoraria from Abbott, Abiomed, Atricure, and Dilon. Dr Tong reports honoraria from Abbott and Abiomed. Dr Roselli reports consulting and speakers bureau and advisory board membership for Artivion, Cook Medical, Edwards Lifesciences, W.L. Gore & Associates, Medtronic, and Terumo Aortic. Dr Unai reports honoraria from Artivion and Lifenet. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

Objective: The study objective was to identify the effects of surgeon experience and age, in the context of cumulative institutional experience, on risk-adjusted hospital mortality after cardiac reoperations., Methods: From 1951 to 2020, 36 surgeons performed 160,338 cardiac operations, including 32,871 reoperations. Hospital death was modeled using a novel tree-bagged, generalized varying-coefficient method with 6 variables reflecting cumulative surgeon and institutional experience up to each cardiac operation: (1) number of total and (2) reoperative cardiac operations performed by a surgeon, (3) cumulative institutional number of total and (4) reoperative cardiac operations, (5) year of surgery, and (6) surgeon age at each operation. These were adjusted for 46 patient characteristics and surgical components., Results: There were 1470 hospital deaths after cardiac reoperations (4.5%). At the institutional level, hospital death decreased exponentially and became less variable, leveling at 1.2% after approximately 14,000 cardiac reoperations. For all surgeons as a group, hospital death decreased rapidly over the first 750 reoperations and then gradually decreased with increasing experience to less than 1% after approximately 4000 reoperations. Surgeon age up to 75 years was associated with ever-decreasing hospital death., Conclusions: Surgeon age and experience have been implicated in adverse surgical outcomes, particularly after complex cardiac operations, with young surgeons being novices and older surgeons having declining ability. However, at Cleveland Clinic, outcomes of cardiac reoperations improved with increasing primary surgeon experience, without any suggestion to mid-70s of an age cutoff. Patients were protected by the cumulative background of institutional experience that created a culture of safety and teamwork that mitigated adverse events after cardiac surgery., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: XC001 is a novel adenoviral-5 vector designed to express multiple isoforms of VEGF (vascular endothelial growth factor) and more safely and potently induce angiogenesis. The EXACT trial (Epicardial Delivery of XC001 Gene Therapy for Refractory Angina Coronary Treatment) assessed the safety and preliminary efficacy of XC001 in patients with no option refractory angina., Methods: In this single-arm, multicenter, open-label trial, 32 patients with no option refractory angina received a single treatment of XC001 (1×10 11 viral particles) via transepicardial delivery., Results: There were no severe adverse events attributed to the study drug. Twenty expected severe adverse events in 13 patients were related to the surgical procedure. Total exercise duration increased from a mean±SD of 359.9±105.55 seconds at baseline to 448.2±168.45 (3 months), 449.2±175.9 (6 months), and 477.6±174.7 (12 months; +88.3 [95% CI, 37.1-139.5], +84.5 [95% CI, 34.1-134.9], and +115.5 [95% CI, 59.1-171.9]). Total myocardial perfusion deficit on positron emission tomography imaging decreased by 10.2% (95% CI, -3.1% to 23.5%), 14.3% (95% CI, 2.8%-25.7%), and 10.2% (95% CI, -0.8% to -21.2%). Angina frequency decreased from a mean±SD 12.2±12.5 episodes to 5.2±7.2 (3 months), 5.1±7.8 (6 months), and 2.7±4.8 (12 months), with an average decrease of 7.7 (95% CI, 4.1-11.3), 6.6 (95% CI, 3.5-9.7), and 8.8 (4.6-13.0) episodes at 3, 6, and 12 months. Angina class improved in 81% of participants at 6 months., Conclusions: XC001 administered via transepicardial delivery is safe and generally well tolerated. Exploratory improvements in total exercise duration, ischemic burden, and subjective measures support a biologic effect sustained to 12 months, warranting further investigation., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04125732., Competing Interests: Disclosures Dr Nakamura received institutional research support from XyloCor Therapeutics and consulting fees from XyloCor Therapeutics and Sana Biotechnology. Dr Henry received consulting fees (Steering Committee) from XyloCor Therapeutics. Dr Latter received consulting fees from and is a data and safety monitoring board (DSMB) member of XyloCor Therapeutics. Dr Mokadam received consulting fees from Abbott, Medtronic, SynCardia, and XyloCor Therapeutics and is a DSMB member of XyloCor Therapeutics, Medtronic, and Carmat. Dr Williams received consulting fees from XyloCor Therapeutics. Dr Sun received consulting fees from Abbott Vascular and is a DSMB member of 4C Medical and Abbott. Dr DiCarli received institutional research support from XyloCor Therapeutics and Gilead Sciences, consulting fees from Sanofi and MedTrace Pharma, and institutional in-kind research support from Amgen. Dr Chaitman received consulting fees and institutional research support from XyloCor Therapeutics. M.W. Peterson is an employee of XyloCor Therapeutics. D.G. Byrnes is an employee of XyloCor Therapeutics. Dr Ohman is an employee of Amgen. Dr Pepine received institutional research support from XyloCor Therapeutics, BioCardia, Caladrius, Duke Clinical Research Institute, the Gatorade Foundation, the McJunkin Family Foundation Trust, Mesoblast, National Institutes of Health/National Heart, Lung, and Blood Institute, Patient-Centered Outcomes Research Institute/National Patient-Centered Clinical Research Network, Pfizer, Sanofi, University of Florida Clinical and Translational Science Institute, and US Department of Defense and consulting fees from AbbVie, Akros, BioCardia, Bloomer Tech, Caladrius, Imbria Pharmaceuticals, Ironwood Pharmaceuticals, Milestone Pharmaceuticals, and Verily Life Sciences LLC. Dr Crystal received consulting fees from and has equity in XyloCor Therapeutics. Dr Rosengart is an advisor of, is a board of directors member of, and received consulting fees, royalties, and honoraria from XyloCor Therapeutics. Dr Kowalewski received institutional research support from XyloCor Therapeutics. Dr Koch received institutional research support from XyloCor Therapeutics. Dr Dittrich is an employee of XyloCor Therapeutics. Dr Povsic received institutional research support from XyloCor Therapeutics, CSL Behring, Priovant, Bayer, Ionis Pharmaceuticals, UCB Biopharma SRL, BodyPort, and Merck Pharmaceuticals; consulting fees from AstraZeneca, Biocardia, Boehringer Ingelheim, Caladrius Biosciences, Recardio, Veralox Therapeutics, Sana Biotechnology, Inc, Guidepoint Global LLC, and the Gerson Lehrman Group; is a DSMB member of Corvia, Novo Nordisk, and Parexel International; and has leadership or fiduciary role in the American Heart Association and the American College of Cardiology.

There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Published by Elsevier Inc.)

Coronary artery bypass grafting (CABG) is the most commonly performed and studied major cardiac operation worldwide. An understanding of the evolution of CABG, including the early days of cardiac surgery, the first bypass operation, continuous improvements in techniques, and streamlining of the operation, is important to inform current trends and future innovations. This article will examine how CABG evolved (from techniques to conduits), describe current trends in the field, and explore what lies on the horizon for the future of CABG.

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements., Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs)., Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P  = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P  = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P  = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% ( P  = .33) and 87% versus 100% ( P  = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P  = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively ( P  = .47)., Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach., Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2023 The Author(s).)

Purpose of Review: The surgical management of patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction presents unique challenges that require meticulous attention to details and good surgical technique and judgement. This review details the latest evidence and best practices in the care of such patients., Recent Findings: CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity related to the development of postcardiotomy shock. Preoperative optimization with pharmacological or mechanical support is required, especially in patients with cardiogenic shock. Rapid and complete revascularization is what CABG surgeons aim to achieve. Multiple arterial revascularization should be reserved to selected patients. Off-pump CABG, on-pump breathing heart CABG, and new cardioplegic solutions remain of uncertain benefit compared with traditional CABG., Summary: Tremendous advancements in CABG allowed surgeons to offer revascularization to patients with severe left ventricular dysfunction and multivessel disease with acceptable risk. Despite that, there is a lack of comprehensive and robust studies particularly on long-term outcomes. Individualized patient assessment and a heart team approach should be used to determine the optimal surgical strategy for each patient., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: A number of publicly available rating algorithms are used to assess hospital performance in coronary artery bypass grafting (CABG). However, concerns remain that these algorithms fail to correlate with each other and inadequately capture the case complexity of individual center practices., Methods: Composite star ratings for isolated CABG from the Society of Thoracic Surgeons public reporting database were extracted for 2018-2019. U.S. News & World Report Best Hospitals was used to extract CABG ratings as well as overall cardiology and heart surgery ranking, and the Centers for Medicare & Medicaid Services Hospital Compare was used to extract CABG volume and 30-day mortality. Spearman correlation coefficients were used to assess possible relationships. Expert opinion on risk adjustment and program evaluation was incorporated., Results: Correlations between Society of Thoracic Surgeons star rating and U.S. News & World Report overall ranking in cardiology and heart surgery (r = 0.15) and Centers for Medicare & Medicaid Services 30-day mortality (r = -0.27) were poor. Society of Thoracic Surgeons star rating correlated weakly with U.S. News & World Report CABG ratings (r = 0.33) and with Centers for Medicare & Medicaid Services CABG volume (r = 0.32), whereas the latter 2 correlated moderately (r = 0.52) with each other. Of the 75 centers with accredited cardiac surgery training programs, 13 (17%) did not participate in Society of Thoracic Surgeons public reporting. Important gaps were identified in risk assessment, and potential solutions are proposed., Conclusions: Correlations between current CABG public reporting systems are weak. Further work is needed to refine and standardize CABG rating systems to more adequately capture the scope and complexity of an individual center's clinical practice and to better inform patients., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The saphenous vein graft (SVG) is the most used conduit in CABG. With standardization of its use as a conduit came an understanding of its accelerated atherosclerosis, known as saphenous vein graft disease (SVGD). Given its extensive use, a review of the pathophysiology and management of SVGD is important as we optimize its use., Areas Covered: For this review, an extensive literature search was completed to identify and examine the evolution of SVG in CABG, mechanisms driving SVGD, and methods developed to prevent and manage it. This includes a review of relevant major papers and trials in this space., Expert Opinion: Eras of evolution in SVG usage in CABG include an experimental era, era of SVG dominance in CABG, and the current era of mixed venous and arterial grafting. As SVGD was studied, the mechanisms behind it became more understood, and prevention and management methods were developed. As advances in surgical techniques and pharmacotherapy continue to reduce occurrence and severity of SVGD, long-term patency of SV grafts continues to improve and remain excellent in optimized settings. With continued innovation and improvement in operative techniques, the SVG conduit is and will remain an important player in the field of coronary bypass.

Introduction: Temporary epicardial pacing wires (TEPW) are commonly placed during cardiac surgery, and a known complication is the migration into visceral and vascular structures. Previous reports have identified TEPW migrating into the ascending aorta. These cases were managed conservatively with the initiation of antithrombotic medications and surveillance. We report the first case of TEPW migration associated with an ascending aortic aneurysm and the operative management., Case Presentation: A 73-year-old man with a history of aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) in 2009 presented to the outpatient clinic for re-operative consideration due to severe bioprosthetic aortic stenosis, ascending aortic aneurysm, and multi-vessel coronary artery disease with occlusion of previous graft. He was incidentally found to have a TEPW eroding into his ascending aorta on pre-operative imaging. He was taken to the operating room for an AVR, ascending aorta replacement, and CABG. The TEPW was removed during the re-operation and the patient recovered well., Clinical Discussion: This is the first reported case of TEPW migration into an aneurysmal ascending aorta and the operative management. The patient tolerated the procedure well and was discharged home. Pre- and intra-operative images were obtained of TEPW extending into the lumen of the ascending aorta. If the patient did not have additional operative indications, conservative management could have been considered with antithrombotic medications and surveillance., Conclusion: TEPW migration is a rare complication and requires special considerations with balancing risk for intervention., Competing Interests: Conflict of interest statement The authors have no financial or personal disclosures related to this work., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Spontaneous coronary artery dissection is an uncommon cause of myocardial ischemia. Conservative management is the mainstay, although a few patients will require revascularization. We present a case of a 31-year-old woman whose extensive dissection necessitated coronary artery bypass grafting requiring an extended arteriotomy for excision of the thrombus and dissection flap. ( Level of Difficulty: Advanced. )., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2023 The Authors.)