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AIMS: Data suggest that women have worse outcomes than men after coronary artery bypass grafting (CABG), but results have been inconsistent across studies. Due to the large differences in baseline characteristics between sexes, suboptimal risk adjustment due to low-quality data may be the reason for the observed differences. To overcome this limitation, we undertook a systematic review and pooled analysis of high-quality individual patient data from large CABG trials to compare the adjusted outcomes of women and men. METHODS AND RESULTS: The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE). The secondary outcome was all-cause mortality. Multivariable mixed-effect Cox regression was used. Four trials involving 13 193 patients (10 479 males; 2714 females) were included. Over 5 years of follow-up, women had a significantly higher risk of MACCE [adjusted hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04–1.21; P = 0.004] but similar mortality (adjusted HR 1.03, 95% CI 0.94–1.14; P = 0.51) compared to men. Women had higher incidence of MI (adjusted HR 1.30, 95% CI 1.11–1.52) and repeat revascularization (adjusted HR 1.22, 95% CI 1.04–1.43) but not stroke (adjusted HR 1.17, 95% CI 0.90–1.52). The difference in MACCE between sexes was not significant in patients 75 years and older. The use of off-pump surgery and multiple arterial grafting did not modify the difference between sexes. CONCLUSIONS: Women have worse outcomes than men in the first 5 years after CABG. This difference is not significant in patients aged over 75 years and is not affected by the surgical technique.

Background Recent improvements in speckle tracking echocardiography have made sectionalized quantification of layer-specific global longitudinal strain (GLS) possible. Prior studies have reported prognostic value of GLS in several cardiac diseases, however, the use of layer-specific strain has not been investigated in patients undergoing coronary artery bypass grafting (CABG). Purpose To determine the prognostic value of layer-specific GLS for predicting all-cause mortality after CABG. Methods In this retrospective cohort study, consecutive patients undergoing isolated CABG between 2006 and 2011 were included. The patients were followed through nation-wide registries for the endpoint of all-cause mortality. Multivariable Cox regression models adjusted for clinical and echocardiographic baseline characteristics were used to assess the association between layer-specific GLS and all-cause mortality. Cumulative survival was stratified by clinical age and gender-dependent cut-off values for the layer-specific GLS, which was obtained from a large healthy population study. Results Of 641 patients included (mean age 67 years, 84% male), 70 (10.9%) died during follow-up (median 3.8 years [IQR: 2.7; 4.9 years]). Patients who died during follow-up were significantly older (71 years vs. 67 years, P = Conclusion Layer-specific GLS is an independent prognosticator of all-cause mortality after CABG. In multivariable models, GLSepi provided significant prognostic value after adjusting for echocardiographic parameters and EuroScore II. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Research grant from Herlev & Gentofte University Hospital's internal research funds. Figure 1. Kaplan-Meier survival estimatesFigure 2. Incidence rate of all-cause mortality

Background Coronary artery bypass grafting (CABG) is widely performed across China. Understanding current between-hospital variation is important for further quality improving initiatives. Purpose To assess the between-hospital variation comprehensively on outcomes of isolated CABG, and explore hospital-level characteristics and practice patterns explaining the variation. Methods We used the data of Chinese Cardiac Surgery Registry (2013–2019) to examine the between-hospital variation of outcomes, including in-hospital mortality (or treatment withdrawal) and major complications (mortality, postoperative myocardial infarction, stroke, renal failure, mediastinal infection, and reoperation for bleeding). Multilevel mixed-effect models and propensity score adjusting technique were used to quantify the variability and study hospital-level factors associated with the variation. Risk-standardized mortality rate (RSMR) was used to classify hospital performance. Results Among 60876 patients (62.6 years old, 75.4% male) undergoing isolated CABG in 70 hospitals, the mortality was 2.0% and 5.3% had major complications. After adjusting for patient case-mix, the median hospital RSMR was 2.1% (inter-quartile range [IQR], 1.3%-3.1%), with the median odds ratio (MOR) of 2.1; and 5.7% (IQR, 3.7%-7.5%) for risk-standardized major complications, with the MOR of 1.9. Compared with patients admitted in average-performance hospitals, patients undergoing CABG in worse-performance hospitals had a nearly twofold higher odds of in-hospital mortality (adjusted odds ratio [AOR]=1.92; 95% confidence interval (CI), 1.37–2.69), whereas patients in better-performance hospital had an approximately 60% lower odds (AOR=0.41; 95% CI, 0.30–0.57). Hospital location and average surgeon volume explained 20.2% of the between-hospital variation, where hospital-level perioperative blood transfusion rate and use of secondary prevention medication further contributed to the proportion change variance of 3.3% and 2.3%, respectively. Similar results were obtained for major complications. Conclusion(s) Consistent between-hospital variation of CABG performance exists in China. Improving the clinical practice management and reducing variability may better the overall outcomes. Funding Acknowledgement Type of funding sources: None.

Background A long-standing persistent form of atrial fibrillation (AF) in anamnesis, requiring surgical ablation together with coronary artery bypass surgery (CABG), significantly increases the risk of reccurence in the postoperative period. Before operation should consider the predictors of AF for long-term preservation of rhythm after surgery. Purpose To evaluate the predictors of AF recurrence on 3rd day and at discharge in patients after CABG with concomitant surgical ablation of long-standing persistent AF. Methods A prospective randomized single-center analysis was performed on patients with long-standing persistent AF, undergoing CABG with concomitant left atrial ablation (LAA) or biatrial ablation (BA) between 2016 and 2019. 116 patients were randomized into two groups: 58 in LAA+CABG, 58 in BA+CABG. The median age of the patients was 65 (IQR, 61 to 67.75) years in gr. BA and 62 (IQR, 58 to 66) in gr. LAA (Mann-Whitney U-test, p=0.050), 83% of men were in gr. BA (Fisher test, p>0.999). Predictors of AF development on day 3 were identified using multivariable logistic regression from the following baseline characteristics: myocardial infarction in anamnesis, time of artificial circulation, time of application of radiofrequency energy, the size of the left and right atrium, funcrional class of cardiac angina and heart failure, gender, age, acute cerebrovascular accident (CVA), additional intervention on the heart (operations for aortic aneurysm, mitral, aortic and tricuspid valves replacement), concomitant cardiovascular, respiratory, digestive and urogenital diseases. Results Using a multivariate model of logistic regression, the following significant predictors of arrhythmias on the 3rd day in gr. BA were included: additional intervention on the heart valves (OR 63.13, p=0.001); an increase in the functional class (FC) of chronic heart failure (CHF) NYHA by 1 (OR 40.06, p=0.018); a history of CVA (OR 9.13, p=0.026). The following significant predictors of AF reccurence on the 3rd day in gr.LAA were identified: an increase in the long axis of the right atrium by 1 cm (OR 3.05, p=0.006); an increase of the FC of cardiac angina by 1 (OR 7.11, p=0.011); in women (OR 7.14, p=0.017). In BA significant predictors of AF reccurence at discharge were: an increase in the long axis of the left atrium by 1 cm (OR4.86, p=0.015); reccurence of AF on the 3rd day (OR 17.45, p=0.005); 1 year increase in age (OR 1.24, p=0.023); the presence of diabetes (OR 47.67, p=0.002). In gr. LAA the predictors at discharge were: reccurence of AF on 3rd day (OR 38.35, p=0.001); a history of CVA increases the chances of arrhythmia (OR 210.83, p=0.032). Conclusion Number of clinical and functional characteristics of a patient may be predictors of AF. We examined the predictors of reccurence of AF after surgical ablation of long-standing persistent AF with concomitant CABG. Taking them into account when choosing the optimal strategy of treatment is important. Funding Acknowledgement Type of funding sources: None.

Background The role and the indications for using off-pump coronary artery bypass surgery (OPCAB), instead of the traditional on-pump (ONCAB), is still to be addressed. Aim To describe our centre experience and to compare 15-years survival and early safety outcomes between OPCAB and ONCAB. Methods Single-centre retrospective cohort including 9-years of isolated first CABG (2005–2013). Multi-vessel disease with at least 2 surgical grafts patients were considered and the first 50 surgeries of each surgeon with each technique were excluded to account for the learning curve effect. Emergent surgeries and on-pump beating heart procedures were also excluded. A propensity-score matching (PSM) analysis was performed to balance groups and both survival and early outcomes comparison was done within the matched cohort using Kaplan-Meier or Cox stratified and paired tests, respectively. The median follow-up was 9 years, maximum 15 years. Results From 3012 multi-vessel patients with at least 2 surgical grafts, 2503 were included at the main analysis: 1487 ONCAB and 1016 OPCAB. ONCAB patients presented more frequently 3-vessels disease and left ventricular dysfunction, but received similar number of grafts than OPCAB, who in turn, received more frequently multiple arterial grafts. The surgical completeness of revascularization (CR) was similar, but hybrid procedures were more frequent in OPCAB raising CR rate in this group. After PSM (646 pairs), both groups were similar regarding pre and peri-operative characteristics. The long-term survival was similar (HR stratified by pair: 1.02 (0.81–1.30), but OPCAB evidenced benefits at early term results including bleeding, postoperative atrial fibrillation and stroke incidence. Conclusion At our centre, OPCAB performed by experienced surgeons provides rates of complete revascularization and long-term survival similar to ONCAB. In-hospital results favoured OPCAB. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Universidade do Porto/FMUP; Social European Fund; FCT-Fundação para a Ciência e a Tecnologia

Background Controversies exist how to predict medium term mortality (Mt) in diabetics (DM) with 3 vessel (3VD) and/or left main (LM) disease undergoing myocardial revascularization ranging from Syntax Score II (SSII) where DM was not predicative variable up to FREEDOM formula which was derived, just from population with DM (without LM), having DM patients (Pts) requirement of insulin as one of predicative variable. Purpose To compare predicative power of SSII, FREEDOM and formula developed in our institution in Pts post first isolated CABG with 3VD and/or LM with DM. Methods From our prospective data base of 2455 consecutive pts who had the first isolated CABG in the period 01/2012–12/2014 with complex Ischemic Heart Disease with 100% follow up of 4 years all-cause Mt we created by random sampling Training (1321; Mt:10.4%; DM 511; Mt:13.3%) and Validation (1134; Mt:10.0%; DM 414; Mt: 11.8%) sets. After deriving predicative formula (Cox regression) from training population we validated FREEDOM, SSII and Our Formula in 414 pts with DM from the Validation set. Results Characteristics of pts, our formula, predicating power by C Statistics, Calibration plots and Brier scores are presented in Picture 1. Conclusions FREEDOM formula designed just for DM pts with complex Ischemic Heart Disease without LM had the smallest standard error in the estimate, but moderate C statistics as Syntax Score II and our formula which may be used for pts with and without DM and 3VD and/or LM. Picture 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of education, science and technology development, Republic of Serbia

Background Cardiac troponins are the preferred biomarkers for the diagnosis of myocardial infarction (MI) and play an important role in coronary artery bypass grafting (CABG) related MI (type 5 MI). Different cut-off values, as defined by multiples of the 99th percentile upper reference limit (URL) for isolated and non-isolated troponin elevations have been proposed. Also, these definitions are based on arbitrarily chosen and varying values (3rd and 4th Universal definition: 10xURL, Society for Cardiovascular Angiography and Interventions (SCAI): 35 and 70xURL) and electrocardiographical or imaging findings. In addition to the controversy in MI definitions, the introduction of high-sensitivity cardiac troponin (hs-cTn) assays and their subsequent lower thresholds warrant a thorough re-assessment of hs-cTn dynamics after CABG. Purpose To evaluate the rise and fall of hs-cTn after CABG in relation to the definitions of myocardial infarction. Methods Studies published between 2008 and 2020 reporting hs-cTn concentrations in relation to CABG were searched through Pubmed and reviewed by 2 independent screeners. The search terms were “coronary artery bypass” AND “high-sensitivity cardiac troponin”, including alternative names and abbreviations. Inclusion criteria were the use of a hs-cTn assay in the postoperative phase, either for cardiac troponin T or I. This study was performed in agreement with the PRISMA guidelines. Results Out of 37 screened studies, 15 studies were included (2860 patients). The overall preoperative hs-cTnT concentration (median, 25th-75th percentile) was 43.5 (16.3–57.9) ng/L. Subsequently, in >80% of CABG patients, preoperative hs-cTnT was elevated >14 ng/L. Hs-cTnT was highly variable over time, with a peak of 408.7 (14.9–717.2) ng/L 6–8 h after CABG. Postoperative peak hs-cTnT concentrations rose >10xURL (Universal definition) in 100% of CABG patients. Peak hs-cTnT >35xURL and ±20% >70xURL (SCAI definition) during the first 48 h was 30% and ∼20%, respectively (estimated from data depicted in Figure 1). Electrocardiographic and imaging findings were available for only 1 study (554 patients). Overall 30-day mortality was 1.7 (0.8–4.0)%, reported by 7 studies (2291 patients). Data regarding the association of hs-cTnT and clinical outcome was reported by 1 study. As only 4 studies (217 patients) reported on the results of hs-cTnI, using assays from different vendors, a meta-analysis for hs-cTnI could not be performed. Conclusion The different definitions of type 5 MI propose arbitrarily chosen cTn cut-off values, varying enormously between the definitions. The current thresholds may not apply to the majority of CABG patients, since >80% had elevated preoperative hs-cTnT. Furthermore, hs-cTnT obtained within 48 h after CABG is highly variable over time. Therefore, further research is needed to establish clinically relevant hs-cTn thresholds and timing of sampling for a more accurate diagnosis of CABG procedure related MI. Figure 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): ZonMw Veni grant

Background Minithoracotomy avoids the complications specific to sternotomy access, which in turn creates the conditions for early activation and rehabilitation of patients, especially elderly, with diabetes mellitus, obesity, disorders of the musculo-skeletal system. Purpose To assess the patency of grafts after minimally invasive coronary artery bypass grafting (MICS CABG). Methods We analyzed the results of 50 MSCT- angiography made to patients with MICS CABG operated between 2014 and 2016 (28,5±13,5 months after surgery). Totally 132 conduits were used, 47 (35.6%) of them – arterial, 85 (64.4%) – venous. In all cases left internal mammary artery (LIMA) was used for revascularization of the left anterior descending artery (LAD). The great saphenous vein was used as a conduit for revascularization of: diagonal branch (DA) – 10 (11.7%) cases, left circumflex artery (LCx) – 44 (51.8%), right coronary artery (RCA) – 12 (14.1%), posterior interventricular branch – 19 (22.4%). Assessment of the patency of grafts were performed: 1–2 years (33 conduits: 13 arterial, 20 venous), after 2–3 years (51 conduits: 19 arterial, 32 venous) and after 3–4 years (48 conduits: 15 arterial, 33 venous). Results Assessment of coronary grafts patency in the first period revealed occlusion of 3 (15%) venous conduits. In 2 cases, the venous conduit was anastomosed with the LCx, in 1 case with the RCA. The cumulative patency of the grafts was as follows: arterial – 100%, venous – 85%. In the second point of the study occlusion and stenotic changes of LIMA has not been revealed. Determined occlusion 5 (15,6%) venous grafts. In all cases, the occluded venous conduits revascularized the RCA. Total permeability of conduits: arterial – 100%, venous-84.4%. In the third time interval it was revealed: in 1 case of LIMA occlusion and 7 venous grafts, in 4 cases in the area of the LCx, in 2 – DA and in 1 case – in the area of the RCA. Total patency of grafts: arterial – 93.3%, venous – 78.8%. Total permeability of conduits: arterial – 97.9%, venous – 82.4%. Conclusion The analysis shows good long–term results of the functioning of grafts after MICS CABG and their comparability with the results of patency of the conduits after CABG performed by the traditional Funding Acknowledgement Type of funding source: None

Purpose To assess cognitive status after simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy (CEE). Material & methods. Changes in cognitive status and the incidence of POCD were evaluated in the early postoperative period after simultaneous CABG and CEE. 53 patients with polyvascular disease (PolyVD) undergoing CABG and CEE were included in the study. Patients were assigned to two groups. 25 patients without mild cognitive impairment (MCI), the mean age of 64.3±7.9 years, were included in Group 1 and 28 patients with MCI, the mean age of 65.3±6.75 years, were included in Group 2. Neuropsychological testing was performed on days 2 before surgery and on days 7 after surgery using the psycho-physiological testing software “Status PF”. Attention was assessed with the Bourdon's test or proofreading test. Memory was estimated with the 10 numbers memorizing test, 10 words memorizing test, and 10 syllables memorizing test. The assessment of neurodynamics included the measurement of the complex visual-motor reaction time (VMRT), brain performance (BP), and functional mobility of the nervous processes (FMNP). The presence of POCD was estimated as a 20% decline on 20% of the tests. A reference range for neuropsychological indicators (13 indicators of the test battery) was set at the intervals corresponding to the ranges between the quartiles [Q25; Q75] in healthy people. Thus, cognitive status scale includes low cognitive status with the values ranging from 0 to 0.34, below the average - from 0.35 to 0.51, the average - from 0.52 to 0.7, and high cognitive status >0.7 to 1.0. Early postoperative cognitive dysfunction (POCD) was diagnosed as a 20% decline in memory, attention, and neurodynamics from the baseline on 20% of the tests passed. Statistical analysis was performed using the “Advanced” software package. Results At baseline, cognitive status in patients without MCI was below the average (0.38±0.2), whereas in MCI patients it was lower by 32% and corresponded to low (0.26±0.1; p=0.03). Cognitive status did not differ significantly between both groups in the postoperative period, but a trend towards its decrease was determined (0.34±0.2 vs. 0.27±0.13, p>0.5). However, the incidence of early POCD in patients without MCI was 14 (56%), and in patients with MCI - 20 (71%) patients. Conclusion At baseline, patients with PolyVD, regardless of the presence of MCI, according to the results of the comprehensive examination, showed low and below the average cognitive status. Simultaneous CABG and CEE does not prevent the deterioration of cognitive functions in patients with PolyVD in the early postoperative period. Patients with PolyVD undergoing myocardial and brain revascularization have a high risk of worsening cognitive disorders and need to individual approach to make a reasonable choice of the optimal surgical strategy. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Institute

Background Postoperative acute ischemic stroke (AIS) is a catastrophic complication of coronary artery bypass grafting (CABG). There is limited data on the incidence and outcomes of AIS complicating CABG in the contemporary era, and whether these have changed over the years. Purpose To study the incidence and outcomes of postoperative AIS in a nationally representative cohort of CABG procedures over a 12-year period and examine predictors of AIS in patients undergoing CABG. Methods The National Inpatient Sample was used to identify all adult patients (>18 years old) who underwent CABG in the United States between January 2004 and September 2015. Multivariable logistic regression was performed to examine the associations between postoperative AIS and in-hospital mortality and identify predictors of AIS after CABG, expressed as odds ratios (OR) with corresponding 95% confidence intervals (CI). Results A total of 2,569,597 CABG operations were analysed. The incidence of postoperative AIS was 1.8% (n=47,279) in the overall cohort increasing from 1.2% in 2004 to 2.3% in 2015 (p60 years (61–70 years: OR 1.33, 95% CI 1.29, 1.37; 71–80 years: OR 1.49, 95% CI 1.44, 1.54; >80 years: OR 1.42, 95% CI 1.37, 1.48), female sex (OR 1.33, 95% CI 1.31, 1.36) and AF (OR 1.14 95% CI 1.12, 1.16) (p Conclusion In this nationally representative study, we have shown that the rates of postoperative stroke following CABG have increased over time in line with complexity of patient risk profiles. The present findings emphasise the need for further work on strategies to reduce the risk of postoperative stroke after CABG. Trends of postoperative AIS (2004-2015) Funding Acknowledgement Type of funding source: None

Background The debate on the advantages and limitations of off-pump (OPCAB) on long-term outcomes has not still arrived to a conclusion. This study was designed to compare the impact of OPCAB vs on-pump coronary artery bypass grafting (CABG) on long-term mortality and major adverse cardiac events (MACEs). Methods The PRIORITY project was designed to evaluate the long-term outcomes of 2 large prospective multicenter cohort studies on CABG conducted between 2002–2004 and 2007–2008. Data on isolated CABG were linked to 2 administrative datasets. Time-to-event methods were employed to analyze outcomes. Results The population consisted of 11021 patients who underwent isolated CABG (27.2% OPCAB) that were divided into development and validation datasets. The median follow-up time was 8 years (interquartile range 7.6–10 years) and was 100% complete. Unadjusted long-term survival was significantly worst for OPCAB, nonetheless the adjustment did not confirm OPCAB as a risk factor for mortality (HR 0.94, 95% CI 0.85–1.03, p=0.19). OPCAB was associated to an increased risk of MACE at 10 years (adjusted HR 1.14, 95% CI 1.06–1.23, p=0.001). Inside the MACEs, OPCAB was significantly related to increased incidence of rehospitalization for percutaneous cardiac intervention (PCI), (adjusted HR 1.33, 95% CI 1.16–1.53, p Conclusions OPCAB did not affect long-term mortality but is associated with an increased long-term risk of repeat PCI. These findings may have important implications towards health resources allocation, particularly in a climate of cost containment of healthcare expenditures. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Minister of Health

Background The advantages of the employment of double internal thoracic artery grafts (BITA) for coronary artery bypass grafting have been recently questioned and no data on long-term follow-up are available. This observational retrospective cohort study was designed by the PRIORITY planning committee to evaluate 10-year follow-up of isolated CABG performed with and without BITA in order to clarify and consolidate the contrasting literature. Methods The PRIORITY project was designed to evaluate the long-term outcomes of 2 large prospective multicenter cohort studies on CABG conducted between 2002–2004 and 2007–2008. Data on isolated CABG were linked to 2 administrative datasets. Time-to-event distributions were separately analyzed accordingly to primary event-type (death, MACEs), using Kaplan-Meier estimates and Cox regression. Results The population consisted of 11021 patients who underwent isolated CABG that were divided into development and validation datasets; double thoracic internal artery grafts was employed in 24.6%. The median follow-up time was 8 years (interquartile range 7.6–10 years) and was 100% complete. After adjustment for potential confounding factors, BITA was significantly associated with better survival (HR 0.85, 95% CI 0.76–0.95, p=0.003). Moreover, the employment of BITA reduced the incidence of MACEs at follow-up (adjusted HR 0.87, 95% CI 0.80–0.94, p=0.001). In details, BITA was demonstrated to be a protective factor for acute myocardial infarction (adjusted HR 0.84, 95% CI 0.71–0.99, p=0.05) and for rehospitalization for percutaneous cardiac intervention (PCI; adjusted HR 0.82, 95% CI 0.70–0.96, p=0.013). Conclusions The employment of double internal thoracic artery grafts for coronary artery bypass grafting has been associated to survival advantage at 10-year. Moreover, it significantly decreased the incidence of acute myocardial infarction and rehospitalization for percutaneous cardiac intervention. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Minister of Health

Aims Ischemic Stroke (IS) is a devastating complication of coronary bypass (CABG) surgery, significantly increasing mortality, morbidity, cost, and the need for long-term care, and reducing the quality of life. With the aim of a learning-machine method, we investigated factors influencing the occurrence of IS after CABG. Methods and results We employed a statistical learning method – random forests – to examine which of various variables had the greatest impact on postoperative IS. A dataset including 16,255 consecutive patients undergoing isolated CABG between 1997 and 2017 In one Institution was examined. Along with demographic and clinical variables technical-related factors were included, encompassing surgical technique, number of touches on the aorta, cardiopulmonary bypass, total aortic clamping, use of the side-biting clamp, or number of proximal anastomoses. A ranking score based on the average percent increase in mean squared error and obtained for all variables was employed to quantify the importance of any variable in predicting IS. A total of 641 strokes occurred (3.9%). Total aortic clamp showed the highest incidence of stroke (n=570, 88.95% of total). Total aortic clamp had the highest score among all variables followed by previous stroke and carotid artery disease >50%. In contrast, other variables related to surgical technique showed low ranking scores in predicting IS. In patients undergoing CABG with the use of total aortic, a previous brain ischemic insult as well as age >75 years increase the risk of IS (fIGURE) Conclusions The use of total aortic clamp is the strongest predictor of stroke. A clamp-less technique is recommended whenever possible especially in older patients and those who experienced preoperative stroke or who had significant carotid stenosis. Importance of variables in predicting IS Funding Acknowledgement Type of funding source: None

Background Periprocedural myocardial infarction (PMI) occurs frequently after both percutaneous coronary intervention (PCI) and bypass grafting surgery (CABG) in patients with complex coronary artery disease (CAD), and PMI has been shown to have a detrimental impact on mortality. On the other hand, long-term impact of PMI on mortality has not been fully evaluated. Purpose This study aimed to assess the impact of PMI according to SCAI definition on 10-year all-cause death in patients with complex CAD. Methods The SYNTAX Extended Survival (SYNTAXES) study evaluated vital status up to 10 years in 1800 patients with de novo three-vessel disease and/or left main coronary artery disease randomized to treatment with CABG or PCI in the SYNTAX trial. Blood was sampled for creatine kinase (CK) pre- and post-revascularisation, and the cardiac specific MB iso-enzyme (CK-MB) was determined only if the CK ratio ≥2 x the upper limit of normal (ULN). If the CK ratio Results Of 1800 patients, 1679 (93.2%) patients were included. Of 877 patients treated with PCI, PMI occurred in 26 patients (3.0%), whereas 14 (1.7%) PMIs were observed in 802 patients treated with CABG. Compared with patients without PMI, patients with PMI presented with unstable angina more frequently (45.0% vs. 28.7, p=0.033), and had a higher rate of bifurcation lesion (87.5% vs. 72.5, p=0.046). PMI was associated with a higher all-cause mortality at 10 years compared with no PMI (55.3% vs. 25.4%; Log-rank p Conclusion PMI was associated with a poor prognosis at 10 years. The impact of PMI on mortality was strong within one year. Of note, the impact of PMI on mortality persisted beyond 1 year only in patients undergoing PCI. Patients who were treated with PCI and suffered PMI need careful follow-up beyond one year after revascularization. Figure 1 Funding Acknowledgement Type of funding source: None

Background Freedom formula (FF) was derived very recently to assist in decision making by Heart Team in patients (Pts) with diabetes (DM) who are in need for myocardial revascularization (Percutaneous Coronary Intervention or Coronary artery bypass grafting (CABG)) due to complex ischemic Heart disease (but without left main steam disease (LM)). In external validation moderate C statistics values were obtained. Purpose To validate FF predictive value in Pts with DM and more complex patients (three vessel (3VD) and/or LM as well lower left ventricular ejection fraction (LVEF)) than in FREEDOM population. Methods From our prospective data base of 2455 consecutive pts who had the first isolated CABG in the period 01/2012–12/2014 with 3VD and/or LM with 100% follow up of 4 years All-cause Mortality (Mt) we retrieved 925 pts with DM. Results DM was present in 925 Pts (Mt: 12.6%). On insulin were 318 (34.3%; Mt 14.5%). We analysed the predicative value of FF in the whole group (925) of pts with DM as well as in subgroups with LM (294) and without LM (631; most similar to original Freedom population), separately. Characteristics of pts, Freedom formula, predicating power by C Statistics, Calibration plots and Brier scores are presented in Picture 1. Conclusions Our external validation of FF was almost identical as previous published one. Furthermore, the FF may be of value even in pts with LM disease and other vessels involved. Of note our pts as seen by combined LVEF, ClCr and LM were sicker than pts in FREEDOM. Picture 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Ministry of education, science and technological development, Republic of Serbia

Purpose To assess serial changes in the morphological and functional parameters, and indicators of myocardial perfusion in the perioperative period of coronary artery bypass grafting (CABG), depending on the preoperative management strategy. Methods 60 male patients with stable coronary artery disease (CAD) were randomized into two groups before on-pump CABG. Group 1 patients (n=30, aged of 61.5 [56; 63] years) underwent treadmill training at 80% of VO2max for a 7-day period. Group 2 patients (n=30, aged of 62.0 [56; 64] years) underwent routine management without prehabilitation. Cardiac morphological and functional parameters were evaluated using echocardiography in the preoperative period and 5–7 days after CABG. Adenosine loading single-photon emission computed tomography (SPECT) was used to measure the parameters of myocardial perfusion before and after the indexed CABG. Data were processed using the QPS program (Cedars Sinai Medical Center (USA)) and the 17-segment polar mapping. Statistical analysis was performed using commercially available Statistica 10.0 software package (Statsoft, USA). Results Both groups demonstrated a decrease in LVEF in the postoperative period. However, an LVEF decline in Group 1 patients was less significant (p=0.00015) than in the control group (p=0.000003). LV end-systolic dimension increased by 8.5% and LV end-systolic volume by 18% in patients who underwent prehabilitation as compared to the baseline, whereas these changes were more pronounced in the control group (17% (p=0.00029) and 41% (p=0.00028), respectively). Group 1 patients demonstrated better myocardial perfusion parameters in the postoperative period. Patients in the prehabilitation group reported higher accumulation levels of radiopharmaceuticals in the basal (75.0 [72.5; 80] and 72.0 [70; 75]%, p=0.036), middle (87.0 [83; 91] and 81.0 [77; 84]%, p=0.012) and apical (86.0 [82; 89] and 82.0 [78; 86]%, p=0.037) myocardium as compared with those in the control group. The stress-induced ischemia (SDS) was less pronounced in Group 1 compared to Group 2 (p=0.025). Conclusion Optimized myocardial remodeling parameters and improved myocardial perfusion in the postoperative period have proved the effectiveness of high intensity physical trainings introduced in the prehabilitation program for CABG. Funding Acknowledgement Type of funding source: None

Introduction Patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting (CABG) occasionally experience recurrent myocardial ischemia. Because of their severe CAD and its complicated hemodynamics, conventional cardiac perfusion SPECT often cannot reveal the severity and prognosis solely. Hybrid cardiac SPECT/CT imaging simultaneously shows myocardial ischemia distribution, coronary artery lesion distribution, and their relationship, and this modality may enable detailed interpretation and risk stratification for such patients. Aim This study aimed to assess the prognostic value of hybrid cardiac SPECT/CT for patients with CAD and suspected myocardial ischemia after CABG. Methods A total of 201 consecutive patients, registered between April 2016 and September 2018, with suspected recurrent angina pectoris after CABG requiring examinations for myocardial ischemia were included in this study. Among these, 135 patients who underwent cardiac perfusion SPECT, cardiac CT, and hybrid cardiac SPECT/CT imaging were analyzed. In the SPECT-only analysis, SDS was calculated, and the patients were divided into none-to-mild (SDS Results In the SPECT-only analysis, 62 were in the none-to-mild group and 73 were in the moderate-to-severe group. In the SPECT/CT analysis, 61 were in the matched group and 74 were in the unmatched group. Within the follow-up period of 29±8 months, 15 patients experienced MACE. The patients' prognoses were clearly stratified by hybrid SPECT/CT analysis (matched: 13/61, 21.3% vs. unmatched: 2/74, 2.7%) compared with SPECT-only analysis (moderate-to-severe: 11/73, 15.0% vs. none-to-mild: 4/62, 6.5%). The hybrid cardiac SPECT/CT analysis was more strongly associated with the occurrence of MACE compared with SPECT-only analysis (p=0.008 vs. p=0.04, respectively). Conclusions Hybrid cardiac SPECT/CT imaging can have higher prognostic value compared with stand-alone cardiac perfusion SPECT for patients with CAD after CABG. Funding Acknowledgement Type of funding source: None

Purpose To assess the prevalence of frailty in the preoperative period and to evaluate its effect on the risk of complications and adverse outcomes in patients undergoing coronary artery bypass grafting (CABG). Methods 387 patients undergoing preoperative management for elective primary CABG were recruited in the study. The study cohort was divided into three groups depending on the “Age is no disqualification” scores suggesting the presence or absence of frailty and the presence of prefrailty. Demographic and clinical data were collected for each patient, including surgery data, pre- and postoperative treatment, intra- and postoperative complications and outcomes of CABG. Statistical analysis was performed using the commercially available software package IBM SPSS Statistics 26.0.0. Results 74 (19%) patients had frailty, while 225 (58%) patients were diagnosed with prefrailty and 88 (23%) patients did not have any signs of frailty. All three groups had significant age differences, patients without frailty – 56 [63–67] years old, prefrailty group – 59 [65–69] years old, patients with frailty – 62 [66–72] years old, p=0,003. Patients with frailty or prefrailty more often suffered from diabetes mellitus (patients without frailty – 14,8%, prefrailty group – 25,8% and frailty group – 36,5%, p=0,006), atrial fibrillation or flutter (16,7%, 14,3% and 35,6%, respectively, p=0,05) and cerebral atherosclerosis (45,5%, 62,2% and 60,8%, respectively, p=0,02). Three groups were comparable in main clinical and demographic parameters. There were no significant differences found in the incidence of infections (3,4%, 2,2% and 4%, respectively, p=0,655) and haemorrhagic complications (1,2%, 1% and 0,5%, respectively, p=0,680). Patients with frailty or prefrailty in the intra- and early postoperative period after CABG had significantly higher incidence of low output syndrome (1,2%, 7,6% and 13,5%, respectively, p=0,01, OR 8,5, 95% CI, 1,1–63,5) and postoperative atrial fibrillation or flutter (5,7%, 16% and 12,2%, respectively, p=0,04, OR 2,9, 95% CI, 1,1–7,5). The incidence of myocardial infarction in the intra- and early postoperative period after CABG did not differ significantly between the groups (0%, 0,5% and 1,5%, respectively, p=0,476) as well as the incidence of stroke (2,3%, 1,8% and 4,1%, respectively, p=0,523). Patients with frailty and prefrailty had significantly higher cerebrovascular and cardiovascular mortality compared to those without frailty (1%, 0% and 5,4%, respectively, p=0,04, OR 2,6, 95% CI, 1,1–5,9). Conclusion Almost 19% of patients referred to CABG suffered from frailty. The presence of prefrailty or frailty increases the risk of death in the early postoperative period after CABG. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Federal State Budgetary Institution “Research Institute for Complex Issues of Cardiovascular Diseases”, Kemerovo, Russian Federation

Aims To evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin–angiotensin–aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality. Methods and results All patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between medication use and long-term mortality. Statins were dispensed to 93.9% of the patients 6 months after discharge and to 77.3% 8 years later. Corresponding figures for β-blockers were 91.0% and 76.4%, for RAAS inhibitors 72.9% and 65.9%, and for platelet inhibitors 93.0% and 79.8%. All medications were dispensed less often to patients ≥75 years. Treatment with statins [hazard ratio (HR) 0.56, 95% confidence interval (95% CI) 0.52–0.60], RAAS inhibitors (HR 0.78, 95% CI 0.73–0.84), and platelet inhibitors (HR 0.74, 95% CI 0.69–0.81) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all P

The optimal method of revascularization for patients with left main coronary artery disease (LMCAD) is controversial. Coronary artery bypass graft surgery (CABG) has traditionally been considered the gold standard therapy, and recent randomized trials comparing CABG with percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have reported conflicting outcomes. We, therefore, performed a systematic review and updated meta-analysis comparing CABG to PCI with DES for the treatment of LMCAD.We systematically identified all randomized trials comparing PCI with DES vs. CABG in patients with LMCAD. The primary efficacy endpoint was all-cause mortality. Secondary endpoints included cardiac death, myocardial infarction (MI), stroke, and unplanned revascularization. All analyses were by intention-to-treat. There were five eligible trials in which 4612 patients were randomized. The weighted mean follow-up duration was 67.1 months. There were no significant differences between PCI and CABG for the risk of all-cause mortality [relative risk (RR) 1.03, 95% confidence interval (CI) 0.81-1.32; P = 0.779] or cardiac death (RR 1.03, 95% CI 0.79-1.34; P = 0.817). There were also no significant differences in the risk of stroke (RR 0.74, 95% CI 0.35-1.50; P = 0.400) or MI (RR 1.22, 95% CI 0.96-1.56; P = 0.110). Percutaneous coronary intervention was associated with an increased risk of unplanned revascularization (RR 1.73, 95% CI 1.49-2.02; P 0.001).The totality of randomized clinical trial evidence demonstrated similar long-term mortality after PCI with DES compared with CABG in patients with LMCAD. Nor were there significant differences in cardiac death, stroke, or MI between PCI and CABG. Unplanned revascularization procedures were less common after CABG compared with PCI. These findings may inform clinical decision-making between cardiologists, surgeons, and patients with LMCAD.

Background Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease is currently recommended as an alternative to coronary artery bypass grafting (CABG) in patients with low and intermediate SYNTAX score. Purpose We sought to compare clinical outcomes of unprotected left main coronary artery disease by PCI or CABG in a “real world” population referred to high volume center. Methods All consecutive patients with unprotected left main coronary artery disease treated by PCI with second-generation drug-eluting stent were compared to those treated by CABG. The primary endpoint was the composite of death, non-fatal myocardial infarction (MI) or stroke at 2 years follow-up. Results A total of 558 patients were included. The mean age was 71±9 years, diabetes was present in 29%, and 56% of the patients presented with acute coronary syndrome. The distal left main coronary artery was involved in 84.6% of the lesions, the rate of Syntax score >32 was 50%. At 2 years, the primary end-point occurred in 10% of the patients in the PCI group and in 9.6% in the CABG group (p=0.862). The rates of death, non-fatal MI or stroke at 2 years were comparable; conversely the rate of ischemia driven revascularization at 2 years was higher in PCI group than CABG (5.5% and 1.5% p=0.010, respectively in PCI and CABG group). Kaplan-Meier curves of MACCE Conclusions In a “real world” population with unprotected left main coronary artery disease, PCI with second generation stent, as compared to CABG, showed similar rates of the composite end point of death, non-fatal MI or stroke at 2 years, irrespective of coronary anatomy complexity.

Background/Introduction Sleep apnoea (SA) is prevalent and independently associated with adverse cardiovascular events after percutaneous coronary intervention. Patients with complex and high-risk features are often referred for coronary artery bypass grafting surgery (CABG) and it remains unknown if SA is a risk marker. Purpose We evaluated the association between SA and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-urgent CABG. Methods This was a prospective cohort study conducted between November 2013 and December 2018. Patients from 3 public hospitals referred to a tertiary cardiac centre for non-urgent CABG were recruited for an overnight sleep study prior to CABG. The mean follow-up duration was 2.1 years. Results Among the 1007 patients who completed the study, SA (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Most of the patients underwent on-pump CABG (96.7%) and received a left internal mammary artery graft (95.2%). MACCE, a composite of cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke and unplanned revascularisation, occurred in 123 patients (12.2%). The crude incidence of MACCE was higher in the SA than the non-SA group (3-year estimate, 18.8% versus 11.7%; p=0.019). Likewise, the crude incidence of all-cause mortality (7.2% versus 4.3%; p=0.028), sudden cardiac death (3.9% versus 1.6%; p=0.028) and heart failure hospitalisations (10.9% versus 5.3%; p=0.001) was higher in the SA than the non-SA group. Multivariate Cox regression analysis demonstrated that SA was predictive of MACCE with an adjusted hazard ratio of 1.54 (95% confidence interval, 1.06–2.22; p=0.023), after adjusting for the effects of age, gender, body mass index, left ventricular ejection fraction, hypertension and chronic kidney disease. Figure 1. KM curve for MACCE Conclusion Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG. Further evaluation regarding the efficacy of treatment of sleep apnoea in patients undergoing CABG surgery is warranted. Acknowledgement/Funding Clinician Scientist Award from the National Medical Research Council of Singapore (NMRC/CSA-INV/002/2015)

Aim 1. To evaluate whether a supervised cardiac rehabilitation (CR) program improves physical capacity and quality of life (QoL) of patients with LV systolic dysfunction undergoing coronary artery bypass grafting (CABG) compared to patients training by their own. 2. To investigate LV diastolic function dynamics according to the results of tissue Doppler imaging (TDI) in these patients. 3. To define the echographic predictors for long term prognosis in these patients and their adjusted value for calculation of a preoperative risk score. Material and method Prospective randomized study on 665 CABG patients with LV systolic dysfunction (LVEF Results 1. SET was more efficient in rehabilitating CABG patients being an independent predictor for a more favourable postoperative evolution, mostly in patients with normal LV diastolic filling pattern (LVDFP) (97,27%) compared with restrictive LV filling (89.83%). At 5 years postoperatively, cardiovascular event-free survival was significantly higher in nonrestrictive LVDFP group (74.94%) compared with restrictive LVDFP (55,75%). 2. Conventional transmitral diastolic Doppler indices before and after CABG remained unchanged. TDI showed significant improvement in SET group at 3 and 12 months postoperatively of both LV systolic (S: 6.1±0.9, 7.5±1.1 and 7.3±1.2cm/s) and diastolic function (e': 7.2±1.8, 8.3±1.4 and 8.8±1.5cm/s.; E/e' ratio: 17.8±2.1, 13.1±1.7 and 11.3±1.8; Vp 3.2±0.55, 2.4±0.28 and 1.9±0.26) 3. The main predictors for unfavorable evolution at 5 years postoperatively were: age >75 years (RR=7.3), LV end-systolic volume (LVESV) >85cm3 (RR=6.4), restrictive LVDFP (RR=8.9) and pulmonary hypertension (PHT) (RR=5.2). Conclusions 1. SET improves physical capacity and QoL in CABG patients, mainly in those with normal LVDFP, the restrictive LVDFP being associated with an early and late postoperative unfavourable evolution and difficult CR. 2. Exercise capacity and symptoms are more closely correlated with indices assessed by TDI which demonstrate significant improvement of LV systolic and diastolic function in SET patients, regardless of transmitral flow pattern 3. On long term postoperatively the unfavorable evolution was predicted by: age>75 years, LVESV>85cm3, restrictive LVDFP and severe PHT.

Purpose To evaluate the effectiveness and safety of high intensity prehabilitation included in the routine preoperative management of patients with coronary artery disease (CAD) for elective on-pump coronary artery bypass grafting (CABG). Methods 38 male patients with stable CAD referred to on-pump CABG who either underwent prehabilitation or not were assigned into two study groups. Group 1 patients (n=20, the mean age 61.5 years [55; 64] underwent high intensity treadmill exercises. Group 2 patients (n=18, the mean age 62.0 years [56; 65]) underwent routine preoperative management without prehabilitation. Treadmill exercises in Group 1 patients were performed under hemodynamic control and ECG monitoring. The training power of a workout was calculated based on cardiopulmonary exercise test (CPET) performed before preoperative exercises, and was estimated as 80% of the maximal power obtained during the exercise test. Adenosine loading single-photon emission computed tomography (SPECT) was used to measure the parameters of myocardial perfusion before preoperative exercises and on days 5–7 after CABG in both study groups. Biochemical markers of myocardial damage (troponin I, NT-proBNP) were measured before the training session, after it and then in the postoperative period to assess the safety of the prehabilitation program. In-hospital postoperative complications were recorded and analyzed. Results Both study groups were comparable in the main clinical and demographic parameters, intraoperative clinical parameters as well as in preoperative CPET and SPECT results. There were no cases of complications during prehabilitation. The analysis of myocardial perfusion parameters demonstrated that patients who had undergone prehabilitation had significantly higher accumulation of radiopharmaceuticals than those in the control group in basal segments (74.9±3.98% vs. 70.3±7.40% p=0.04), middle (86.7±5.24% vs. 79.6±10.43%, p=0.03) and apical (85.8±5.03% vs. 79.0±8,67%, p=0.02) myocardium. The stress-induced ischemia (SDS) was less pronounced in Group 1 compared to Group 2 (0 scores and 0.9±0.53 scores, respectively, p=0.04). Myocardial perfusion defect significantly decreased during the infusion of adenosine (SSS) (p=0.013), as well as the SDS index (p=0.018) in the prehabilitation group after CABG compared with the baseline. Both groups had similar serum troponin I levels within the normal range before and after CABG. NT-pro BNP levels significantly increased in the postoperative period in patients who did not undergo prehabilitation (p=0.003). Patients who underwent prehabilitation had a significantly lower incidence of the in-hospital postoperative complications compared to patients without exercise trainings (p=0.002). Conclusion The inclusion of high intensity preoperative exercises in the routine preoperative management of patients referred to elective CABG is safe and effective method of cardioprotection improving surgical outcomes.

Psychosocial stress is acknowledged as one of risk of development of cardiovascular pathology. The interrelation between existence personality type D and prevalence of atherosclerosis is recently established. However, predictive value of type D personality in different cultures and the countries are not fully understood. Purpose Study aim was to investigate the association of type D personality with the development of cardiovascular complication in patients in five years after coronary artery bypass grafting (CABG). Materials and methods Evaluation of psychological status and combined risk of nonfatal (strokes, nonfatal myocardial infarctions, repeat procedures of revascularization and hospitalization due to relapse or progression of angina pectoris) and fatal (general and cardiovascular mortality) cases before and in five years after CABG. Patients with chronic ischemic heart disease (n=602, 112 (18.5%) females and 490 (81.5%) males, mean age=57.7±7.3 years.) who had had CABG were included in the study. Who were formed in two groups: patients with the presence of type D (n=134) and patients without type D (n=468). The study of the psychological status was carried out using questionnaire DS-14. Analysis of long-term results were assessed using the Kaplan–Meier method. Results During the 5 years frequency of fatal cases in both groups amounted 8.3% and 8.1% (p=0.145), in turn nonfatal end-points in group with type D amounted 31.8%, and 15.9% in group without type D (p=0.044). Presence of type D personality at initial examination increased 3.21 times combined risk of nonfatal and fatal cases (OR 3.21, 95% CI 2.02–6.14, p=0.002). In long term period there were no differences in survival between groups type D and without type D (95.5% vs. 96.8%), There were differences in groups type D and without type D in nonfatal events (strokes, nonfatal myocardial infarctions, secondary endpoint: repeat procedures of revascularization and hospitalization due to relapse or progression of angina pectoris) (respectively, 97.1% vs 88.0%, (p=0.34). Conclusion Type D patients had a greater risk for nonfatal cardiac events compared with non Type D patients. Accumulated proofs indicate that in detection of patients at risk of development of stress induced cardiac complications after CABG it is reasonable to use approach which involves consideration of personality type.

Background Parental cardiovascular disease (CVD) is a known risk factor for premature CVD in both men and women. It is unknown whether a positive family history (PFH) of premature CVD also affects long-term outcomes after coronary artery bypass grafting (CABG). Purpose We estimated the prevalence of PFH of premature CVD in a large population of CABG patients younger than 60 years of age. We evaluated whether PFH is an independent predictor of survival and freedom from major adverse cardiac and cerebrovascular events (MACCEs) following CABG. Methods Data come from a prospective longitudinal study of first, non-emergent, CABG patients consecutively recruited at the Innsbruck Medical University between August 2001 and February 2018 (n=5389). Patients were followed up for a median of 8 years. From this study, 2553 patients with premature CAD undergoing CABG under the age of 60 years were identified. Self-reported PFH data was available for 99.3% of patients; n=2535 patients were eligible for these analyses. In line with the Framingham offspring study, a premature PFH of CVD was defined when a patient's father and/or mother experienced their first CV event at Results Premature PFH was found in 54.2% of patients (n=1375). Within these patients, 66.1% had a father who experienced a premature CV event (n=909), 27.8% a mother (n=382) and 6.1% both a mother and a father (n=84). In the majority of cases the patient's parent had experienced a premature cardiac event (85.9%, n=1181), 14.1% of patients with PFH reported their parent(s) had a premature stroke (n=194). Patients with a PFH had lower rates of smoking, diabetes and renal disease but were more likely to be hypertensive. Following CABG, PFH was associated with improved long-term survival (adjusted HR, 0.66; 95% CI, 0.50–0.91; p=0.011) and MACCE-free survival (adjusted HR, 0.73; 95% CI, 0.68–0.89; p=0.01). Among the covariates adjusted for, age, diabetes, renal insufficiency, peripheral arterial disease, impaired left ventricular function, previous cerebrovascular events and previous mediastinal radiation were associated with poorer outcomes. In contrast, multiple arterial grafting by bilateral internal thoracic arteries improved both survival (adjusted HR, 0.52; 95% CI, 0.36–0.74; p Conclusion In this cohort of high-risk patients undergoing CABG under 60 years of age, PFH was highly prevalent. Whilst it is evident that a PFH increases the risk of requiring CABG at younger ages, this study shows that PFH is also, paradoxically, protective regarding long-term outcomes; PFH is associated with both improved overall and MACCE-free survival following CABG.

Introduction The association of diabetes and vein graft patency after coronary artery bypass grafting (CABG) remains controversial. In patients with diabetes, impaired endothelial function in vein grafts and high platelet turnover might result in early vein graft failure. The DACAB trial showed ticagrelor plus aspirin significantly increased 1-year vein graft patency vs. aspirin alone, while no significant difference between ticagrelor alone and aspirin alone. However, whether the results is different between the patients with or without diabetes is unknown. Purpose To assess the effects of ticagrelor with or without aspirin vs. aspirin alone on 1-year vein grafts patency after CABG in patients with or without diabetes. Methods We examined the subgroups of patients with and without diabetes from DACAB trial (NCT02201771), in which 500 patients were randomized to 1 of 3 antiplatelet regimens (ticagrelor 90mg twice daily plus aspirin 100mg once daily, T+A group; ticagrelor 90mg twice daily, T group; or aspirin 100mg once daily, A group) within 24 hours post-CABG. The primary outcome was 1-year vein graft patency (FitzGibbon grade A) assessed by multi-slice computed tomographic angiography or coronary angiography. Results According to the baseline medical history and/or glycated hemoglobin (HbA1c) ≥6.5%, 283 patients with 818 vein grafts were allocated to the non-diabetes subgroup, remaining 217 patients with 642 vein grafts to the diabetes subgroup. By per-graft analysis, no significant difference on 1-year vein graft patency rate was observed between non-diabetes and diabetes subgroup (84.6% [692/881] for non-diabetes vs. 80.2% [515/642] for diabetes, adjusted odds ratio (OR) =1.39, 95% CI: 0.92–2.09, P=0.116). In T+A group, 1-year vein graft patency rates were 91.0% (244/268) for non-diabetes vs. 85.8% (188/219) for diabetes; In T group, 85.0% (221/260) for non-diabetes vs. 80.3% (183/228) for diabetes; In A group, 78.3% (227/290) for non-diabetes vs. 73.9% (144/195) for diabetes. Ticagrelor plus aspirin showed higher vein graft patency rate than aspirin alone in both non-diabetes and diabetes subgroup (non-diabetes: adjusted OR = 0.34, 95% CI: 0.17–0.69, and diabetes: adjusted OR = 0.42, 95% CI: 0.19–0.91, P for interaction = 0.524), whereas ticagrelor alone did not show improvement on vein graft patency compared with aspirin alone in both subgroups (non-diabetes: adjusted OR=0.62, 95% CI: 0.32–1.20, and diabetes: adjusted OR = 0.65, 95% CI: 0.33–1.31, P for interaction = 0.795). Similar results were showed by per-patient analysis. A total 16 major adverse cardiovascular events occurred, 8 (2.8%) for non-diabetes and 8 (3.7%) for diabetes. Conclusion In the DACAB trial, diabetes was not found to be associated with decreased vein graft patency at 1 year after CABG. The effect of ticagrelor plus aspirin on improvement of 1-year vein graft patency, when compared with aspirin alone, is consistent in patients with or without diabetes. Acknowledgement/Funding AstraZeneca

Objective Coronary artery bypass grafting (CABG) is still one of the most common surgical procedures aimed at improving blood circulation in atherosclerotic coronary arteries.Graft occlusion influences outcome CABG. The risk factors of long-term graft occlusion remain uncertain.The aim of the present study was to investigate the clinical predictors of graft occlusion after CABG. Methods All patients with prior CABG in our center who underwent coronary computed tomography angiography (CTA) and/or percutaneous coronary angiography for follow-up between Aug 2013 and Dec 2017 were included in the present study. We excluded patients who underwent multiple CABG surgeries or percutaneous coronary intervention after index CABG. With regard to one patient with two or more different angiography results, we selected the angiography result which showed graft occlusion for the first time or the last angiography result. The baseline clinical data at index CABG was analyzed for their independent impact on graft occlusion in a case-control study using multivariate logistic regression. Results 1178 (27.5%) of 4289 patients experienced at least one graft occlusion. The mean age was 63.23±9.02 years, 1004 (23.4%) patients were female. From all the occlusion cases, artery occlusion occurred in 337 (28.6%) patients and saphenous vein graft occlusion occurred in 875 (74.3%) patients.Complete baseline data was available for evaluation from 1178 of them (case group). We matched these patients through gender, age and time interval between the index CABG and angiography/CTA to another 1178 patients who did not have graft occlusion (control group). After multivariate logistic regression, chronic renal dysfunction (OR=1.008; 95% CI, 1.001–1.021; P=0.038) hyperuricemia (OR=1.89; 95% CI, 1.101–3.876; P=0.040) and hyperlipemia (with low density lipoprotein increased) (OR=1.377; 95% CI, 1.021–1.926; P=0.042) significantly increased the risk of long-term graft occlusion. Conclusions Chronic renal dysfunction hyperurcemia and hyperlipemia were independent risk factors of long-term graft occlusion. Acknowledgement/Funding National Key Research and Development Program of China (2017YFC0908800)

Background Myocardial tissue velocities by tissue Doppler imaging (TDI) have proven superior predictors of outcome to left ventricular ejection fraction (LVEF) in ischemic heart disease, with early diastolic myocardial relaxation velocity (e') being an early sign of LV dysfunction in the ischemic cascade. Purpose We hypothesized that e' predicts outcome after coronary artery bypass grafting (CABG). Methods We included patients treated with isolated CABG (n=679). Before surgery, all patients had an echocardiogram performed with TDI to measure tissue velocities: systolic (s'), e' and late diastolic (a'). Endpoint was all-cause mortality retrieved from national registries. We performed Cox regressions and C-statistics. Net reclassification index was used to test improvement of EuroSCOREII. Results Of 679 patients, 79 (n=12%) died during follow-up (median: 3.8 years (IQR: 2.8; 5.0y). Follow-up was 100%. Mean age was 68 years, LVEF 50%, and 86% were male. All tissue velocities were univariable predictors of outcome (s': HR=1.46 [1.21; 1.78], p40% (HR=1.39 [1.11; 1.74], p=0.005, per 1cm/s decrease). When split by the median (−4.95cm/s), patients in the lowest group had a 3-fold increased risk of death (HR=3.31 [1.98; 5.56], p The e' improved the net reclassification improvement index when added to EuroSCOREII, with a net reclassification of 39%. Conclusion After CABG, e' is a strong predictor of all-cause mortality and improves the predictive value of the established prediction model, the EuroSCOREII. We identified a possible effect modifier in LVEF, such that e' was a strong predictor in patients with LVEF >40% and not when LVEF is below 40%.

Background It remains controversial whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is more effective in the prevention of myocardial infarction (MI). MI has been evaluated only as a secondary endpoint without a focused systematic review in multiple meta-analyses. Purpose To compare the risk of MI at the latest follow-up available between CABG versus PCI with stents in patients with multivessel or left main coronary artery disease in a pairwise meta-analysis of randomised controlled trials (RCT). Methods We searched EMBASE, Cochrane, and Pubmed databases for articles comparing CABG versus PCI for the treatment of multivessel or left main disease. We utilised random-effects model to calculate pooled risk ratio (RR) and 95% confidence interval (CI). Fifteen trials with a total of 13,592 patients treated with either CABG (n=6,596) or PCI (n=6,996) were eligible and included. A multivariable random-effects meta-regression model, including variables such as age, sex, diabetes mellitus, publication year, follow-up duration, type of stent used, and type of coronary artery disease, was used to explore the source of potential heterogeneity of the primary result. Results After a weighted follow-up of 4.3 years, patients treated with CABG had a significantly lower risk of MI than patients treated with PCI (RR 0.75, 95% CI 0.58–0.96, P=0.024, I2=66%). The lower risk of MI with CABG as compared to PCI was more evident during a longer duration of follow-up (≥3 years, RR 0.69, 95% CI 0.52–0.91, P=0.008; ≥5 years, RR 0.64, 95% CI 0.48–0.86, P=0.003) and in diabetic population (RR 0.55, 95% CI 0.44–0.70, P Forest plots Conclusions In patients undergoing revascularization for multivessel or left main disease, the risk of MI was lower with CABG compared to PCI. The quality assurance for MI definition and treatment-specific procedures should be emphasized for future RCTs.