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Introduction: Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs)., Evidence Acquisition: A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI)., Evidence Synthesis: Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, P=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, P=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, P=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs. 29% in ONCAB, P<0.01)., Conclusions: Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early re-revascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.

Background: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). We aim to compare the survival and safety outcomes of DAPT versus aspirin (ASA) within a 24h window after CABG., Methods: Single-center retrospective cohort study on consecutive patients undergoing 1st isolated CABG surgery in 2010. Survival analysis (median follow-up 9 years) was performed using Kaplan-Meier curves and multivariable Cox regression using propensity score (PS) as a covariate along with DAPT. Bleeding was assessed through red blood cells' (RBC) transfusion, re-exploration of thorax and drainage., Results: We included 351 patients (251 were DAPT). Kaplan-Meier curves showed similar cumulative survival between groups (9y: 75% DAPT vs. 67% ASA, Log-rank P=0.103), as well as the PS adjusted analysis (HR DAPT: 0.93, 95% CI: 0.57-1.51). We found no differences in early mortality (2 DAPT and 1 ASA). Total median cell-saver transfusion (300 mL vs. 250 mL) and the re-exploration of thorax due to bleeding (1.6% vs. 4%) showed no statistical significance either. On the other hand, postoperative total median chest tube drainage was higher in the ASA group (1220 mL DAPT vs. 1320 mL ASA, P=0.034). There was also a lower frequency of DAPT patients requiring RBC transfusions (≥3 units 4.8% vs. 13%, P=0.009, respectively). Redo-CABG was performed in 3 patients (2 DAPT vs. 1 ASA) during follow-up., Conclusions: Compared with ASA, DAPT showed a non-significant impact on long-term survival and demonstrated to be a safe option. Further studies are needed to provide recommendations on the therapeutical strategy following CABG.

Background: Most observational studies support long-term survival benefit after bilateral internal mammary artery (BIMA) compared with single internal mammary artery (SIMA) coronary artery bypass grafting (CABG) but data on females is scarce. We compared survival and safety of BIMA versus SIMA CABG between males and females at our tertiary care center., Methods: Single-center retrospective cohort including consecutive patients with at least 2 left-coronary system (LCS) vessel disease who underwent isolated CABG with at least 1 IMA conduit and a minimum of 2 conduits targeting the LCS in 2004-2013. All-cause mortality was the primary outcome, secondary outcomes were early mortality and reoperation due to sternal wound complications (SWC). Kaplan-Meier analysis after inverse probability weighting using propensity score (IPW) was used to compare BIMA and SIMA CABG amongst genders. Results were confirmed in subgroup analysis., Results: BIMA CABG was performed in 39% out of 2424 eligible procedures and in 27% of 460 females. No differences were found in survival after BIMA and SIMA CABG (median and maximum follow-up of 5.5 and 12 years, respectively) but a statistical interaction was observed with gender (P < 0.001). Females who underwent BIMA CABG showed higher mortality (weighted HR in females subset: 3.16; 95% CI: 1.56-6.29, P = 0.001). BIMA CABG showed a higher incidence of reoperation due to SWC (IPW adjusted model OR: 1.74; 95% CI: 1.16-2.60) that was mostly ascribable to males (weighted OR in males: 3.10; 95% CI: 1.74-5.51, P < 0.001)., Conclusions: Females may experience higher mortality after BIMA CABG which should be further explored., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: To compare survival and safety of BIMA versus SIMA CABG between males and females at our tertiary care center., Methods: Single-center retrospective cohort including consecutive patients with at least 2 left coronary system (LCS) vessel disease who underwent isolated CABG with at least 1 IMA conduit and a minimum of 2 conduits targeting the LCS between 2004 and 2013. All-cause mortality was the primary outcome, secondary outcomes were in-hospital mortality and reoperation due to sternal wound complications (SWC). Kaplan-Meier analysis after inverse probability weighting using propensity score (IPW) was used to compare BIMA and SIMA CABG amongst genders. Results were confirmed by subgroup analysis., Results: BIMA CABG was performed in 39% out of 2424 eligible procedures and in 27% of 460 females. No differences were found in survival after BIMA and SIMA CABG (median and maximum follow-up of 5.5 and 12 years, respectively) but a statistical interaction was observed with gender (P<0.001). Females who underwent BIMA CABG showed higher mortality (weighted HR in females subset: 3.16; 95%CI: 1.56-6.29, P=0.001). BIMA CABG showed a higher incidence of reoperations due to SWC (IPW adjusted model OR: 1.74; 95% CI: 1.16-2.60) that were mostly ascribable to males (weighted OR in males: 3.10; 95%CI: 1.74-5.51, P<0.001)., Conclusion: Females may experience higher mortality after BIMA CABG which should be further explored.

Introduction: Postoperative atrial fibrillation (PoAF) is the most common arrhythmia following cardiac surgery, which increase the patient's morbidity and mortality., Purpose: The aim of this study was to evaluate new onset of atrial fibrillation (AF) after isolated coronary artery bypass grafting (CABG) surgery, its clinical and surgical predictors, and its impact in immediate and long-term outcomes., Methods: Retrospective study including all CABG surgeries performed in a tertiary centre, between 2004 and 2011. Patients with documented episodes of AF or pacing rhythm before cardiac surgery were excluded. Preoperative, surgical and postoperative data were collected through clinical files and informatics databases. Qui-square tests and independent t-tests were used to compare categorical and continuous data, respectively, between patients with and without PoAF. A multivariate logistic regression model was used to identify independent risk factors of PoAF. To determine the effect of PoAF in long-term survival, we used Kaplan-Meier curves, Log Rank test and multivariate Cox regression (maximum follow-up time: 13 years)., Results: We included 2511 patients, mean age of 63±10 years, 78.7% being male. PoAF occurred in 450 patients (18.0%), 3±3 days after surgery, the majority pharmacologically cardioverted with amiodarone (96.2%). These patients were older (67±9 vs. 62±10 years, p<0.001), more frequently obese (27.8% vs. 22.9%, p=0.026), hypertensive (76.7% vs. 69.7%, p=0.003) and had lower preoperative creatinine clearance (CC) values (73.2±27.4 vs. 81.4±28.3 ml/min, p<0.001), longer cardiopulmonary bypass time (60.0% vs. 54.8%, p=0.043) compared with patients without PoAF. In multivariate analysis, older age (OR: 1.035, 95% CI: 1.015-1.056, p=0.001), lower preoperative CC values (OR: 0.992, 95% CI: 0.985-0.999, p=0.032) and larger left atrial diameter (OR: 1.058, 95% CI: 1.024-1.093, p=0.001) were determined as independent predictors of PoAF. These patients also revealed longer hospitalization time (8 [4 to 193] vs. 6 [4 to 114] days, p<0.001) and higher hospital mortality (2.9% vs. 0.8%, p<0.001). Regarding long-term survival, patients with PoAF showed lower cumulative survival than patients without AF events (52% vs. 66%, p<0.001). PoAF was also found as an independent predictor of mortality in multivariate Cox regression (HR: 1.394, 95% CI: 1.147- 1.695, p=0.001)., Conclusion: PoAF incidence after CABG surgery was 18%. Older age, lower CC values and larger left atrial diameter were settled as PoAF independent predictors. Additionally, the occurrence of this arrhythmia was independently associated with lower long-term survival, after CABG surgery.

Introduction: Coronary artery bypass graft (CABG) patency is an important variable, but rarely studied as the main outcome. The best use of bilateral internal mammary artery (BIMA) grafting regarding configuration type or combination with saphenous vein graft (SVG) is still debated., Purpose: To find independent predictors for need of cardiac catheterization and for significant lesions in CABG follow-up., Methods: Retrospective cohort including all patients who underwent isolated CABG with BIMA grafts between 2004 and 2013 in a tertiary center. Preoperative, surgical and postoperative data were collected through clinical files and informatics databases. Kaplan-Meier curves, Cox regression and logistic regression were used to find predictors for the need of catheterization and for significant angiographic lesions after CABG. Secondary end-points studied were mid- term survival and need of re-revascularization either surgically or percutaneously., Results: We included 1030 patients in this analysis. Median follow-up time was 5.5 years and 150 (15%) patients were re-catheterized in that period. Most of these procedures was due to ischemia suspicion (74%) and 61 (41%) were positive for significant angiographic lesions of conduits (IMA: 3.2% and SVG: 3.8%, p=0.488). In multivariate analysis, SVG use was found as an independent predictor of cardiac catheterization on follow-up (HR: 1.610, CI 95%: 1.038-2.499, p=0.034). On the other side, independent predictors of graft lesions were younger age (OR: 0.951, CI 95%: 0.921-0.982, p=0.002), female gender (OR: 2.231, CI 95%: 1.038-4.794, p=0.040), arterial hypertension (OR: 1.968, CI 95%: 1.022-3.791, p=0.043) and 3-vessel disease (OR: 2.820, CI 95%: 1.155-6.885, p=0.023). Among the patients with significant angiographic lesions, 48 underwent repeat revascularization (44 PCI e 4 CABG). Arterial hypertension and younger age were independent predictors of re-revascularization., Conclusion: In BIMA patients the addition of SVG predicts the need of catheterization; however prevalence of significant angiographic lesions was similar in IMA and SVG. Our results suggest that arterial hypertension is an independent predictor of graft patency and re-revascularization rate.

We conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies comparing survival and major adverse cardiac and cerebrovascular events (MACCEs) of patients who underwent coronary artery bypass grafting (CABG) with multiple (MAG) versus single arterial grafting (SAG). MEDLINE, Web of Science and Cochrane Library were used to find relevant literature (1960–2018). Survival at a follow-up ≥1 year, MACCEs and early outcomes were evaluated. Time-to-event outcomes were collected through hazard ratio (HR) along with their variance, and the other endpoints using frequencies from matched sample or adjusted odds ratios. Random effect models were used to compute combined statistical measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events). Twenty-nine PS cohorts and 8 RCTs comprising 122,832 patients (52,178 MAG and 70,654 SAG) were included in this meta-analysis. MAG was associated with lower early mortality (OR: 0.82, 95%CI: 0.71–0.95, p =.007), long-term mortality (HR: 0.76, 95%CI: 0.73–0.78, p <.001) and MACCEs (HR: 0.85, 95%CI: 0.79–0.91, p <.001). Increased risk of sternal wound complications (SWC) was only observed when the bilateral internal mammary artery configuration was used for MAG (OR MAG BIMA: 1.96, 95%CI: 1.37–2.81, p <.001). Although the BIMA configuration increases the risk of SWC, MAG improves both early and long-term survival as well as MACCEs in CABG. Unlabelled Image • This meta-analysis suggests a benefit of MAG vs. SAG in long-term survival and MACCEs. • BIMA configuration in MAG associates with higher risk of sternal complications. • Powered RCTs are needed to settle MAG vs. SAG issue which ROMA trial aims to address. [ABSTRACT FROM AUTHOR]

Dual antiplatelet therapy after coronary artery bypass grafting: A safe option after all? While writing an original article, comparing survival of dual antiplatelet therapy (DAPT) vs aspirin monotherapy (ASA) following coronary artery bypass graft surgery, we came across a large meta-analysis entitled " I Dual antiplatelet therapy after coronary artery bypass grafting: is there any benefit? Randomized trial of aspirin and clopidogrel versus aspirin alone for the prevention of coronary artery bypass graft occlusion: the preoperative aspirin and postoperative antiplatelets in coronary artery bypass grafting study. [Extracted from the article]