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Machine learning may enhance prediction of outcomes after coronary artery bypass grafting (CABG). We sought to develop and validate a dynamic machine learning model to predict CABG outcomes at clinically relevant pre- and postoperative time points.The Society of Thoracic Surgeons (STS) registry data elements from 2086 isolated CABG patients were divided into training and testing datasets and input into Extreme Gradient Boosting decision-tree machine learning algorithms. Two prediction models were developed based on data from preoperative (80 parameters) and postoperative (125 parameters) phases of care. Outcomes included operative mortality, major morbidity or mortality, high cost, and 30-day readmission. Machine learning and STS model performance were assessed using accuracy and the area under the precision-recall curve (AUC-PR).Preoperative machine learning models predicted mortality (accuracy, 98%; AUC-PR = 0.16; F1 = 0.24), major morbidity or mortality (accuracy, 75%; AUC-PR = 0.33; F1 = 0.42), high cost (accuracy, 83%; AUC-PR = 0.51; F1 = 0.52), and 30-day readmission (accuracy, 70%; AUC-PR = 0.47; F1 = 0.49) with high accuracy. Preoperative machine learning models performed similarly to the STS for prediction of mortality (STS AUC-PR = 0.11; P = .409) and outperformed STS for prediction of mortality or major morbidity (STS AUC-PR = 0.28; P.001). Addition of intraoperative parameters further improved machine learning model performance for major morbidity or mortality (AUC-PR = 0.39; P.01) and high cost (AUC-PR = 0.64; P.01), with cross-clamp and bypass times emerging as important additive predictive parameters.Machine learning can predict mortality, major morbidity, high cost, and readmission after isolated CABG. Prediction based on the phase of care allows for dynamic risk assessment through the hospital course, which may benefit quality assessment and clinical decision-making.

Background The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures. Methods Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration. Results C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample. Conclusions New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.

Background Cardiothoracic surgery is one of the more highly litigated medical specialties, and coronary artery bypass grafting (CABG) constitutes a substantial portion of cardiothoracic surgery cases. Therefore, understanding litigations relating to CABG would be of benefit to surgeons working to uphold the standards of care that their patients seek and minimize their own legal liability. This study analyzed CABG litigations to identify predictive factors of litigation and verdict type. Methods This study utilized the Westlaw legal database to compile litigations from 1994-2019 across the United States, and resulted in 307 total litigations. After individual screening, 211 litigations met the criteria for inclusion, and were analyzed for demographic, clinical, chronological, and verdict characteristics. Results Litigations were present in 33 US states, with California, New York, and Florida having the most litigations. Defendant verdicts were reached in 67.78% of litigations, followed by 20.38% of plaintiff verdicts, and 11.85% of settlements. Plaintiff verdicts were associated with the incidence of myocardial infarction during hospitalization. The winter season had the most litigations (42.18%), and the most defendant verdicts (37.76%). Patient mortality occurred in 47.39% of litigations. The most common alleged reason for litigation was a procedural error (55.45%). Conclusions Defendant verdicts were significantly associated with an alleged reason of procedural errors, an alleged reason of a failure to monitor, and congestive heart failure present in patients. The common nature of defendant verdicts, and the significantly greater occurrence of defendant verdicts during the highly litigated winter season, suggest that surgeons frequently satisfy the legal standard of care.

Background: Coronary artery bypass grafting 30-day unplanned readmission is a focus for the CMS Hospital Readmissions Reduction Program. Awareness of the critical elements of the care delivery environment, including hospital infrastructure and patient clinical profiles that predispose toward readmission, is essential to proactively decrease readmissions. Methods: The Healthcare Cost and Utilization Project-State Inpatient Database, American Hospital Association Annual Health Survey Database, and Healthcare Information Management Systems Society data sets were merged to create a single data set of patient- and hospital-level data from 8 states. Isolated coronary artery bypass grafting procedures were queried for all-cause 30-day readmission, and backwards stepwise logistic regression was performed. Readmission rate was then used to categorize hospitals into quartiles, and analysis focused on the hospitals with the lowest (Q1) and highest (Q4) readmission rates. Univariate analysis was performed comparing Q1 and Q4 hospitals. Results: A total of 150,215 patients underwent isolated coronary artery bypass grafting with 23,244 (15.5%) readmitted patients among 903 hospitals. Model area under the curve was 0.709 (95% confidence interval, 0.702–0.716), with the top 3 readmission determinants related to discharge disposition. Compared to Q1, Q4 patients more often were female, were >70 years of age, and had Medicare as a primary payor (P < .001). Low readmission rate hospitals were characterized by higher costs; not-for-profit status; having Joint Commission accreditation; and higher total admissions, operative volume, hospital/ICU beds, full-time physicians, nurses, and ancillary personnel (P < .001). Conclusion: Readmission after coronary artery bypass grafting is strongly influenced by discharge disposition. However, hospital factors such as scale, personnel, and ownership structure are significant contributors to readmission. Focus beyond patient factors to include the entire continuum of care is required to enhance outcomes, of which readmission is one surrogate measure.

In Japan, off-pump coronary artery bypass (OPCAB) is more common than on-pump coronary artery bypass. Superior early results of OPCAB have been reported; however, long-term results were still unclear. Purpose of this study is to evaluate the clinical outcomes of OPCAB in Japan using Japan Adult Cardiovascular Surgery Database. Between 2008 and 2010, 23,633 patients who underwent isolated coronary artery bypass were reported in database. We selected the cases from the hospital with mean annual coronary surgery volume of more than 50. Among the total of 7724 cases at 41 institutions, 2150 (31.2%) on-pump coronary artery bypass (ONCAB) and 5574 (68.8%) OPCAB cases were included. Propensity score (PS) matching was performed using PS developed from patient characteristics and preoperative factors resulting in 2007 cases matched pairs. Long-term follow-up data on patients’ mortality and stroke were collected. In-hospital mortality was significantly lower in OPCAB (ONCAB 1.1%, OPCAB 0.4% p = 0.01). Stroke was low in OPCAB group (ONCAB 1.7%, OPCAB 0.8%, p = 0.01). There was no statistically significant difference between OPCAB and ONCAB regarding 7-year overall survival (86.1% vs 88.1% respectively), composite outcomes (72.0% vs 73.9% respectively), or cardiac deaths (97.3% vs 97.1% respectively). Subgroup analysis (more than 75 years old) showed a worse trend in OPCAB group. Only in OPCAB group, incomplete revascularization significantly influenced 7-year survival. OPCAB is associated with early prognostic benefits; however, it might be less favorable outcomes in the long term when patients are older or with incomplete revascularization.

Fei Gao,1,&ast; Lingtong Shan,2,&ast; Chong Wang,3,&ast; Xiaoqi Meng,4 Jiapeng Chen,5 Lixiang Han,6 Yangyang Zhang,3 Zhi Li6 1Cardiovascular Department, Huaiyin Hospital of Huai’an City, Huai’an, Jiangsu, People’s Republic of China; 2Department of Thoracic Surgery, Sheyang County People’s Hospital, Yancheng, Jiangsu, People’s Republic of China; 3Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, People’s Republic of China; 4The Second Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China; 5Xinglin College, Nantong University, Nantong, Jiangsu, People’s Republic of China; 6Department of Cardiovascular Surgery, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Zhi LiDepartment of Cardiovascular Surgery, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, People’s Republic of ChinaTel +86 13770606815Email zhili_cths@163.comYangyang ZhangDepartment of Cardiac Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, 241 Huaihai West Road, Shanghai, 200120, People’s Republic of ChinaTel +86 13818132320Email zhangyangyang_wy@vip.sina.comObjective: To evaluate the powers of European Heart Surgery Risk Assessment System II (EuroSCORE II) and the Society of Thoracic Surgeons (STS) score in predicting in-hospital and medium-term mortality of patients undergoing coronary artery bypass grafting (CABG).Methods: Totally 1628 Chinese patients were included between January 2000 and January 2018. Their perioperative clinical data were collected and the patients were closely followed up. According to the length of follow-up time, the total cohort was divided into 1-year, 2-year, 3-year, 4-year and 5-year groups. The in-hospital and medium-term risk prediction of EuroSCORE II and STS score were comparatively assessed by calibration, discrimination, decision curve analysis (DCA), net reclassification index (NRI), integrated discrimination improvement (IDI) and Bland-Altman analysis.Results: About 36 (2.21%) patients died during hospitalization. Both EuroSCORE II and STS score performed extremely well in predicting in-hospital mortality (area under curve = 0.900 and 0.879, respectively). However, calibration and discrimination analyses showed gradual decrease when these two risk evaluation systems were used to predict mortality during the follow-up period. At the same time, the predictive ability of EuroSCORE II was better than STS score. DCA curves showed that the performances of the two evaluation systems were roughly equal between the threshold probability of 0% to 20%. The percentage of correct reclassification of EuroSCORE II was 21.64% higher than that of STS score in predicting 2-year postoperative mortality. The IDI index showed that the predictive capabilities of these two systems were roughly equivalent. Bland-Altman analysis showed no significant difference between the values of the two systems.Conclusion: EuroSCORE II and STS score have excellent predictive powers in predicting in-hospital mortality of patients undergoing CABG. In particular, EuroSCORE II is superior in calibration and discrimination. The prediction efficiency of the two risk evaluation systems is still acceptable for two-year postoperative mortality, but decreases year by year.Keywords: EuroSCORE II, STS score, coronary artery bypass grafting, in-hospital mortality, medium-term prognosis

Background The long-term outcomes for patients after coronary artery bypass grafting (CABG) have been received more and more concern. The existing prediction models are mostly focused on in-hospital operative mortality after CABG, but there is still little research on long-term mortality prediction model for patients after CABG. Objective To develop and validate a novel nomogram for predicting 3-year mortality in critically ill patients after CABG. Methods Data for developing novel predictive model were extracted from Medical Information Mart for Intensive cart III (MIMIC-III), of which 2929 critically ill patients who underwent CABG at the first admission were enrolled. Results A novel prognostic nomogram for 3-year mortality was constructed with the seven independent prognostic factors, including age, congestive heart failure, white blood cell, creatinine, SpO2, anion gap, and continuous renal replacement treatment derived from the multivariable logistic regression. The nomogram indicated accurate discrimination in primary (AUC: 0.81) and validation cohort (AUC: 0.802), which were better than traditional severity scores. And good consistency between the predictive and observed outcome was showed by the calibration curve for 3-year mortality. The decision curve analysis also showed higher clinical net benefit than traditional severity scores. Conclusion The novel nomogram had well performance to predict 3-year mortality in critically ill patients after CABG. The prediction model provided valuable information for treatment strategy and postdischarge management, which may be helpful in improving the long-term prognosis in critically ill patients after CABG.

Adult spinal deformity (ASD) surgeries are complex, involving long operative times and surgical morbidity. It is currently unclear how the invasiveness of ASD surgery compares to other major operations.To: (1) develop a quantitative score of surgical morbidity and invasiveness, and (2) compare this score between ASD surgery and other major operations.Retrospective review of prospectively collected data.A prospective surgical registry was used to identify all patients undergoing ASD surgery involving ≥ 7 segments. Seventeen additional procedures were included: coronary artery bypass grafting (CABG), pancreatectomy, and esophagectomy, among others.Perioperative factors (operative time, transfusions, ventilation) and complications were collected and combined with a previously validated Postoperative Morbidity Survey to create a Surgical Invasiveness and Morbidity Score (SIMS).Computed scores were compared across surgeries using Welch's t-test. Multiple linear regression modeling was used to compare the SIMS of major surgeries relative to ASD while controlling for patient demographics and comorbidities.A total of 1,245,282 surgical patients were included, 4,656 of which underwent ASD surgery. After multiple regression modeling controlling for patient demographics and comorbidities, ASD surgery ranked fourth in SIMS. ASD surgery had a significantly greater SIMS than 13 other major procedures including 6th esophagectomy (adjusted mean difference=-0.05, 95%CI -0.01-0.09, p.001), 8th pancreatectomy (-0.40, 0.37-0.44, p.001), 11th craniotomy for tumor (-1.01, 0.98-1.04, p.001), and 12th sacral chordoma resection (-1.31, 1.26-1.37, p.001).ASD surgery was associated with significantly greater SIMS than many other major operations, even when controlling for important perioperative factors. These data have implications for patient counseling, resource allocation, and informed consent.

OBJECTIVES Sequential radial artery (RA) grafting has the potential to enhance arterial revascularization compared to single grafting. Sequential RA grafting was performed predominantly with a single side-to-side anastomosis. The study aimed to assess if sequential RA grafting improved long-term graft patency compared to single RA grafting. In addition, the anastomotic patencies of side-to-side and end-to-side anastomoses in sequential RA grafting were assessed. METHODS Two hundred nineteen patients underwent isolated coronary artery bypass grafting with skeletonized RA conduits between 2005 and 2016. Of these, 208 patients underwent radiological graft assessment; thus, 125 and 83 patients underwent single and sequential RA grafting, respectively. The graft and anastomotic patency rates were estimated using the Kaplan–Meier method. RESULTS The median follow-up period was 9.1 years, and the radiological assessment lasted 5.1 years. The overall RA graft patency rates at 1, 5 and 10 years were 99.4%, 92.7% and 88.1%, respectively. The RA graft patency rate for sequential grafting was similar to that for single grafting (88.7% vs 87.4% at 10 years; P = 0.88). In the stratified analysis of anastomotic patency, the patency rate of side-to-side anastomoses of sequential RA grafting was significantly better than that of end-to-side anastomoses (100% vs 88.7% at 10 years; P = 0.01). CONCLUSIONS The long-term RA graft patencies of sequential and single grafting were equally high. The anastomotic patency of side-to-side anastomoses of sequential RA grafting was remarkably high. Considering these findings, the RA can be effectively used for multiple arterial coronary revascularizations.

The article presents a clinical case of a staged hybrid treatment for an aortic arch aneurysm in patient who previously underwent coronary artery bypass grafting and exoplasty of the ascending aorta. Possible alternative treatment options for this pathology are reviewed, and the features of surgical and endovascular treatment are also described.

Background and aim In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted the first-year residents' duty-hour to less than 16-hour shifts, decreased the maximum shift duration for senior residents, and increased minimum time off after on-call duties. Whether these changes may have impacted the outcomes in cardiac surgery remains unclear. Methods We performed a difference-in-difference analysis of the New York State Cardiac Surgery Reporting System data in 2004-2006 (before the duty-hour policies change) and 2014-2016 (after the change). We evaluated differences in 30-day risk-adjusted mortality rates (RAMR) in coronary artery bypass grafting (CABG) and valve surgeries, stratifying data by hospital type: teaching hospitals (TH) versus nonteaching hospitals (NTH). NTH served as the control not affected by the duty-hour policies. Results (1) The overall surgical volume for CABG surgery has decreased over time (37,645-24,991), while the volume for valve surgery remained similar (20,969-21,532); (2) TH had better short-term outcomes for CABG procedures during 2014-2016 (median RAMR: 1.01% vs. 1.55% in TH vs. NTH, respectively; p = .025) as well as for valve procedures during both 2004-2006 (5.16% vs. 7.49%, p = .020) and 2014-2016 (2.59% vs. 4.09%, p = .033); (3) at difference-in-difference analysis, trainees' duty-hour regulations were not associated with worsening short-term outcomes in both CABG (p = .296) and valve (p = .651) procedures performed in TH. Conclusion The introduction of the 2011 trainees' duty-hour regulations was not associated with worse short-term outcomes for CABG and valve surgery performed in the State of NY by TH.

Background: Vein graft occlusion is deemed a major challenge in coronary artery bypass grafting. Previous studies implied that the no-touch technique for vein graft harvesting could reduce occlusion rate compared with the conventional approach; however, evidence on the clinical benefit and generalizability of the no-touch technique is scare. Methods: From April 2017 to June 2019, we randomly assigned 2655 patients undergoing coronary artery bypass grafting at 7 hospitals in a 1:1 ratio to receive no-touch technique or conventional approach for vein harvesting. The primary outcome was vein graft occlusion on computed tomography angiography at 3 months and the secondary outcomes included 12-month vein graft occlusion, recurrence of angina, and major adverse cardiac and cerebrovascular events. The generalized estimate equation model was used to account for the cluster effect of grafts from the same patient. Results: During the follow-up, 2533 (96.0%) participants received computed tomography angiography at 3 months after coronary artery bypass grafting and 2434 (92.2%) received it at 12 months. The no-touch group had significantly lower rates of vein graft occlusion than the conventional group both at 3 months (2.8% versus 4.8%; odds ratio, 0.57 [95% CI, 0.41–0.80]; P P P P Conclusions: Compared with the conventional vein harvesting approach in coronary artery bypass grafting, the no-touch technique significantly reduced the risk of vein graft occlusion and improved patient prognosis. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03126409.

BACKGROUND: Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG). METHODS: A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival. RESULTS: Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with 1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival. CONCLUSIONS: Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.

Background Flowable hemostatic agents are advantageous in that they can be applied to irregular wound surfaces and to areas that are difficult to approach directly. We sought to compare the effectiveness and safety of the flowable hemostatic sealants Collastat® (collagen hemostatic matrix, [CHM]) and Floseal® (gelatin hemostatic matrix, [GHM]) during off-pump coronary artery bypass (OPCAB). Methods In this prospective, randomized trial, 160 patients undergoing elective OPCAB surgery were enrolled between March 2018 and February 2020. After primary suture of the aortocoronary anastomosis, an area of hemorrhage was identified, and patients were double blind randomized to receive either CHM or GHM (n = 80, each). Study endpoints were the following: rate of successful intraoperative hemostasis and time required for hemostasis overall postoperative bleeding, rate of transfusion of blood products, rate of surgical revision for bleeding, postoperative morbidity, and intensive care unit stay. Results Of the total patients, 23% were female, and the mean age was 63 years (range: 42–81 years). Successful hemostasis within 5 min was achieved for 78 patients (97.5%) in the GHM group, compared to 80 patients (100%) in the CHM group (p = 0.497). Two patients receiving GHM required surgical revision to achieve hemostasis. There were no differences in the mean time required to obtain hemostasis (GHM vs. CHM, 1.49 ± 0.94 vs. 1.35 ± 0.60 min, p = 0.272), as confirmed by time-to-event analysis (p = 0.605). The two groups had similar amounts of mediastinal drainage for 24 h postoperatively (p = 0.298). The CHM group required less packed red blood cells, fresh frozen plasma, and platelets for transfusion than the GHM group (0.5 vs. 0.7 units per patient, p = 0.047; 17.5% vs. 25.0%, p = 0.034; 7.5% vs. 15.0%, p = 0.032; respectively). Conclusions CHM performed similarly to a commonly used hemostatic agent with regard to achieving effective and fast interoperative hemostasis during OPCAB. The topical flowable hemostatic agent, CHM, could be effectively used during cardiac surgery for intraoperative hemostasis of great vessels with high pressure. Trial registration : ClinicalTrials.gov, NCT 04310150

Актуальность. Хирургическая реваскуляризация миокарда является эффективным способом лечения больных с ишемической болезнью сердца. Обязательным этапом проведения экстракорпорального кровообращения является индуцированная остановка сердца и связанный с этим период общей ишемии. Поэтому при выполнении операций аортокоронарного шунтирования в условиях искусственного кровообращения развивается острая сердечная недостаточность, выраженная в той или иной степени. Несмотря на постоянное совершенствование методов искусственного кровообращения, анестезии и кардиопротекции, частота интраоперационного инфаркта миокарда составляет от 2 до 7,2 % случаев, острой сердечной недостаточности — от 2,7 до 51,2 %, острых нарушений сердечного ритма — от 20 до 63,6 %. Цель исследования: улучшить результаты лечения кардиохирургических больных с сердечной недостаточностью, перенесших оперативное вмешательство — шунтирование коронарных артерий с применением экстракорпорального кровообращения, путем усовершенствования протокола периоперационного ведения пациентов. Материалы и методы. На базе Государственного научного учреждения «Научно-практический центр профилактической и клинической медицины» Государственного управления делами было прооперировано 100 кардиохирургических больных ишемической болезнью сердца, которым было выполнено аортокоронарное шунтирование с использованием искусственного кровообращения. От всех больных было получено информированное согласие на участие в исследовании. Пациенты были разделены на две группы. Пациентам группы 1 (40 больных) в послеоперационном периоде коррекцию гемодинамических расстройств выполняли по стандартным действующим протоколам. В группе 2 (60 больных) был применен дифференцированный подход к коррекции гемодинамических расстройств. В подгруппе 1 (20 больных) в послеоперационном периоде коррекцию гемодинамических расстройств выполняли с помощью добутамина и достигли стабилизации. В подгруппе 2 (11 больных, у которых была диагностирована в предоперационном периоде гипофосфатемия) для коррекции гемодинамических расстройств кроме добутамина использовали препарат фруктозо-1,6-дифосфат по схеме: 5 г препарата вводили непосредственно перед началом перфузии и 5 г — на 30-й минуте искусственного крово­обращения. Препарат, эндогенный высокоэнергетический промежуточный метаболит гликолитического пути, непосредственно усиливает образование высокоэнергетического фосфата (аденозинтрифосфата). В подгруппе 3 (6 больных) в послеоперационном периоде кроме добутамина для коррекции гемодинамических расстройств применили препарат тиворель (1 мл 42 мг аргинина гидро­хлорида и 20 мг левокарнитина). В подгруппе 4 (23 больных) в послеоперационном периоде не было гемодинамических расстройств, коррекцию не выполняли. Результаты. Был разработан периоперационный анестезиологический менеджмент у кардиохирургических больных с сердечной недостаточностью, перенесших аортокоронарное шунтирование с использованием искусственного кровообращения. Для мониторинга функции сердечно-сосудистой системы использовали электрокардиографию, эхокардиографию, фазаграфию, определяли вариабельность сердечного ритма по Р.М. Баевскому. Фазаграфия — это инновационный метод обработки электрокардиограмм, разработанный НАН Украины. Суть метода — исследование симмет­рии/асимметрии зубца Т электрокардиограммы как маркера ишемических изменений миокарда. Определение симметричности волны Т в фазовом пространстве является эффективным диагностическим критерием наличия ишемии (показатель βТ) на электрокардиограмме. Результаты исследований свидетельствуют о возможности использования метода фазаграфии, в частности анализа симметрии зубца Т как маркера ишемических изменений в миокарде, у кардиохирургических больных, перенесших аортокоронарное шунтирование с использованием искусственного кровообращения. Установлено, что в группе 2 для стабилизации гемодинамики, кислородного статуса, микроциркуляции были использованы меньшие дозы симпатомиметиков, были меньше продолжительность их применения, частота гемодинамически значимой фибрилляции предсердий, доза введенного амиодарона, продолжительность искусственной вентиляции легких по сравнению с группой 1. Выводы. Полученные данные свидетельствуют, что разработанный алгоритм периоперационного ведения кардиохирургических больных с сердечной недостаточностью дает возможность значительно ускорить реабилитацию кардиохирургических больных, повысить комфорт пациента и сократить срок пребывания в больнице до 6–7 суток.

Objectives: The aim of this study was to determine the frequency of operative mortality in patients who had low serum albumin on admission and were undergoing coronary artery bypass grafting (CABG) after nutritional support at a tertiary care cardiac center in Karachi, Pakistan. Methodology: A retrospective study was conducted at an adult cardiac surgery department of the largest tertiary care cardiac center in Karachi, Pakistan. Patients who had undergone isolated CABG during January to December 2019 admitted with low serum albumin (less than 3.5mg/dl) and received nutritional treatment before surgery were included in the study. Patients were monitored for a month to measure the 30 day mortality. Results: There were 82.4% male patients and the mean age was 55.49±8.52 years. Preoperative mean serum haemoglobin, serum creatinine, and serum albumin levels were 12.225±1.19 mg/dl, 1.05±0.21 mg/dl, and 2.825±0.39 mg/dl respectively. Postoperative mortality was recorded in 1.7% of the total patients. Conclusion: In patients with low serum albumin levels and had undergone isolated CABG after nutritional pre-treatment, mortality was mainly associated with peri-operative myocardial infarction. While, the incidence of delayed wound healing and atrial fibrillation were found to be high in these patients.

Background: The aim of this study is to compare the efficacy of the microplegia solution and Del Nido cardioplegia solution in coronary artery bypass surgery with clinical, biochemical, and echocardiographic data. Methods: Three hundred patients, who underwent coronary artery bypass surgery between January 2017 and January 2020, by the same surgical team were included in the study. Preoperative, operative and postoperative data (cardiac biomarker levels, cross-clamp and CPB times, echocardiographic measurements, etc.) of the patients were compared. Results: In the study, cross-clamp time was significantly shorter in the DN cardioplegia group (55.60 ± 13.49 min/75.58 ± 12.43 min, P = 0.024). No significant difference was observed between the two groups in terms of intensive care stay, extubation time, hospital stay, and cardiopulmonary bypass time. In our study, it was shown that both the left and right ventricular ejection fraction was better protected in the Del Nido cardioplegia group (5.34±3.03 vs. 3.40±2.84, P = 0.017 and 3.82±1.19 vs. 2.28±1.87, P = 0.047, respectively), and the need for inotrope support was lower in this group (28% vs. 44%, P < 0.021). There was no significant difference between the groups, in terms of blood transfusion rates, IABP requirement. Conclusion: In light of short-term results, we can say that Del Nido cardioplegia provides better myocardial protection than microplegia. In addition, Del Nido cardioplegia can be given as a single dose for 90 minutes of cross-clamp time and therefore can be preferred to increase surgical comfort and reduce cross-clamp times.

Double valve replacement is now-a-days a common procedure to treat diseased cardiac valves and the primary aim of prophylactic aortic replacement during concomitant valve replacement is to prevent dreadful complication like dissection, aortic rupture and even death. Although aortic surgeries are complex and have high morbidity and mortality rates, additional double valve procedure with coronary surgery can make it even worse. But for these patients, surgery remains the one and only treatment option for symptom relieve and prolongation of life. We herein present a case of severe aortic stenosis (AS) with severe aortic regurgitation (AR) with severe mitral regurgitation (MR) with coronary artery disease (CAD) and aortic aneurysm treated successfully by us at Square Hospitals; and to our best knowledge and according to the published articles, this is probably the first time, this type of combined cardiac procedure has been accomplished along with aortic surgery, in our country. We recommend that surgeons should perform bypass grafting along with aortic replacement and valve replacement surgery when indicated, without worrying that adding such a procedure will escalate post-operative adverse effect. Cardiovasc j 2021; 14(1): 82-87

Background Incisional negative pressure wound therapy has been described as an effective method to prevent wound infections after open heart surgery in several publications. However, most studies have examined relatively small patient groups, only a few were randomized, and some have manufacturer-sponsorship. Most of the studies have utilized Prevena; there are only a few reports describing the PICO incisional negative pressure wound therapy system. Methods We conducted a prospective cohort study involving a propensity score-matched analysis to evaluate the effect of PICO incisional negative pressure wound therapy after coronary artery bypass grafting. A total of 180 high-risk patients with obesity or diabetes were included in the study group. The control group included 772 high-risk patients operated before the initiation of the study protocol. Results The rates of deep sternal wound infections in the PICO group and in the control group were 3.9 and 3.1%, respectively. The rates of superficial wound infections needing operative treatment were 3.1 and 0.8%, respectively. After propensity score matching with two groups of 174 patients, the incidence of both deep and superficial infections remained slightly elevated in the PICO group. None of the infections were due to technical difficulties or early interruption of the treatment. Conclusion It seems that incisional negative pressure wound therapy with PICO is not effective in preventing wound infections after coronary artery bypass grafting. The main difference in this study compared with previous reports is the relatively low incidence of infections in our control group.

Background: We aimed to investigate the neutrophil-lymphocyte ratio (NLR) as a predictor of mortality in patients, who had undergone on-pump and off-pump coronary artery bypass grafting (CABG). Methods: This retrospective study comprised of 457 patients, who underwent CABG (323 on-pump and 134 off-pump) between January 2014 and October 2019. Preoperative, postoperative (PO) 1st hour, PO 1st day, and PO 5th day neutrophil-lymphocyte ratios were calculated. The patients were compared, according to demographic, laboratory, and clinical data. A receiver operating characteristics curve was applied to estimate a cut-off value of NLR for mortality. Results: The on-pump group was older (P = 0.001), had a lower Euroscore II (P = 0.036), had a higher graft number (P < 0.001), intensive care unit stay (P = 0.001), and all PO NLRs, except preoperative NLR. There were 14 (3.06%) patients with mortality. Overall (N = 457), PO 1st hour (P = 0.001), PO 1st day (P < 0.001), and PO 5th day (P = 0.016) NLRs were considerably higher in patients with mortality. While none of the NLRs revealed a significant difference in the off-pump group, PO 1st hour (P = 0.004) PO 1st day (P < 0.001), and PO 5th day (P = 0.007) NLRs were higher in patients with mortality in the on-pump group. The increase in odds ratio of PO NLR was higher in patients with mortality in the overall group of PO 1st day and in the on-pump group of PO 1st hour and PO 1st day. The best combination of sensitivity and specificity was reached at a cut-off value of 6.4 for PO 1st hour NLR and 31.8 for PO 1st day NLR. Conclusions: As in indicator of inflammatory state, NLR readily can be used as a predictor of mortality. Regardless of the CABG technique used, postoperative 1st hour and postoperative 1st day NLR >6.4 and 31.8, respectively, are highly related to mortality.

OBJECTIVES Previous reports have found females are a higher risk of morbidity and mortality following isolated coronary artery bypass grafting (CABG). Here, we describe the differences in outcomes following isolated CABG between males and females. METHODS Following a systematic literature search, studies reporting sex-related outcomes following isolated CABG were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was operative mortality. Secondary outcomes included rates of stroke, repeat revascularization, myocardial infarction, major adverse cardiac events, and late mortality. Subgroup analyses were performed for studies published before and after the year 2000 and for the type of risk adjustment. RESULTS Eighty-four studies were included with a total of 903 346 patients. Females were at higher risk for operative mortality (odds ratio: 1.77, 95% confidence interval [CI]: 1.64–1.92, P 0.001) but not repeat revascularization (IRR: 0.99, 95% CI: 0.76–1.29, P = 0.95). The use of the off-pump technique or multiple arterial grafts was not associated with the primary outcome. CONCLUSIONS Females undergoing CABG are at higher risk for operative and late mortality as well as postoperative events including major adverse cardiac events, myocardial infarction and stroke. PROSPERO registration CRD42020187556

Aim. To identify the factors influencing the development of postoperative atrial fibrillation (POAF).Methods. The study included 100 patients with indications for cardiac surgery, aged 53 to 82 years (mean age 67.2±17 years). The group included patients who had no history of AF before surgery. Cardiac surgery in the group was presented in 63 patients by coronary artery bypass grafting, and in 37 – by intervention on the heart valves. All respondents were divided into 2 groups: the first included 39 people (39%) who had AF paroxysms lasting more than 30 seconds in the early postoperative period, with a peak at 1–2 days, in 13 (33.3%) cases of AF relapsed. The second group of patients was represented by 61 patients (61%) without cardiac arrhythmias after surgery.Results. The dependence of the development of POAF on age, the concentration of C-reactive protein in the peripheral blood taken on the day of cardiac surgery, the longitudinal size of the left atrium before surgery was revealed.Conclusion. It was found out that a number of factors such as age, preoperative left atrium size, C-reactive protein level in the first days after surgery suggest the development of POAF. The use of the predictors obtained can make it possible to develop an effective strategy for the prevention of POAF.

Introduction: In Malaysia, MIDCABG started in 3 centers developing the technique. As the technique is gaining traction in the country, this study aims to compare the quality of life following MIDCABG compared with conventional CABG in one of the centers actively developing this technique. Methods: A retrospective cohort study was performed involving 30 post CABG patients which consists of 15 MIDCABG and 15 conventional CABG from January 2015 to May 2018. 15 from 21 post-MIDCABG patients were included and selected, based on EuroSCORE II less than 5. Modified Post-Operative Quality of Recovery Scale was used to assess and compare the quality of life following respective approaches. Data were analyzed using SPSS version software and comparison using mean rank with p 0.05. Conclusion: There is no significant difference in quality of recovery following MIDCABG compared to conventional CABG. Modified PostOPQRS system can be a useful assessment tool to evaluate the impact of an intervention in relation of quality of life.

BACKGROUND Medicaid expansion (ME) under the Affordable Care Act has reduced the number of uninsured patients, although its preferential effects on vulnerable populations have been mixed. This study examined whether ME preferentially improved cardiac surgery use by insurance strata, race, and income level. METHODS Non-elderly adults (aged 18-64 years) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair were identified in the State Inpatient Databases for 3 expansion states (Kentucky, New Jersey, and Maryland) and 2 non-expansion states (North Carolina and Florida) from 2012 to the third quarter of 2015. We used adjusted Poisson interrupted time series to determine the impact of ME on cardiac surgery use for Medicaid or uninsured (MCD/UIS) patients, racial and ethnic minorities, and individuals from low-income areas. RESULTS In expansion states, use among non-White MCD/UIS patients had a positive trend after ME (2.3%/quarter; P = .156), whereas use for White MCD/UIS patients fell (-1.7%/quarter; P = .117). In contrast, use among non-White MCD/UIS in non-expansion states decreased by 4.4% (P < .001) which was a greater decline than among White MCD/UIS patients (-1.8%/quarter; P = .057). There was no substantial effect of ME on cardiac surgery use for MCD/UIS patients from low- versus high-income areas. CONCLUSIONS These findings demonstrate that the use of cardiac surgical procedures was generally unchanged after ME; however, nonsignificant trend differences suggest a narrowing gap between vulnerable and non-vulnerable groups in ME states. These preliminary findings help describe the association of insurance coverage as a driver of cardiac surgery use among vulnerable patients.

Purpose: The principal of this analysis was to understand global feature of the number and type of grafts and number of diseased vessels of those undergoing coronary artery bypass grafting (CABG) and their short-term clinical results. Methods and Results: This report presents annual report on the collective data of CABG in the year 2018 (1 January–31 December). Data were collected based on the series of questionnaire which has been performed by The Japanese Association for Coronary Artery Surgery (JACAS), capturing the corresponding data from the Japan Adult Cardiovascular Surgery Database (JCVSD). We also analyzed descriptive clinical results of those undergoing surgeries for acute myocardial infarction and ischemic mitral regurgitation. Conclusion: This is the first article summarizing the results from annually performed questionnaires by JACAS based on JCVSD, on the trend of CABG procedures and clinical results in Japan as a scientific manuscript.

Background The current representation of female patients and racial and ethnic minorities in cardiovascular trials is unclear. We evaluated these groups’ inclusion in U.S. cardiovascular trials. Methods Using publicly available data from ClinicalTrials.gov , we evaluated cardiovascular trials pertaining to coronary artery bypass grafting (CABG), heart valve disease, aortic aneurysm, ventricular assist devices, and heart transplantation. This yielded 178 U.S. trials (159 completed, 19 active but not recruiting) started between September 1998 and May 2017, with 237,132 participants. To examine female patients’ and racial and ethnic minorities’ representation in these trials, we calculated participation-to-prevalence ratios (PPRs). Values of 0.8 to 1.2 reflect similar representation. Results All 178 trials reported sex distribution, whereas only 76 (42.7%) trials reported racial distribution and 52 (29.2%) trials reported ethnic (Hispanic vs non-Hispanic) distribution. Among all trials, participants were 28.3% female, 11.2% were Hispanic/Latino, 4.0% were African American, 10.4% were Asian, and 2.3% were other. The CABG PPR for female patients was 0.64, for Hispanic patients was 0.72, for African American patients was 0.28, and for Asian patients was 3.20. Between 2008-2012 and 2013-2017, the CABG PPR decreased for female patients (0.67→0.50) and African American patients (0.37→0.17) but increased for Hispanic patients (0.38→1.32) and Asian patients (3.51→4.57). Conclusions Participation in cardiovascular trials by female patients and minorities (except Asian patients) remains low. Given that inherent differences among the previously mentioned groups could affect outcomes, balance is clearly needed. The engagement of our surgical leadership, community, and industry to address these disparities is vitally important.

OBJECTIVES Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years. METHODS Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization. RESULTS The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%. CONCLUSIONS We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

Coronary artery fistula (CAF) is one of the most common coronary artery anomalies. The most common fistulas originate from the right coronary artery and drain into the right heart structures. Due to the variety of coronary fistulas, the surgical treatment strategy is individualized for each case. We report two cases of giant aneurysmal CAF originating from the left circumflex artery. One case required coronary artery bypass grafting, while the other did not.

This literature review focuses on the choice of treatment strategies in patients with aortic stenosis. The main surgical techniques for this condition are presented. The rationale for the efficiency of transcatheter aortic valve implantation is provided. The results of studies comparing the outcomes of surgical and endovascular correction of aortic stenosis are analyzed. Particular attention is paid to the treatment choices in patients with aortic stenosis and a history of coronary artery bypass grafting. Conclusions on the perspectives of transcatheter aortic valve implantation in this cohort of patients are reached.

BACKGROUND Equipment entrapment during percutaneous coronary intervention (PCI) may lead to acute ischemia necessitating emergency surgery. CASE PRESENTATION This is the first case report where emergency surgery had to be performed on beating heart, for removal of retained PCI equipment, due to an incidental finding of severely atheromatous aorta precluding cross-clamp. Ultrasound-guided aortic cannulation and off-pump strategy made the complex reconstruction of left anterior descending artery possible. CONCLUSIONS PCI equipment entrapment and subsequent myocardial ischemia, with or without hemodynamic compromise, necessitates emergency surgery and should involve an early discussion with a cardiothoracic team. Each case poses different challenges and requires surgical planning to devise an individualized management strategy. Intraoperative finding of atheromatous aorta may be managed with pump-assisted beating heart surgery and clampless technique to achieve satisfactory results.

Background:Although coronary artery bypass grafting is not frequently performed in children, Kawasaki disease is one of the most common indications for coronary artery bypass grafting in children. Here, we reviewed the long-term clinical outcomes including graft patency after coronary artery bypass grafting.Methods:Between March 2004 and March 2013, six patients with Kawasaki disease underwent coronary artery bypass grafting. All patients were male. Their median age was 13.0 years (interquartile range, 7.8–17.8 years) at the timing of coronary artery bypass grafting, and the median age at the onset of Kawasaki disease was 3.3 years (interquartile range, 1.0–7.0 years). Four patients presented with multiple lesions including aneurysms.Results:The median follow-up duration was 12.1 years (interquartile range, 9.5–13.1 years), and there were no operative complications or overall mortality. One patient had pre-operative symptoms such as exertional chest pain and dyspnoea on exertion, whereas one patient had ventricular tachyarrhythmia. There was an improvement in subjective symptoms after surgery in two patients. The left internal thoracic artery, right internal thoracic artery, and saphenous vein were used in five (83.3%), one (16.7%), and two (33.3%) cases, respectively. In all six patients, post-operative single-photon emission CT findings showed improved perfusion compared with pre-operative single-photon emission CT. All grafts were patent as confirmed by coronary angiography or CT angiography.Conclusions:Coronary artery bypass grafting could be a good surgical option in children with coronary lesions caused by Kawasaki disease in terms of graft patency and myocardial perfusion.

Introduction: Throughout the world, cardiovascular disease is a leading cause of not only morbidity but also mortality too. Myocardial infarction is the primary reason for admission in cardiac rehabilitation unit, patients of Coronary artery bypass Graft (CABG) surgery along with other cardiac condition like valve surgery, post PTCA (Percutaneous Transluminal Coronary Angioplasty) are also being referred for cardiac rehabilitation. Coronary artery bypass surgery, also known as coronary artery bypass graft (CABG) surgery, is a surgical procedure for partially obstructed coronary artery (the "target vessel"). The purpose is to restore normal blood ow to the partially obstructed coronary artery. Our study is an attempt to understand the age, gender and risk factors pattern in patients attending for cardiac rehabilitation after Coronary Artery Bypass Grafting (CABG) Surgery. Material And Methods: This Retrospective Cohort Study was conducted in the Department of Physical Medicine and Rehabilitation of Institute of Post Graduate Medical Education and Research (IPGME & R) and SSKM Hospitals, Kolkata after getting Institutional ethical committee clearance and informed consent. Relevant data regarding medical, personal history and demographics collected from the patients attended for cardiac rehabilitation (CR) after coronary artery bypass grafting (CABG) surgery between January, 2014 to June, 2015 (18 months) were being used for analysis. Results: Data were summarised by routine descriptive statistics. Maximum number of patients are in the age group of 51-60 years. Most of study population are male (90%). Study showed show 42.5 % are smoker, 37.5 % diabetic, 27.5 % are obese, 82.5 % are dyslipidaemic, 57.5 % are hypertensive. Conclusion: Our study shows most of our patient is male of 5th decade. Minimum age is 46-year, maximum age is 71 years with the mean age 55.4 years. most of study population are male (90%). Among the study population, 42.5 % are smoker, 37.5 % diabetic, 27.5 % are obese, 82.5 % are dyslipidaemic, 57.5 % are hypertensive. Hence male sex is an important risk factor for coronary artery disease. Early and aggressive attention to these risk factors e.g., smoking, diabetes, obesity, dyslipidaemia, hypertension could drastically reduce the need for coronary procedures such as angioplasty, stent, and bypass surgeries.

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG).Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression.Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P = .002), while annual mortality rates declined (nonparametric test for trend P.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P.001), and more commonly female (32.8% vs 26.2%, P.001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P.001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P.001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P.001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P.001).Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

Introduction: Cardiovascular disease is leading cause of mortality and morbidity throughout the world. Despite optimum medical and surgical management, a large number of patients became unable to maintain normal activity of daily living due to inadequate rehabilitation. Rehabilitation cannot be regarded as an isolated form or stage of therapy. Coronary artery bypass surgery, also known as coronary artery bypass graft surgery, is a surgical procedure to bypass the obstructed coronary artery (the "target vessel"). India has a large number of patients of coronary artery disease who needs CABG operation. Over few decades post-operative rehabilitation of CABG patients is done though there is no separate national level guidelines for Indian population even in post myocardial infarction patients like western countries though socio economic prole, health infrastructure and need are different from rest of the world. So, our study is a humble attempt to examine the efcacy of rehabilitation programme followed in western world. Material and methods: In this Open labelled parallel group prospective randomised trial, conducted in the Department of Physical Medicine and Rehabilitation in collaboration with the cardio-thoracic and vascular surgery (CTVS) unit of the Institute of Cardio-Vascular Sciences, at the Institute of Post Graduate Medical Education and Research (IPGMER) and SSKM Hospitals, Kolkata between January, 2014 to June, 2015 (18 months). Patients who undergone CABG operation in CTVS Department SSKM Hospital, Kolkata were included. Total 80 patients, 40 in each group were recruited. Patients were randomised to cardiopulmonary rehabilitation group (n=40); named as cases and usual care group (n=40); named as control. Institutional ethical committee clearance was taken. Informed consent was taken from each patient before including them in this study. Every patient was explained about the programme. Parameters used:1. Forced vital capacity (FVC), 2. Metabolic Equivalent (MET), 3. Functional assessment (6MWT). Patient will be assessed at the end of 1 week,6 week and 3month of operation. FVC and 6MWT were performed in each visit where MET assessment was done in 6 week and 3 months. Results: Data will be summarised by routine descriptive statistics. Numerical variables will be compared between groups by Student's Unpaired 't' test if normally distributed or by Mann-Whitney's 'U' test if otherwise. Variation over time would be assessed through repeated measures Analysis of Variance (ANOVA) or by Friedman's ANOVA if otherwise. Chi-Square test or Fisher's Exact test would be employed for inter-group comparison of categorical variance. Analysis will be two-tailed and p

Burr entrapment is a rare but serious complication during rotational atherectomy (RA). The Japanese have termed this the Kokeshi phenomenon named after a wooden doll found in northern Japan consisted of a simple trunk but a large head akin to the Rotablator (Mechery et al., 2016; Kaneda et al., 2000). The reason underlying this complication is the lack of diamond dust on the back end of the burr (Lin et al., 2013). The burr is olive-shaped and has diamond coating at its distal surface for antegrade ablation. The proximal part is smooth without diamonds, which prevents backward ablation of tissues when retracted (Lin et al., 2013; Dahdouh et al., 2013). Rota entrapment usually needs surgical management with coronary artery bypass grafting (CABG) surgery. To date, only few cases of successful non-traumatic retrieval using nonsurgical bailout techniques have been published (Grise et al., 2002). We report a case of burr entrapment within the left anterior descending (LAD) artery which was successfully retrieved by combination of multiple maneuvers and the patient underwent routine PCI following the retrieval.

Background: In this study, we investigated the impact of concomitant coronary artery bypass grafting (CABG) on operative and midterm mortality in patients with acute type A aortic dissection (ATAAD) undergoing surgical repair. Methods: From January 2012 to December 2014, among 489 patients (mean age: 47.6 ± 10.4 years, 77.1% male) with ATAAD who received surgical repair at our institute, 21 patients (4.3%) underwent concomitant CABG. Isolated aortic repair was performed in the remaining 468 cases (95.7%). Coronary dissection was indicated in 15 patients (Neri classification type B in 2, type C in 13), concomitant coronary artery disease in five and coronary artery compression in one. The follow-up time was 97.3% at 44.1 ± 13.9 months. Results: A total of 44 patients (9%) died from surgery, and operative mortality in the concomitant CABG group was significantly higher than that in the isolated aortic repair group (47.6%, 10/21 vs. 7.3%, 34/468; P