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Although coronary artery disease is a well recognized clinical entity and very common in India, there is paucity of literature on the patients undergoing surgical revascularization in the form of coronary artery bypass grafting (CABG) at a young age (<40 years). The aim of this study is to analyze the details of patients with premature coronary artery disease (PCAD) who underwent CABG at a tertiary care cardiac center in India. A retrospective observational study was conducted for the present study. All patients aged <40 years with Premature Coronary artery disease (PCAD) were registered in the PCAD Registry at Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore. The electronic database of case records of all patients with PCAD who underwent CABG at Sri Jayadeva Institute of Cardiovascular Sciences and Research, between April 2018 and March 2019 was analyzed. Patients were selected based on the database of PCAD registry at our institute under CTRI regulation of India (registration number CTRI/2018/03/012544), All patients were diagnosed with Coronary angiogram (CAG) and required further treatment in the form of CABG. Binary logistic regression was used to test the hypothesis (n= 100) cases, out of which LIMA was grafted in 84 cases (n=84), (odd ratio 3.55); of which LIMA to LAD was grafted in 81 cases (n=81); LIMA to RIMA –OM1 was grafted in 2 cases (n=2), and LIMA - Radial - Y was grafted in 1 case (n=1). Off - pump CABG (OPCAB) was done in 79 cases (79%) and the remaining cases were operated On - pump. Most common conduits that were used for grafting in CABG were LIMA (84%); SVG (82%), RIMA (9%) and radial artery (1%). Mean Ejection Fraction was 51.28%, with Standard Deviation (SD) of 5.80. Carotid artery stenosis (> 50%narrowing of the internal carotid artery) was seen in 11% of the cases. Peripheral Arterial Disease (PAD) was seen in 4% of cases (odds 1.18). Mortality rate (CFR) was negatively correlated in the younger population; deaths were seen in only 2 cases (n =2). The extent of CABG characteristics was positively correlated and statistically significant (p=0.001). In conclusion, Cardiovascular Disease (CVD) risk is more common in resource-poor and developing countries. Considering all the research findings, the present study concludes that CABG surgery can be treated with comparable components for the management of patients diagnosed to be suffering from Coronary artery disease below the age of 40 years. Relative long-term survival rate after CABG surgery, regardless of gender needs to be assessed for over a period of time at the population level. [ABSTRACT FROM AUTHOR]

Background Revascularization strategies might be limited in patients with lack of sufficient bypass graft material and increased risk of wound healing disturbances. In this regard, we present first results of patients treated with left internal mammary artery (LIMA) as T-graft with itself due to left-sided double-vessel disease, elevated risk of wound healing infection, and lack of graft material. Methods Eighteen patients were retrospectively analyzed in this study. All patients received LIMA grafting, and additional T-graft with itself during off-pump coronary artery bypass surgery. The investigation was focused on intraoperative and postoperative outcomes. Results LIMA-LIMA T-graft was performed in a total of 18 patients. Mean Fowler score accounted for 18.2 ± 2.9. Severe vein varicosis was present in 9 patients, and 38.9% of patients had lacking venous graft material due to prior vein stripping. A total of 2.5 ± 0.5 distal anastomoses were performed. Mean flow of LIMA—left anterior descending anastomosis was 41.72 ± 12.11 mL/min with a mean pulsatility index (PI) of 1.01 ± 0.21. Mean flow of subsequent T-graft accounted for 26.31 ± 4.22 mL/min with a mean PI of 1.59 ± 0.47. Median hospital stay was 7(6.75;8) days. No incidence of postoperative wound healing disorders was observed and all patients were discharged off hospital. Conclusions LIMA as T-graft with itself to treat left-sided double-vessel disease is feasible and safe in patients with missing bypass graft material and increased risk of deep sternal wound infection. Further prospective studies are necessary to confirm our results. [ABSTRACT FROM AUTHOR]

Background Myocardial infarction on non-occluded coronary artery represents a very specific subset of acute coronary syndrome (ACS). Coronary subclavian steal syndrome (CSSS) is defined by a left subclavian artery stenosis in case of (i) left internal mammary artery (LIMA) used to bypass left anterior descending artery (LAD) and (ii) >75% stenosis of the left subclavian artery prior to the origin of the LIMA to LAD graft. Here we report the case of a CSSS causing ACS. Case summary A 71-year-old man with history of LIMA to LAD coronary artery bypass surgery was admitted to the nephrology intensive care unit for acute kidney injury requiring dialysis. Due to rapid deterioration, altered left ventricular ejection fraction and elevated c -troponin levels, an urgent coronary angiography was performed. It revealed a subtotal occlusion of the left subclavian artery prior to the origin of the LIMA to LAD graft. This was responsible for a severely altered coronary flow in the LIMA and LAD. Revascularization of the proximal left subclavian artery with a stent was performed, enabling instant recovery of distal coronary flows. Discussion ACS due to CSSS in this report highlights the complexity of the cardio–renal interaction. Patients with coronary artery bypass graft and chronic kidney disease commonly exhibit a higher risk for severe progression of atherosclerosis at multiple sites. CSSS treatments include secondary prevention measures and revascularization (if indicated) such as an endovascular approach. [ABSTRACT FROM AUTHOR]

Background: Combining preoperative angiography findings with intraoperative transit time flow measurements (TTFM) may improve patency of coronary artery bypass grafts. Nevertheless, graft flow might be impaired by native coronary flow based on the severity of stenoses, with inferior long‐term outcomes. This study investigates the impact of left anterior descending artery (LAD) stenosis on competitive flow measured in left internal mammary artery (LIMA) grafts during off‐pump coronary artery bypass grafting. Methods: Fifty patients were included in this prospective single‐center cohort study. LAD stenosis was assessed with quantitative coronary analysis (QCA) and stratified into three groups based on its severity. TTFM of LIMA grafts were performed with LAD open and temporarily occluded. Change in mean graft flow after LAD snaring was the primary endpoint. Secondary endpoints included further TTFM parameters, clinical outcomes, and competitive flow index (CFI), defined as the ratio of mean graft flow with open or closed LAD. Results: Mean LAD stenosis as objectified with QCA was 58 ± 15%. Mean LIMA graft flow increased from 20 ml/min with open LAD to 30 ml/min with snared LAD (p <.001). TTFM cut‐off values for graft patency improved in 26%–42% of patients after LAD occlusion. Median CFI was 0.66 (IQR: 0.56–0.82). Postoperative myocardial infarction occurred in 2.0% of patients, 120‐day mortality was 0%, and 2‐year mortality was 6.0%. Conclusions: Routine snaring of the LAD with CFI calculation during coronary artery bypass grafting is useful to detect significant competitive flow in LIMA grafts, potentially preventing unnecessary intraoperative graft revisions. [ABSTRACT FROM AUTHOR]

Background: Graft patency is a fundamental predictor of long-term survival after coronary artery bypass surgery. Left and right internal thoracic artery (arterial) graft patency has been shown to be superior to that of saphenous vein grafts. More recently, the radial artery has been used as an a ortocoronary graft, but little is known about the midterm and long-term patency of this conduit. The ultimate goal of this operation is to achieve complete revascularization of the patient with conduits that will remain patent for the duration of the patient's lifetime. The excellent patency rates achieved with the pedicled left internal mammary artery are well described. Over the past decade, there has been considerable interest in whether the left internal mammary radial artery may provide results comparable to the arterial conduit. However, other studies have described that mild proximal stenosis of target vessels correlated with graft occlusion when an RA graft was used. Thus, we compared the short- and long-term results of patients who received an RA graft to the OM with those of patients who received an SVG. Methods: Following approval by the ethics and research committee of Kasr el Ainy faculty of Medicine Cairo University, and obtaining an informed consent, a prospective randomized clinical study was conducted on FIFTY who were operated upon with CABG. Requiring in addition to LIMA to LAD, revascularization of an obtuse marginal. These patients included 25 patients who received radial artery as the conduit. The selected patients for this study were evaluated postoperatively by MSCT angiography to comparative study between radial artery versus saphenous vein grafts patency after 5 years. Results: In our study according to graft patency by MSCT postoperative after 5 years of both groups showed statistically significant difference in group A which is p value 0.047 in group A 22 patients (88.0%) with radial to OM graft were patent while 3 patients (12.0%) with radial to OM were occluded. But in group B 16 patients (64.0%) with saphenous to OM graft were patent while 9 patients (36%) with saphenous to OM were occluded. Conclusion: In the long-term study, there was significant difference between total arterial revascularization and conventional CABG. Total arterial revascularization having low operative mortality and morbidity [ABSTRACT FROM AUTHOR]

This case describes multiple forms of short term mechanical circulatory support (sMCS) used sequentially in the same patient, and illustrates the role of different clinical goals of sMCS. A 59 year old man with previous coronary artery bypass surgery attended with troponin positive acute coronary syndrome. After workup, he went for PCI to a native coronary chronic total occlusion using anterograde/retrograde wires. Unfortunately, the left internal mammary graft was dissected, and he suffered cardiac arrest. Day 0: Impella CP as bridge to recover y : During resuscitation an Impella CP was placed via his right femoral artery and resolved circulatory arrest. Further PCI was performed to the LIMA ostium with restoration of flow. He was transferred to ITU. Day 3: Peripheral VA-ECMO as bridge to decision: His clinical status improved, but he remained in shock. His support was upgraded to peripheral veno-arterial (VA) extra-corporeal membrane oxygenation (ECMO), leaving the Impella in place as an LV vent. Day 14: BIVAD as bridge to transplantation: He remained MCS-dependent, and had no absolute contraindications to advanced therapies. He went to theatre for implantation of bilateral short term ventricular assist devices (BI-VAD) to optimise his organ support prior to transplantation. He was placed on the super-urgent waiting list. He had intermittent ventricular fibrillation but continued to mobilise on the ITU. Day 48: Transplantation and bridge to recovery with central ECMO: After 34 days on BIVAD, he underwent orthotopic cardiac transplantation. Due to vasoplegia and RV dysfunction, he was weaned from cardiopulmonary bypass onto central ECMO. Day 50: Weaning support - percutaneous RVAD as bridge to recover y : There was persistent RV dysfunction. Central ECMO was exchanged for a Protek RVAD. Day 56: Explant of RVAD: His status continued to improve. The RVAD was weaned and explanted after 6 days. Day 73: Discharge home: He required intense physiotherapy. After 73 days in hospital he was discharged home. At the time of submission he is alive at 291 days post transplant. This man's successful outcome was facilitated by judicious use of sMCS, on each occasion with a clear strategy in mind. Surgically implanted and percutaneous modes were used. Collaboration between cardiologists, intensivists and cardiac surgeons was essential to facilitate optimal care. [ABSTRACT FROM AUTHOR]

Background: Coronary artery bypass surgery (CABG) has contributed to an increase in survival, quality of life and life expectancy. The anastomotic quality and graft patency is directly associated with both early and long-term clinical results after CABG. It is a complication that can lead to refractory angina, myocardial infarction, arrhythmias, and even mortality. Objectives: This study was aiming to evaluate the effect of use of TTFM on the outcome of CABG operations and it was carried out on 100 patients and examined 282 grafts, we use inotropic agents to maintain the systolic pressure at 90- 100mmHg if the blood pressure was lower than that limit. Patients and Methods: An observational exploratory study was carried on 100 patients operated in Police authority hospitals, cardiothoracic surgery department. The study period of the study was 6 months, study population: The included population will be patients with Coronary Artery Disease (CAD) undergoing Coronary Artery Bypass Grafting (CABG) surgery. Results: TTFM data was described as two main readings which are MF in ml/min (mean flow), PI (pulsatility index) and it was measured for the all types of the grafts. In MF it was the highest in AO-OM system (34.5 ± 18.46) followed by LIMA- LAD system (33.0 ± 19.65) then AO-Diagonal (31.0 ± 26.38) and lastly AORCA( 29.50 ± 32.22). For the PI the lowest measurements was 0.8 and it was for both LIMA to LAD and then 1.2 for AO-OM system and 1.4 for AO-DIAG system and 1.8 for AO-RCA system. The most important finding in this study which represents the usefulness of the usage of TTFM is how much grafts needed to be revised according to the grafts measurements and it was 14 grafts in 14 patients (one grafts for each patient) among 100 patients which account for 14%. Conclusion: Regarding the other studies that compare the TTEM with other ways for detection of graft patency, they prefer the TTFM due to: TTFM is easy to use, accurate and relatively inexpensive, TTFM helps prevent missed technical surgical errors in distal and proximal anastomosis, it has shown that TTFM improved outcome in many situations, TTFM provides excellent documentation of the surgical outcome and allows for better understanding of procedural complications. [ABSTRACT FROM AUTHOR]