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Surgery in a patient with hepatic cirrhosis entails risk of complications and of death. Association of end stage renal disease (ESRD) along with cirrhosis further increases perioperative risk of morbidity and mortality. There are no reports in the literature of patients with liver cirrhosis and ESRD having undergone cardiac surgery. We present a report of a successfully operated case of ESRD with compensated hepatic cirrhosis posted for coronary artery bypass grafting., Операция у пациента с циррозом печени влечет за собой риск осложнений и смерти. Связь терминальной стадии почечной недостаточности (ТПН) с циррозом дополнительно увеличивает периоперационный риск заболеваемости и смертности. В литературе нет сообщений о пациентах с циррозом печени и ТПН, перенесших кардиохирургические вмешательства. Мы представляем отчет об успешно прооперированном случае ТПН с компенсированным циррозом печени, отправленном на аортокоронарное шунтирование., Операція у пацієнта з цирозом печінки тягне за собою ризик ускладнень та смерті. Зв'язок термінальної ниркової недостатності (ТНН) з цирозом печінки ще більше підвищує періопераційний ризик захворюваності та смертності. У літературі немає повідомлень про пацієнтів з цирозом печінки і ТНН, які перенесли операцію на серці. Ми представляємо звіт про успішно прооперований випадок ТНН з компенсованим цирозом печінки, направлений на аортокоронарне шутнування.

BackgroundClinical trials routinely have patients lost to follow up. We propose a methodology to understand their possible effect on the results of statistical tests by altering the concept of the fragility index to treat the outcomes of observed patients as fixed but incorporate the potential outcomes of patients lost to follow up as random and subject to modification.MethodsWe reanalyse the statistical results of three clinical trials on coronary artery bypass grafting (CABG) to study the possible effect of patients lost to follow up on the treatment effect statistical significance. To do so, we introduce the LTFU-aware fragility indices as a measure of the robustness of a clinical trial’s statistical results with respect to patients lost to follow up.ResultsThe analyses illustrate that clinical trials can either be completely robust to the outcomes of patients lost to follow up, extremely sensitive to the outcomes of patients lost to follow up, or in an intermediate state. When a clinical trial is in an intermediate state, the LTFU-aware fragility indices provide an interpretable measure to quantify the degree of fragility or robustness.ConclusionsThe LTFU-aware fragility indices allow researchers to rigorously explore the outcomes of patients who are lost to follow up, when their data is the appropriate kind. The LTFU-aware fragility indices are sensitivity measures in a way that the original fragility index is not.

One of the key aspects to obtain good long-term outcomes after coronary artery bypass grafting is graft quality. Meticulous graft harvesting is an important technical aspect in successfully performing high-quality coronary surgery and is associated with improved long-term graft patency. Hence, developing surgical skills in this necessary surgical step is of utmost importance in coronary bypass surgery. The following video tutorial presents a step-by-step audiovisual description of the skeletonized harvesting technique of the left internal mammary artery, open and endoscopic radial artery harvesting, and open saphenous vein graft harvesting.

Introduction: Coronary artery bypass grafting (CABG) is a procedure associated with a decline in pulmonary function. Among the main causes is the presence of the drain that is usually positioned in the intercostal or subxiphoid region. Objective: To measure the interference of drains positioning on pulmonary function in patients undergoing CABG. Methods: Observational study that assessed preoperative pulmonary function through vital capacity (VC), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and peak expiratory flow (PEF). These variables were evaluated in three different moments: in the presence of two drains, when removing one, and after removing all drains. Results: We evaluated 45 patients with a mean age of 62 ± 7 years with male prevalence of 29 (64%) individuals. The insertion of drains caused a decline in pulmonary function after surgery by reducing MIP by 48%, MEP by 11%, VC by 39%, and PEF by 6%. Conclusion: This study has demonstrated that drains positioning after CABG surgery may produce weakness of the respiratory muscles, change ventilatory mechanics, and impair normal pulmonary function postoperatively.

Introduction Atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is correlated with poor patient outcomes. The study evaluated the association of patients' clinical and sociodemographic characteristics with the incidence of atrial fibrillation, postoperatively. Methodology A longitudinal study was performed in the cardiology department of a tertiary care unit, Sindh, Pakistan between October 2019 and November 2020. All patients who underwent CABG surgery irrespective of gender aged 30 to 75 years were included in the study. Patients with a history of atrial fibrillation or severe left ventricular dysfunction were excluded from the study. The incidence of atrial fibrillation was determined by observing an irregular pattern on electrocardiography (ECG) with no definite P-wave and irregular R-R interval. The patients were monitored for seven postoperative days. The final outcome was measured on the seventh postoperative day. Results A total of 247 patients with a mean age of 63.43 ± 9.72 were enrolled in the study. Out of the 247 patients, 9.7% developed new-onset atrial fibrillation, postoperatively. Age above 65 years was associated with the occurrence of AF but it was not statistically significant (p>0.05). Similarly, patients who developed AF were more likely to have a left ventricle ejection fraction (LVEF) of less than 35% than those without AF (66.67% vs 43.95%; p=0.033). Conclusion A high rate of AF was observed in the study. Older age and impaired ventricular function were significantly associated with atrial fibrillation. It is recommended that hospitals should devise guidelines and protocols for the prevention and management of atrial fibrillation in patients undergoing cardiothoracic surgeries in order to minimize patient mortality and improve patient outcomes.

Lay abstract Mortality, morbidity and complications of coronary artery disease depend largely on inflammatory processes. The CANLPH score, a combination of three different ratios, can better determine inflammation. We aimed to evaluate the CANLPH score in in-hospital mortality after coronary artery bypass grafting. The 999 patients were classified into two groups according to the primary end point. Twenty-five patients (2.5%) who reached the primary end point were defined as the mortality group and the remaining 974 patients as the nonmortality group. The multivariate logistic regression analysis showed that the European System for Cardiac Operative Risk Evaluation II, neutrophil/lymphocyte ratio, platelet/hemoglobin ratio and the CANLPH score were independent predictors of primary end point after coronary artery bypass grafting. The CANLPH score may be more appropriate than neutrophil/lymphocyte ratio, C-reactive protein/albumin ratio and platelet/hemoglobin ratio in assessing the risk of in-hospital mortality after coronary artery bypass grafting.

Patients diagnosed with COVID-19 infection undergoing surgical procedures have been reported to have increased post-operative complications and mortality. These findings are important when considering cardiac surgical procedures, specifically coronary artery bypass grafting (CABG). This case series describes the clinical course following a CABG procedure in two patients that went on to develop COVID-19 infection post-operatively, having previously tested negative. We aim to illustrate the similarities in clinical presentation, but differences in eventual outcomes for both patients and hypothesize the reasons for the differences. Patients with comorbidities such as advanced age, diabetes mellitus, obesity, hypertension, and COPD are possibly at increased risk of adverse outcomes should they contract the infection, and special care should be taken in this population. Early institution of VV-ECMO may be beneficial, but further studies are needed in this matter.

Euglycemic diabetic ketoacidosis (EDKA) is a rare and serious adverse effect of sodium-glucose cotransporter 2 inhibitors (SGLT-2i). The diagnosis is challenging due to the rarity, nonspecific symptoms, and absence of the alarmingly high blood glucose levels, and thus, it could be initially missed resulting in delayed treatment. This is particularly important for sedated patients, as the absence of typical clinical signs and symptoms can obscure the diagnosis. We present the case of a patient with type 2 diabetes mellitus on empagliflozin who developed EDKA while sedated after coronary artery bypass grafting (CABG) despite stopping the medication 24 hours prior to surgery. We also summarize the current literature on EDKA after CABG. Physicians must be aware and maintain a high index of suspicion for the illness, especially in patients with T2DM taking SGLT-2i and undergoing a major operation such as CABG. Emergent treatment and multidisciplinary follow-up are needed to improve patient outcomes and mitigate complications. Physicians should also consider identifying the optimal time to discontinue SGLT-2i before major surgeries and possible ketone studies in such patients, especially those sedated following the surgery.

Background: Bypass grafting for chronic total occlusions remains surgically challenging and controversial. Therefore, we evaluated the incidence and clinical outcomes of revascularization on chronic total occlusions undergoing coronary artery bypass surgery.Methods: Among 828 patients who underwent isolated coronary artery bypass surgery from January 2010 to December 2018, 245 patients (29.5%) diagnosed with at least one chronic total occlusion were included and retrospectively reviewed. Primary endpoints were 30-day and overall mortality. Secondary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events. Results: With a mean follow-up of 56.6 ± 6.5 months in 245 patients with chronic total occlusions, 51 patients (20.9%) received incomplete revascularization for chronic total occlusions. Risk factor analysis showed that incomplete revascularization was associated with increased 30-day (odds ratio 8.62; 95% confidence interval (CI) 1.64 – 50; p = 0.011) and overall mortality (hazard ratio (HR) 2.13; 95% CI 1.07 – 4.21; p = 0.03). ICR also increased the risk of major adverse cardiac and cerebrovascular events (HR 1.98; 95% CI 1.12 – 3.54; p = 0.01). Freedom from overall mortality was 92.8%, 90.4%, and 86.8% in the complete revascularization group, and 86.3%, 80.0%, and 72.7% in the incomplete revascularization group, at 1, 3, and 5 years, respectively (p = 0.004).Conclusions: In patients with chronic total occlusions undergoing coronary artery bypass surgery, the rate of incomplete revascularization was 20.9%, and it significantly increased the risk of mortality and major adverse cardiac and cerebrovascular events. Further studies in a large cohort are needed.

A 54-year-old male patient underwent coronary artery bypass graft surgery. No complications occurred after the surgery. Control posteroanterior thorax X-ray showed a mass lesion with radiopaque linear densities superposed with the left ventricle. A mass lesion containing linear metallic densities was seen adjacent to the left ventricular free wall in the thorax computed tomography images (Figure 1). The appearance was consistent with a retained surgical sponge.

A 67-year-old man undergoing coronary artery bypass grafting had aortic calcification that prohibited aortic cross-clamping. When ventricular fibrillation developed during surgery, we instituted hypothermic fibrillatory arrest to avoid aortic cross-clamping. In addition to our patient's case, we discuss the advantages and disadvantages of using hypothermic fibrillatory arrest during cardiac surgery.

INTRODUCTION Minimally invasive cardiac surgery (MICS) has attracted increasing attention, with institutions increasingly adopting this approach over conventional median sternotomy (MS). This study aimed to describe the outcomes of minimally invasive cardiac surgery in our institution as the only centre with an established MICS programme in Singapore. METHODS Patients who had undergone cardiac procedures such as heart valve replacement or repair, coronary artery bypass grafting or atrial septal defect repair were included in the study. We analysed 4063 patients who had undergone MS and 390 patients who had undergone MICS between January 2009 and February 2020. RESULTS Over the years, the number of MICS procedures performed increased, along with an increase in MICS operations with two or more concomitant cardiac procedures and a decrease in postoperative length of stay. Compared with patients who underwent MS, those who underwent MICS had shorter length of postoperative hospital stay (p < 0.001). On multivariate analysis, patients who underwent MICS had lower rates of atrial fibrillation (p = 0.021), reoperation (p = 0.028) and prolonged ventilation (p < 0.001). However, the rates of other postoperative complications were comparable between patients who underwent MICS and those who underwent MS. CONCLUSION In our institution, MICS is a safe, reproducible and efficacious technique that yields superior outcomes compared with conventional MS procedures, in some aspects. The results of this study provide further evidence and support towards adopting the minimally invasive approach to cardiac surgery in a carefully selected group of cardiac patients in Singapore.

Background Postoperative atrial fibrillation (POAF) is common both after cardiothoracic and non cardiothoracic surgery.In patients undergoing cardiothoracic surgery, the incidence of 16–46% has been reported. Even though POAF can be selflimiting, it may be associated with hemodynamic instability, postoperative stroke, myocardial infarction, ventricular arrhythmias and heart failure. Objective To determine the effect of certain predictors on the incidence of postoperative atrial fibrillation during the ICU stay after coronary artery bypass graft surgery. Patients and Methods This prospective cohort study was done after approval of the Institutional Review Board and written informed consent from patients or first kin. Patients undergoing isolated CABG or CABG with valve replacement were included and monitored for POAF during their postoperative ICU stay and the potential predictors of POAF as age, sex, smoking and left atrial diameter, serum Potassium and Magnesium levels, CHA2DS2-VASc score, valve replacement and inotropic support were recorded. Results 123 patients were included in the study, 76.4% were males with a mean age of 57.4 ±8.7 years and mean left atrial diameter 4.1 ±0.52 cm. The incidence of POAF following CABG surgery was almost 33.3%. There was no statistically significant association between POAF and smoking (P = 0.123). However there were statistically significant associations between POAF and CHA2DS2-VASc score, valve replacement (P 0.05). Conclusion There are a wide range of significant epidemiological, clinical, and operative predictors for the development of post-CABG AF including older age, female gender, large LA diameter, higher CHA2DS2-VASc score, valve replacement and postoperative inotropic support. Nevertheless, further large-scale studies are still needed to confirm our findings.

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.

Tissue-engineered small-diameter vascular grafts are required to match mechanical properties as well as cellular and extracellular architecture of native blood vessels. Although various engineering technologies have been developed, the most reliable strategy highlights the needs for incorporating completely biological components and anisotropic cellular and biomolecular organization into the tissue-engineered vascular graft (TEVG). Based on the antithrombogenic, immunoregulatory, and regenerative properties of human mesenchymal stem cells (hMSCs), this chapter provides a step-by-step protocol for generating a completely biological and anisotropic TEVG that comprises of hMSCs and highly aligned extracellular matrix (ECM) nanofibers. The hMSCs were grown on an aligned nanofibrous ECM scaffold derived from an oriented human dermal fibroblast (hDF) sheet and then wrapped around a temporary mandrel to form a tubular assembly, followed by a maturation process in a rotating wall vessel (RWV) bioreactor. The resulting TEVG demonstrates anisotropic structural and mechanical properties similar to that of native blood vessels. A completely biological, anisotropic, and mechanically strong TEVG that incorporates immunoregulatory hMSCs is promising to meet the urgent needs of a surgical intervention for bypass grafting.

Background Postoperative atrial fibrillation (POAF) complicates 20–40% of cardiac surgical procedures and 10–20% of non-cardiac thoracic operations. Typical features include onset at 2–4 days postoperatively, episodes that are often fleeting and a self-limited time course. Associated adverse consequences of POAF include hemodynamic instability, increased risk of stroke, lengthened hospital and intensive care unit stays and greater costs (Dobrev et al., 2019). Aim The aim of this work is to detect the echo-cardio graphic parameters for prediction of post-operative atrial fibrillation in patients with ischemic heart disease undergoing isolated coronary artery bypass graft. Methods One hundred patients with multivessel disease for CABG were prospectively enrolled; all of them were in sinus rhythm at the moment of enrollment. LA maximal volume, LV ejection fraction, LVESV &LVEDV and TDI were assessed. Moreover, LA strain and Left Ventricular Global Longitudinal Strain % were analyzed by speckle tracking technique. Patients were followed up for 1 week after surgery in order to identify occurrence of atrial fibrillation. Results We found a statistically significant difference between patients undergoing CABG who are older in age with mean ± SD 64.455 ± 6.254 in group I (AF) vs. 54.577 ± 6.710 in group II with p value Conclusions There is no significant difference between the two groups regarding conventional echo parameters, TDI & by speckle tracking technique (LA strain & LVGLS %). However, patients who developed POAF were older, & left main lesions are more likely to have left main lesions.

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 There are limited data on the management strategies, temporal trends and clinical outcomes of patients who present with non–ST‐segment–elevation myocardial infarction and have a prior history of CABG. Methods and Results We identified 287 658 patients with non–ST‐segment–elevation myocardial infarction between 2010 and 2017 in the United Kingdom Myocardial Infarction National Audit Project database. Clinical and outcome data were analyzed by dividing into 2 groups by prior history of coronary artery bypass grafting (CABG): group 1, no prior CABG (n=262 362); and group 2, prior CABG (n=25 296). Patients in group 2 were older, had higher GRACE (Global Registry of Acute Coronary Events) risk scores and burden of comorbid illnesses. More patients underwent coronary angiography (69% versus 63%) and revascularization (53% versus 40%) in group 1 compared with group 2. Adjusted odds of receiving inpatient coronary angiogram (odds ratio [OR], 0.91; 95% CI, 0.88–0.95; P P P =0.44), all‐cause mortality (OR, 0.96; 95% CI, 0.88–1.04; P =0.31), reinfarction (OR, 1.02; 95% CI, 0.89–1.17; P =0.78), and major bleeding (OR, 1.01; 95% CI, 0.90–1.11; P =0.98) were similar across groups. Lower adjusted risk of inpatient mortality (OR, 0.67; 95% CI, 0.46–0.98; P =0.04) but similar risk of bleeding (OR,1.07; CI, 0.79–1.44; P =0.68) and reinfarction (OR, 1.13; 95% CI, 0.81–1.57; P =0.47) were observed in group 2 patients who underwent percutaneous coronary intervention compared with those managed medically. Conclusions In this national cohort, patients with non–ST‐segment–elevation myocardial infarction with prior CABG had a higher risk profile, but similar risk‐adjusted in‐hospital adverse outcomes compared with patients without prior CABG. Patients with prior CABG who received percutaneous coronary intervention had lower in‐hospital mortality compared with those who received medical management.

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

Objectives: Non-ST-elevation acute coronary syndrome (NSTE-ACS) affects millions of patients. Although an invasive strategy can improve survival, the optimal treatment (i.e., percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) is not clear. We performed a meta-analysis of studies reporting outcomes between PCI and CABG in patients with NSTE-ACS.Methods: MEDLINE, EMBASE and Cochrane Library were assessed. The primary outcome was long-term mortality. Inverse variance method and random model were performed.Results: We identified 13 observational studies (48,891 patients). No significant difference was found in the primary endpoint (CABG vs. PCI, incidence rate ratio [IRR]= 0.93, 95% confidence interval [CI] 0.70; 1.23). CABG was associated with lower long-term major adverse cardiovascular events (MACE) (IRR= 0.64, 95% CI 0.54; 0.76) and lower long-term re-revascularization (IRR= 0.37, 95% CI 0.30; 0.47). There was no significant difference in long-term myocardial infarction (CABG vs. PCI, IRR= 0.96, 95% CI 0.50; 1.84) and peri-operative mortality (CABG vs. PCI, odds ratio [OR]= 1.36, 95% CI 0.94; 1.95).Conclusion: For the treatment of NSTE-ACS, CABG and PCI are associated with similar rates of long-term mortality and myocardial infarction. CABG is associated with lower rates of long-term MACE and re-revascularization. Randomized comparisons in this setting are necessary.

Background and aim: Ischemic heart disease is the leading cause of death around the world. Coronary artery bypass grafting offers efficient surgical revascularization for ischemic disease. Both on- or off-pump coronary artery bypass methods provide promising results to octogenarians, once complete vascularization is achieved. However, off-pump bypass requires a certain level of experience to achieve sufficient results. We have applied an off-pump coronary artery bypass-first strategy to all generations since 2008. This study investigated early and long-term results of surgical revascularization for octogenarians by a team with an off-pump-first strategy. Methods: All cases of isolated coronary artery bypass grafting performed since 2008 were identified and divided into a young group (age =80 years). Peri-operative results were investigated retrospectively in both groups and long-term results for the old group were assessed. Results: Among the 707 patients, 97% underwent off-pump bypass, and 94 cases were classified to the old group. Distal anastomoses and ventilator time were identical between groups (young vs. old: 3.3 vs. 3.2; 3.7 h vs. 3.7 h). In-hospital death rates were 0.5% and 0% in the young and old groups, respectively. With a mean follow-up of 1318 days, actual 1-, 3-, and 5-year survival rates for octogenarians were 92.1%, 81.2% and 68.3%, respectively. Nearly half of the patients reached their nineties, which was close to the life expectancy of the national general octogenarian. Conclusions: An experienced team with an off-pump-first strategy could provide valid therapeutic options for octogenarians.

Background. We have observed reopening of the occluded “no-touch” saphenous vein (NT SV) composite grafts on follow-up angiograms in patients who underwent coronary artery bypass graftings (CABG). Methods. Between 2008 and 2018, 1283 patients received NT SV conduits without or with surrounding pedicle tissue as composite grafts based on the in situ left internal thoracic artery (ITA) for CABG and underwent early postoperative angiographies. Among the 1283 patients, 53 patients showed 55 occluded SV conduit anastomoses, and 46 patients who had 48 occluded SV anastomoses were re-evaluated by 1-year postoperative angiographies. Results. Early postoperative angiographies in 1283 patients demonstrated overall occlusion rates of 1.2% (56/4518); occlusion rates of the ITA and SV were 0.08% (1/1259) and 1.7% (55/3260), respectively. One-year angiograms demonstrated that 14 occluded SV anastomoses (29.2% [14/48 occluded SV]) of 14 patients became patent. Reopening of occluded SV conduits occurred more frequently in NT SV with pedicle tissue than in NT SV without pedicle tissue (45.0% [9/20] versus 17.9% [5/28]; P=0.057). When we examined the preoperative and 1-year postoperative angiograms, reopening of the occluded SV conduits was not related with progression (P=0.258) or preoperative reversibility score (P=0.115) of native target coronary artery disease. Conclusions. More than a quarter of the occluded SV composite grafts on early postoperative angiograms were patent in the 1-year angiograms. The reopening rates were higher in patients who had received NT SV conduits with pedicle tissue than those who had received NT SV conduits without pedicle tissue.

Objective: To determine the patterns of per-operative parameters and early outcomes of patients that underwent CABG surgery during a four-year period. Methods: This is a cross-sectional descriptive study conducted in a tertiary care of hospital from November 2020 to January 2021. All the patients that underwent the isolated coronary artery bypass grafting (CABG) procedure were included in the study from June 2017 till June 2020. Data was collected on a data extraction form and stored in SPSS format which was analyzed for qualitative statistics keeping p

Femoral endarterectomies are often performed by means of longitudinal arteriotomies with patching. Autologous and synthetic patches can be used. Synthetic patches in the groin may expose patients to infection. We present two alternative techniques for the treatment of femoral atherosclerotic lesions.The alternative endarterectomies (AE) included eversion (EE) and semi-closed endarterectomies (SCE). An EE with an oblique transection of a femoral bifurcation (FB) was used for lesions extending to the FB. The artery was reconstructed in an end-to-end manner. An SCE with a bovine pericardium patch (BPP) was used for lesions extending further. An arteriotomy was made from the superficial femoral artery just past the level of the profunda femoris opening (PFO). The plaque was cut proximally to the PFO, dissected circularly with a Swedish-type dissector, and then removed with Crile forceps. The distally remaining plaque was endarterectomized in a conventional manner. The arteriotomy was closed with a BPP.A total of 21 AEs were performed, 8 of which were accomplished in a hybrid setting. There were no periprocedural complications. One distal embolization after a balloon dilatation was registered during the early postoperative period. The median follow-up was 3 months. There were no deep wound infections, pseudoaneurysms, amputations, or deaths. A total of 20/21 patients reported complete symptom relief, with one requiring an additional femoro-popliteal bypass grafting owing to poor outflow. The primary patency rate of the endarterectomized segments was 100%.Alternative methods of local endarterectomy can extend the available range of procedures for patients suffering from chronic lower-limb ischemia. According to our results, these endarterectomy techniques are safe and could be taken into consideration, as they provide some advantages over conventional methods.Актуальность. Традиционно эндартерэктомия из бедренных артерий выполняется через продольную артериотомию с дальнейшим закрытием дефекта заплатой. Варианты последних варьируют от аутологичных до синтетических, использование которых может быть ограничено ввиду риска инфицирования. В данной статье представлены две альтернативные методики эндартерэктомии из бедренных артерий при их атеросклеротическом поражении. Материалы и методы. Альтернативные эндартерэктомии включали эверсионную и полузакрытую. Первая, с косым рассечением бифуркации общей бедренной артерии, использовалась при ее локальном атеросклеротическом поражении. В последствии артерию анастомозировали по типу 'конец-в-конец'. При поражении бедренной артерии, распространяющемся как в проксимальном, так и дистальном направлении, нами применялась методика закрытия дефекта заплатой из ксеноперикарда. После произведенного разреза по передней поверхностной бедренной артерии над устьем глубокой бедренной артерии осуществлялось циркулярное отсечение атеросклеротической бляшки. Затем происходило ее выделение по кругу при помощи диссектора в проксимальном направлении и механическое удаление бляшки. Дистальный край извлекался обычным способом, пластика артериотомии выполнялась заплатой из ксеноперикарда. Результаты исследования. Проведена 21 альтернативная эндартерэктомия, причем 8 из них выполнены гибридно. Периоперационных осложнений не наблюдалось. Зафиксирована 1 дистальная эмболия после баллонной дилатации в раннем послеоперационном периоде. Медиана продолжительности диспансерного наблюдения составила 3 мес. За этот период данных за инфицирование, формирование ложных аневризм, ампутаций или смерти оперированных пациентов не было. У большинства (20 из 21) больных отмечено полное купирование симптомов ишемии. В 1 случае в результате сохранения явлений ишемии потребовалось дополнительное бедренно-подколенное шунтирование. Первичная проходимость оперированных сегментов составила 100%. Заключение. Наличие альтернативных методик локальной эндартерэктомии позволяет расширить диапазон помощи пациентам, страдающим хронической ишемией нижних конечностей. Как показало наше исследование, использованные варианты реконструкции считаются безопасными и имеют ряд преимуществ по сравнению с классическими способами восстановления сосудистого просвета.

Coronary Artery Bypass Grafting surgery is the most commonly performed and thoroughly examined adult cardiac surgery procedure in the world. Minimally invasive techniques which include Robotic-Assisted Minimally Invasive Direct Coronary Artery Bypass Grafting and Totally Endoscopic Coronary Artery Bypass Grafting have been helping to lessen the postoperative complications, pain, and length of stay, while enhancing postoperative quality of life of patients. However, practical application of these advanced procedures has yet to be broadly mastered for expanding the usage of minimally invasive robotic assisted techniques. This chapter describes the development and application of Minimally Invasive CABG procedures as well as the current knowledge and future perspectives on Robotic-Assisted CABG procedures.

Background The aim is to compare the use of adenosine and verapamil for management of postoperative supraventricular tachycardia in terms of time of conversion of SVT to normal sinus rhythm, success rate, hospital stay length and adverse eventsMethods Patients (54–65 years old) received adenosine or verapamil groups. In the adenosine group, patients received IV adenosine 6 mg bolus then wait 2 minutes, if it failed another 12 mg IV of adenosine was administered. In the verapamil group, patients received IV verapamil 5mg bolus slowly over 2 minutes followed by a second IV bolus of 10 mg, 30 minutes after the initial dose in persistent supraventricular tachycardia (SVT). If SVT persisted, the patient was shifted to adenosine. Results Patients were followed up regarding the efficacy of drug, blood pressure, mean time of conversion of SVT (time elapsed from effective dose of the study drug till conversion of SVT to sinus rhythm) and incidence of adverse events were recorded. The efficacy of adenosine was significantly higher than verapamil (P Conclusions Intravenous administration of adenosine effectively treat SVT in terms of higher efficacy and shorter time of conversion of SVT to normal sinus rhythm compared with verapamil without any significant difference regarding the incidence of side effects between the study groups.Trial registrationThis study was approved by Medical ethics committee of Ain Shams University approval number FMASU R 62/ 2019). and the protocol was prospectively registered at ClinicalTrials.gov : NCT 04203368 on December 16, 2019.

PURPOSE OF REVIEW Coronary revascularization is known to be an excellent treatment for coronary artery disease. However, whether incomplete myocardial revascularization compromises long-term outcomes, as compared to complete revascularization (CR), remains contentious. Herein, we review the concept of and evidence on CR/incomplete revascularization (ICR) and discuss future perspectives. RECENT FINDINGS When possible, achieving CR in coronary artery bypass grafting is desirable; nonetheless, ICR is also a reasonable option to balance the therapeutic benefits against the risks. SUMMARY Although angiography-based assessment currently remains the standard of care, fractional flow reserve guidance may reduce the number of lesions requiring revascularization, which may be helpful for an appropriate surgical revascularization strategy. In particular, utilizing this approach may refine hybrid revascularization procedures, especially among high-risk patients.

Aim Guidelines recommend 12 months of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) followed by emergency coronary artery bypass grafting (CABG). In patients with stable coronary artery disease (CAD) undergoing CABG, DAPT does not give a survival benefit but may prevent venous graft occlusion. Variation exists in practice between consultants with regards to duration of DAPT after CABG in stable CAD patients. Method All patients who underwent CABG in our centre in October and November 2020 were identified. Type and duration of antiplatelet and/or anticoagulant were recorded, as was history of MI and/or PCI. An antiplatelet prescription aid, taking into account surgeon preference, was designed and the effect on prescribing re-audited. Results 35 patients underwent CABG. All patients except 2 received lifelong aspirin or a DOAC/NOAC. 3 patients had STEMI/NSTEMI in the preceding 12 months; two received DAPT and one received aspirin and a DOAC. Variation exists for DAPT prescribing duration following CABG for stable CAD. Re-audit results shows improvement in consistency of prescribing following implementation of the prescription aid. Conclusions Adherence to DAPT guidelines following PCI and CABG is good. However, variation exists in DAPT prescribing in stable CAD patients, between consultants and between patients for the same consultant. Consistency improved with implementation of the prescription aid.

Background Coronary artery bypass grafting has remained an important treatment option for acute coronary syndromes, particularly in patients (1) with ongoing ischemia and large areas of jeopardized myocardium, if percutaneous coronary intervention (PCI) cannot be performed; (2) following successful PCI of the culprit lesion with further indication for coronary artery bypass grafting; and (3) where PCI is incomplete, not sufficient, or failed. Methods and Results We aimed to analyze coronary artery bypass grafting outcome following prior PCI in acute coronary syndromes from the North‐Rhine‐Westphalia surgical myocardial infarction registry comprising 2616 patients. Primary end points were in‐hospital all‐cause mortality and major adverse cardio‐cerebral event. Patients were 68±11 years of age, had 3‐vessel and left main‐stem disease in 80.4% and 45.3%, presenting a logistic EuroSCORE of 15.1% in unstable angina, 20.3% in non–ST‐segment–elevation myocardial infarction, and 23.5% in ST‐segment–elevation myocardial infarction. A history of PCI was present in 36.2% and PCI was performed within 24 hours before surgery in 5.2% in unstable angina, 5.9% in non–ST‐segment–elevation myocardial infarction, and 16.1% in ST‐segment–elevation myocardial infarction. PCI failed in 5.3% in unstable angina, 6.8% in non–ST‐segment–elevation myocardial infarction and 17.2% in ST‐segment–elevation myocardial infarction, and 28.8% of patients presented with cardiogenic shock. In‐hospital mortality without PCI was 7.4%, but increased to 8.7% with prior PCI >24 hours, 14.5% with prior PCI P 24 hours, 25.6% with prior PCI P =0.014). Multivariable logistic regression analysis showed prior PCI ( P =0.039), as well as failed PCI ( P =0.001) to be predictors for in‐hospital all‐cause mortality and major adverse cardio‐cerebral event. Conclusions In the current PCI era, immediately prior or failed PCI before coronary artery bypass grafting in acute coronary syndromes is associated with high perioperative risk, cardiogenic shock, and increased morbidity and mortality.

Aim Reduced Left Ventricular Ejection Fraction (LVEF) is a risk factor for patients undergoing Coronary Artery Bypass Grafting (CABG). The aim of our study was to compare short term outcomes and long-term (20 years) survival rates of patients with reduced LVEF undergoing CABG. Method Between 1996 and 2015, 5016 patients with reduced LVEF underwent CABG: 1024 (20.4%) had poor LVEF (< 30%) and 3992 (79.6%) had moderate LVEF dysfunction (30-49%). After excluding reoperations and combined procedures, the final sample consisted of 3867 patients. Our primary outcomes were early in-hospital mortality and complications and long-term survivals. Results In-hospital mortality rate was 4.4%, stroke rate 1.4% and renal failure 2.9%. Survival rates at 1, 5, 10 and 20 years were 91.1%, 76.7%, 55.1% and 22.1% respectively. Additive Euroscore and Logistic Euroscore (AUC 0.78) is less reliable compared to normal LV patients. Complete revascularization was an independent factor affecting long term survival (HR: 0.85). No difference between OPCABG and ONCABG were found. Conclusions CABG is still safe and most likely the best treatment option for patients with reduced LVEF. Completeness of revascularization plays an important role in long term outcomes while OPCABG has no significant advantages. Euroscore has a reduced predicting ability in this group of patients.

Aim There is still no consensus whether percutaneous coronary intervention (PCI) is as safe and effective as coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease. Recent updates from key clinical trials necessitated an updated examination of the literature on this topic. Method A systematic search was performed of the MEDLINE (via PubMed), EMBASE, Cochrane and clinicaltrials.gov databases from inception to December 20th, 2020. Selected studies were analysed using the random effects model. Outcomes measured included all-cause mortality, MACCE, myocardial infarction (MI), stroke and revascularization. Follow up points were 30 days, 1 year, 5 years and 10 years. Results Six RCTs with a total population of 4700 were included in the analysis. For all-cause mortality PCI was non-inferior to CABG at all time points. MACCE favoured PCI at 30 days, and CABG at 5 years. No difference was seen at 1 year and 10 years. MI favoured CABG at 5 years follow up, with no difference seen at 30 days, 1 year or five years. For stroke, PCI was favourable to CABG at 30 days and 1 year, with no difference at 5 years and 10 years. Revascularisation favoured CABG at 1 year and 5 years, with no difference at other time-points. Conclusions PCI may be considered as an alternative to CABG for uncomplicated LMCA disease. More complex lesions may still benefit from CABG. CABG may be of benefit where future revascularisation would rather be avoided. Further clinical trials examining this research question are needed.

Background and Aims: Patients with heart failure with reduced ejection fraction (HFrEF) are among the most challenging patients undergoing coronary artery bypass grafting surgery (CABG). Several surgical risk scores are commonly used to predict the risk in patients undergoing CABG. However, these risk scores do not specifically target HFrEF patients. We aim to develop and validate a new nomogram score to predict the risk of in-hospital mortality among HFrEF patients after CABG.Methods: The study retrospectively enrolled 489 patients who had HFrEF and underwent CABG. The outcome was postoperative in-hospital death. About 70% (n = 342) of the patients were randomly constituted a training cohort and the rest (n = 147) made a validation cohort. A multivariable logistic regression model was derived from the training cohort and presented as a nomogram to predict postoperative mortality in patients with HFrEF. The model performance was assessed in terms of discrimination and calibration. Besides, we compared the model with EuroSCORE-2 in terms of discrimination and calibration.Results: Postoperative death occurred in 26 (7.6%) out of 342 patients in the training cohort, and in 10 (6.8%) out of 147 patients in the validation cohort. Eight preoperative factors were associated with postoperative death, including age, critical state, recent myocardial infarction, stroke, left ventricular ejection fraction (LVEF) ≤35%, LV dilatation, increased serum creatinine, and combined surgery. The nomogram achieved good discrimination with C-indexes of 0.889 (95%CI, 0.839–0.938) and 0.899 (95%CI, 0.835–0.963) in predicting the risk of mortality after CABG in the training and validation cohorts, respectively, and showed well-fitted calibration curves in the patients whose predicted mortality probabilities were below 40%. Compared with EuroSCORE-2, the nomogram had significantly higher C-indexes in the training cohort (0.889 vs. 0.762, p = 0.005) as well as the validation cohort (0.899 vs. 0.816, p = 0.039). Besides, the nomogram had better calibration and reclassification than EuroSCORE-2 both in the training and validation cohort. The EuroSCORE-2 underestimated postoperative mortality risk, especially in high-risk patients.Conclusions: The nomogram provides an optimal preoperative estimation of mortality risk after CABG in patients with HFrEF and has the potential to facilitate identifying HFrEF patients at high risk of in-hospital mortality.

Background Data are limited about young adults' characteristics and outcomes undergoing coronary artery bypass grafting (CABG). Methods and Results We used the National Inpatient Sample database to identify adults aged 18 to 45 years who underwent CABG between 2004 and 2018. The data were weighted to generate national estimates of the entire US hospitalized population. We identified 110 463 CABG cases, equivalent to 62.2 per 1 000 000 person‐years; 27.1% were women, and 70.2% were White adults. Overall, annual CABG volume per 1 000 000 significantly decreased from 87.3 in 2004 to 45.7 in 2018. The prevalence of obesity, diabetes mellitus, hypertension, drug abuse, and chronic medical conditions increased over time. Overall, inpatient mortality was 1.76%; ST‐segment–elevation myocardial infarction, non–ST‐segment–elevation myocardial infarction, heart failure, peripheral vascular disease, renal failure, and valvular surgery were associated with higher inpatient mortality. Women had higher inpatient mortality than men (2.29% versus 1.57%), and Black patients had higher deaths than White patients (2.86% versus 1.58%). Inpatient mortality remained stable overall, according to sex, race, or clinical indication of CABG. However, the mean length of stay (8.4 days in 2004 to 9.5 days in 2018) and inflation‐adjusted cost of care ($40 522.8 in 2004 to $52 434.2 in 2018) significantly increased during the study period. Conclusions Despite the increased burden of cardiometabolic risk factors, the inpatient mortality in young adults undergoing CABG remained stable during the last 15 years. However, CABG volumes have decreased, but length of stay and inflation‐adjusted costs have increased over time.

Aim Lengthy hospital length of stay (LOS) has a direct impact on healthcare costs. We aimed to design predictive models of prolonged LOS after coronary artery bypass grafting (CABG) with only preoperative characteristics and machine learning (ML) strategies. Method In a single centre retrospective analysis, 2,082 consecutive patients underwent first-time elective/urgent CABG: 1,262 has a short postoperative LOS (≤ 6 days) while the remaining 820 had a long LOS (> 6 days). 70/30 training/testing ratio and resampling methods were used, and cross-validation was conducted. Results The two groups differ significantly in terms of pre-operative variables: short LOS patients were younger (p Conclusions Developing a reliable predictive model with only pre-operative variables proved to be difficult, but several preoperative characteristics have a significant impact on the probability of prolonged LOS after CABG. Larger studies are needed to investigate the possibility of developing a reliable predictive model that would help to improve surgical planning.

Aim We aim to present here a case of a painless anterior chest wall mass which was first noted during routine follow up post coronary artery bypass graft surgery Case presentation An 80-year-old male developed an asymptomatic slow growing pronounced swelling over the right anterior chest wall post CABG. His other past medical history includes chronic obstructive pulmonary disease, pulmonary fibrosis, ischaemic heart disease, an AICD for complete heart block, hypertension, hyperlipidaemia and osteoarthritis. A CT scan demonstrated a 10 x 12 x 6.5 cm subcutaneous lesion at the mid-line of the lower chest wall adjacent to the xiphisternum and the previous sternotomy site. On clinical examination there was a large non-tender cystic swelling with peripheral calcifications, but overlying skin was normal. Fluid was aspirated from the lesion and cytology showed a paucicellular specimen with features in keeping with seroma. Due to the progressive increase in size patient underwent surgical resection. A gelatinous bloody fluid was aspirated from the lesion and it was then resected enbloc. The tumour base appeared to arise from 6/7th costal cartilage and tumour was shaved away. The mass was confirmed histologically to be chondrosarcoma. Conclusions Given the uncommon prevalence of malignant primary chest wall tumours this case highlights the importance of high clinical suspicion even after developing post CABG.

Coronary artery bypass grafting is the mainstay of revascularization worldwide. However, the most widely used saphenous vein grafts are related to a number of late sequelae. Aortocoronary saphenous vein graft aneurysms mainly diagnosed incidentally are one of these complications. Although rare, given the fatal risk of rupture if left untreated, management either with percutaneous intervention or open redo surgery should be considered. However, no guidelines are established in current scarce literature. Hereby, we present the successful percutaneous management of a huge saphenous vein graft aneurysm via coiling, avoiding the risks of repeat sternotomy.