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Coronary Revascularization (coronary + revascularization)
Selected AbstractsCT01 IMPACT OF COMPLETION ANGIOGRAPHY AFTER SURGICAL CORONARY REVASCULARIZATIONANZ JOURNAL OF SURGERY, Issue 2007S. Kumar Background Coronary revascularization surgery does not traditionally employ angiography to assess procedural success. Early graft failure is reported up to 30% in one year (JAMA Nov 2005) may relate to technical errors or conduit problems. We hypothesize that intra-operative assessment of graft by angiography identifies graft defects and may improve the long term graft survival. Methods We have developed one of the first hybrid operation room in the USA. In one year period 203 consecutive patients (age:63+/,16, M/F:126/39) underwent coronary revascularization with angiography before decannulation. Results Of 436 grafts, 72 angiographic defects were detected in 69 grafts (17% of total grafts). There were 11% conduit defects, 3% anastomotic defects, and 3% target vessel error. Of 72 defects, 25/72 defects required minor revision, 47/72 required either surgical or percutaneous intervention. Intra-operative angiography added an average 20+/,12 minutes to the surgery and 112+/,56 ml contrast. Renal function at 24hours and 48 hours after procedure did not vary significantly between patients who did vs. those did not have revisions. There were no significant differences in cardiopulmonary bypass time, aortic cross clamp time, and length of hospital stay for patients who underwent revision compared to those who did not. Renal function, bleeding complication, transfusion were similar in patients with percutaneous vs. surgical revision. Conclusions Intraoperative graft angiography performed at the time of CABG identifies graft defects, allowing for immediate surgical or percutaneous revision. Long-term study is in progress to assess whether intra-operative completion angiography decreases the rate of early graft failure. [source] Beating Heart Ischemic Mitral Valve Repair and Coronary Revascularization in Patients with Impaired Left Ventricular FunctionJOURNAL OF CARDIAC SURGERY, Issue 5 2003Edvin Prifti M.D., Ph.D. Materials and Methods: Between January 1993 and February 2001, 91 patients with LVEF between 17% and 35% and chronic ischemic MVR (grade III,IV), underwent MV repair in concomitance with coronary artery bypass grafting (CABG) Sixty-one patients (Group I) underwent cardiac surgery with cardioplegic arrest, and 30 patients (Group II) underwent beating heart combined surgery. Aortic valve insufficiency was considered a contraindication for the on-pump/beating heart procedure. Mean age in Group I was 64.4 ± 7 years and in Group II, 65 ± 6 years (p = 0.69). Results: The in-hospital mortality in Group I was 8 (13%) patients versus 2 (7%) patients in Group II (p > 0.1). The cardiopulmonary bypass (CPB) time was significantly higher in Group I (p < 0.001). In Groups I and II, respectively (p > 0.1), 2.5 ± 1 and 2.7 ± 0.8 grafts per patient were employed. Perioperative complications were identified in 37 (60.7%) patients in Group I versus 10 (33%) patients in Group II (p = 0.025). Prolonged inotropic support of greater than 24 hours was needed in 48 (78.7%) patients (Group I) versus 15 (50%) patients (Group II) (p = 0.008). Postoperative IABP and low cardiac output incidence were significantly higher in Group I, p = 0.03 and p = 0.027, respectively. Postoperative bleeding greater than 1000 mL was identified in 24 patients (39.4%) in Group I versus 5 (16.7%) in Group II (p = 0.033). Renal dysfunction incidence was 65.6% (40 patients) in Group I versus 36.7% (11 patients) in Group II (p = 0.013). The echocardiographic examination within six postoperative months revealed a significant improvement of MV regurgitation fraction, LV function, and reduced dimensions in both groups. The postoperative RF was significantly lower in Group II patients 12 ± 6 (%) versus 16 ± 5.6 (%) in Group I (p = 0.001). The 1, 2, and 3 years actuarial survival including all deaths was 91.3%, 84.2%, and 70% in Group I and 93.3%, 87.1%, and 75% in Group II (p = ns). NYHA FC improved significantly in all patients from both groups. Conclusion. We conclude that patients with impaired LV function and ischemic MVR may undergo combined surgery with acceptable mortality and morbidity. The on/pump beating heart MV repair simultaneous to CABG offers an acceptable postoperative outcome in selected patients. [source] Replication of the Scandinavian Simvastatin Survival Study using a primary care medical record database prompted exploration of a new method to address unmeasured confoundingPHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 7 2008Mark G. Weiner M.D. Abstract Purpose To examine whether identifiable study characteristics and/or analytic methods used determine observational study validity, as assessed by replicating randomized controlled trials using observational data. Methods A cohort from the United Kingdom General Practice Research Database (GPRD) was used to replicate the Scandinavian Simvastatin Survival Study RCT, which investigated statin treatment of hypercholesterolemic subjects with coronary heart disease. All aspects of the RCT except randomization were replicated to the extent possible in the GPRD study, which included 2,871 Unexposed and 1,280 statin-treated Exposed subjects. Results Overall mortality [adjusted hazard ratio 0.71 (0.53,0.96)] and myocardial infarction [adjusted HR 0.79 (0.61,1.02)] decreased in the GPRD study similar to the RCT. Coronary revascularization increased two-fold in the GPRD study, whereas it decreased significantly in the RCT [0.63 (0.54,0.74)]. This latter disparity prompted use of a new methodology to adjust for unmeasured confounding, which yielded an adjusted HR [1.0 (0.75,1.33)] more comparable to the RCT. Conclusions This study provides additional evidence that a replicated GPRD observational study can yield results reasonably similar to a RCT. More important, it provides preliminary evidence suggesting that a new analytic methodology may adjust for unmeasured confounding, the major limitation to research using observational data. Copyright © 2008 John Wiley & Sons, Ltd. [source] Real-world bare metal stenting: Identification of patients at low or very low risk of 9-month coronary revascularizationCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 2 2004Stephen G. Ellis MD Abstract The high cost of drug-eluting stents (DESs) has made identification of patients who are at low risk for subsequent revascularization after treatment with bare metal stents (BMSs) highly desirable. Previous reports from randomized trials suffer from biases induced by restricted entry criteria and protocol-mandated angiographic follow-up. Between 1994 and 2001, 5,239 consecutive BMS patients, excluding those with coil stents, technical failure, brachytherapy, staged procedure, or stent thrombosis within 30 days, were prospectively identified from a large single-center tertiary-referral-center prospective registry for long-term follow-up. We sought to identify characteristics of patients with very low (, 4%) or low (4,10%) likelihood of coronary revascularization 9 months after BMS. Nine-month clinical follow-up was obtained in 98.2% of patients. Coronary revascularization was required in 13.4% and did not differ significantly by stent type. On the basis of multivariate analysis identifying 11 independent correlates and previous reports, 20 potential low-risk patient and lesion groups (228 ± 356 patients/groups) were identified (e.g, patients with all of the following: native vessel, de novo, reference diameter , 3.5 mm, lesion length < 5 mm, no diabetes, not ostial in location). Actual and model-based outcomes were analyzed. No group had both predicted and observed 9-month revascularization , 4% (very low risk). Conversely, 19 of 20 groups had a predicted and observed revascularization rate of 4,10% (low risk). In the real-world setting, the need for intermediate-term revascularization after BMS may be lower than expected, but it may be very difficult to identify patients at very low risk. Conversely, if the benefits of DESs are attenuated in routine practice, many groups of patients treated with BMSs may have nearly comparable results. Catheter Cardiovasc Interv 2004;63:135,140. © 2004 Wiley-Liss, Inc. [source] Assessment of Myocardial Viability with Dobutamine Stress Echocardiography in Patients with Ischemic Left Ventricular DysfunctionECHOCARDIOGRAPHY, Issue 1 2005Siu-Sun Yao M.D. The noninvasive assessment of myocardial viability has proved clinically useful for distinguishing hibernating and/or stunned myocardium from irreversibly injured myocardium in patients with chronic ischemic heart disease or recent myocardial infarction, with marked regional and/or global left ventricular (LV) dysfunction. Noninvasive techniques utilized for the detection of viability in asynergic myocardial regions include positron emission tomographic imaging of residual metabolic activity, single photon emission tomography (SPECT) of radioisotope uptake with thallium-201, low-dose dobutamine echocardiography assessment of inotropic reserve and myocardial contrast echocardiography for evaluation of microvascular integrity. Of these techniques, dobutamine stress echocardiography is a safe, widely available and relatively inexpensive modality for the identification of myocardial viability for risk stratification and prognosis. Low-dose dobutamine response can accurately predict improvement of dysfunctional yet viable myocardial regions, and thus identify a subset of patients whose LV function will improve following successful coronary revascularization. [source] Plasma matrix metalloproteinase-3 level is an independent prognostic factor in stable coronary artery diseaseEUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 9 2005T. C. Wu Abstract Background, Recent evidence suggests the important role of matrix metalloproteinases (MMPs) in the progression of atherosclerosis and development of clinical events. We assessed the prognostic value of different plasma MMPs in patients with stable coronary artery disease (CAD). Materials and methods, A total of 165 consecutive nondiabetic patients with angiographically significant CAD (n = 150) or normal coronary angiograms despite exercise-induced myocardial ischemia (cardiac syndrome X, n = 15) and 17 normal subjects were evaluated. In each subject, plasma inflammatory markers including high sensitivity C-reactive protein (hsCRP) and MMP-2, 3 and 9 were measured. In CAD patients, major cardiovascular events including cardiac death, nonfatal myocardial infarction, unscheduled coronary revascularization and hospitalization as a result of unstable angina were prospectively followed up for more than 6 months. Results, Plasma levels of MMPs were significantly higher in CAD patients than in those with cardiac syndrome X and in normal subjects (MMP-2: 914·76 ± 13·20 vs. 830·79 ± 31·95 vs. 783·08 ± 28·40 ng mL,1, P = 0·002; MMP-3: 129·59 ± 4·21 vs. 116·86 ± 8·09 vs. 91·71 ± 9·55 ng mL,1, P = 0·011; MMP-9: 31·42 ± 2·84 vs. 11·40 ± 5·49 vs. 6·71 ± 2·89 ng mL,1, P = 0·006). In CAD patients, there were 48 major cardiovascular events during a mean follow-up period of 17·74 ± 0·85 months. The numbers of diseased vessels (HR = 2·19, 95% CI 1·20,1·02, P = 0·011), plasma hsCRP (HR = 2·21, 95% CI 1·18,4·11, P = 0·013) and MMP-3 level (HR = 2·46, 95% CI = 1·15,5·28, P = 0·021) were associated with the development of cardiovascular events. However, only the plasma MMP-3 level was an independent predictor of the adverse events in CAD patients (HR = 2·47, 95% CI 1·10,5·54, P = 0·028). Conclusions, Plasma MMP levels were increased in CAD patients. Plasma MMP-3 level, rather than hsCRP, was an independent prognostic marker for future cardiovascular events, suggesting its potential role in risk stratification and clinical management of stable CAD. [source] Does Aortic Root Enlargement Impair the Outcome of Patients With Small Aortic Root?JOURNAL OF CARDIAC SURGERY, Issue 5 2006Hasan Ardal The aim of this study was to evaluate long-term results of the posterior root enlargement. Methods: Between 1985 and 2002, 124 patients underwent aortic valve replacement with a posterior root enlargement. The main indication was a small aortic valve orifice area to patient body surface area (indexed valve area < 0.85 cm2/m2). Fifty-four (44%) patients were male, and 70 (56%) were female with a mean age 39.1 ± 14.3 years. Indications for operation were severe calcified aortic valve stenosis (37.1%), severe aortic insufficiency (25.8%), or combination (37.1%). Seventy-five (60%) patients received double-valve replacement. A pericardial patch was used in 100 patients (80.6%) and a Dacron patch was used in 24 patients. Results: Operative mortality was 6.4% (8 patients). The causes of hospital mortality were low cardiac output syndrome (LCOS) (in 6 patients), cerebrovascular events (in 1 patient) and multiple organ failure (in 1 patient). Multivariate analysis demonstrated concomitant coronary revascularization to be a significant (p = 0.03) predictor for early mortality. There were six (5.4%) late deaths. Cox proportional hazards regression analysis demonstrated LCOS (p = 0.013) and infective endocarditis (p = 0.003) to be significant predictors for late mortality. Atrioventricular block required a permanent pacemaker was observed in 4 patients (3.2%). Conclusions: Posterior aortic root enlargement techniques can be easily applied without additional risks. Long-term survival and freedoms from valve-related complications are satisfactory. [source] Does Off-Pump Revascularization Reduce Coronary Endothelial Dysfunction?JOURNAL OF CARDIAC SURGERY, Issue 5 2004Harold L. Lazar M.D. This experimental study sought to determine whether OPCAB reduces endothelial dysfunction, compared to standard cardiopulmonary bypass (CPB) with and without the anticomplement agent soluble complement receptor-1 (sCR1). Methods: In 10 pigs, OPCAB was simulated by snaring the left anterior descending (LAD) artery for 15 minutes followed by 3 hours of reperfusion. On-pump revascularization was simulated in 20 pigs by 15 minutes of LAD occlusion on CPB with cold blood cardioplegic arrest followed by 3 hours of reperfusion. Ten of these animals received sCR1 (10 mg/kg) prior to CPB. Inflammatory response was monitored by percent (%) lung water increase, wall motion scores (WMS) with transthoracic echocardiography where 4 = normal to ,1 = dyskinesia, and endothelial function in the distal LAD with bradykinin-induced coronary artery relaxation using organ chamber methodology. Results: OPCAB had no effect on lung edema (% increase = 1.7 ± 1.4 OPCAB vs. 3.4 ± 0.5 CPB vs. 2.3 ± 0.9 CPB + sCR1) and failed to prevent wall motion changes (WMS = 2.65 ± 0.08 OPCAB vs. 2.70 ± 0.04 CPB vs. 3.10 ± 0.07* CPB + sCR1, *p < 0.01) and coronary endothelial dysfunction (% relaxation = 41 ± 9 OPCAB vs. 40 ± 9 CPB vs. 78 ± 8** CPB + sCR1, **p < 0.001), which was best preserved with sCR1. Conclusions: This study suggests that agents which directly inhibit complement activation such as sCR1 are more important in preventing endothelial dysfunction during coronary revascularization than merely avoiding CPB. [source] Left Ventricular Reconstruction for Ischemic CardiomyopathyJOURNAL OF CARDIAC SURGERY, Issue 3 2002Vincent Dor M.D. The technique is conducted under a totally arrested heart; coronary revascularization is accomplished first. The mitral valve is checked by TEE and repaired if necessary. Endocardectomy and cryotherapy are used in case of ventricular tachycardia. At the limit between scarred and normal tissue, a continuous suture is tied on a balloon inflated at the theoretical diastolic volume of the patient, and a patch is fixed inside the ventricle. Autologous tissue can be also used. The experience of the author is more than 1000 cases since 1984. The global hospital mortality of the whole series is 7.3%, and 13% in patients with very poor ejection fraction (<30%). In the series of the last 3 years, these mortality rates are 4.8% and 7.9%, respectively. Both geometry and performances of the LV are improved, and the mean increase of ejection fraction is between 10 and 15 points. Three causes can explain delayed impairment; continuum in remodeling, lack in diastolic capacity, or absence of mitral repair. After an infarct, with or without successful coronary recanalization, that leaves a large asynergic scarred ventricle (50% of LV circumference), LVR is recommended to avoid or prevent permanent congestive heart failure with global dilatation. In end-stage ischemic cardiomyopathy with congestive heart failure, and poor response to full medical therapy, LVR, with acceptable risk, could slow down the remodeling and avoid or delay heart transplantation. [source] New Considerations Relating to Class Effect With Angiotensin-Converting Enzyme Inhibitors-The PEACE StudyJOURNAL OF CLINICAL HYPERTENSION, Issue 3 2005Domenic A. Sica MD Angiotensin-converting enzyme inhibitor therapy provides positive outcome benefits in a number of cardiac scenarios including congestive heart failure, postmyocardial infarction, as well as in the hypertensive patient at cardiac risk. This benefit exists both in normotensive and hypertensive individuals and is present in those with various grades of cardiovascular risk. This beneficial cardiovascular effect has now been observed with several angiotensin-converting enzyme inhibitors, suggesting a class effect. The Prevention of Events with Angiotensin-Converting Enzyme Inhibition trial studied the effect of adding the angiotensinconverting enzyme inhibitor trandolapril to a contemporary therapeutic regimen of patients with stable coronary artery disease and preserved left ventricular function. In this study, the addition of trandolapril did not confer any additional benefit in terms of reducing the incidence of cardiovascular death, myocardial infarction, or coronary revascularization. The neutral findings in this trial add a new wrinkle to the concept of class effect for cardiovascular protection with angiotensin-converting enzyme inhibitors in patients with coronary artery disease. [source] Management of Multivessel Coronary Disease after ST Elevation Myocardial Infarction Treated by Primary AngioplastyJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 1 2008Ph.D., STEFANO RIGATTIERI M.D. Background: Optimal treatment strategy of patients with ST elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD) undergoing primary angioplasty is still unclear. Percutaneous coronary intervention (PCI) of non-culprit vessels simultaneously or soon after primary angioplasty is feasible and safe, but available data failed to consistently show a benefit in long-term clinical outcomes. Methods: We retrospectively compared in-hospital and long-term outcomes for patients with STEMI and multivessel CAD treated by primary angioplasty with (Group 1, n=64) or without (Group 2, n=46) early, staged PCI of other angiographically significant coronary lesions. In-hospital major adverse cardiovascular events (MACE) were defined as a composite of death, periprocedural myocardial infarction after staged, elective PCI, stroke, stent thrombosis, major bleeding, and vascular complications. MACE at follow-up were defined as a composite of death, stroke, stent thrombosis, any coronary revascularization, and re-hospitalization for acute coronary syndrome. Results: Group 1 patients underwent staged PCI 5.9 ± 3.5 days after primary angioplasty. The mean length of follow-up was 13 months (392 ± 236 days). The incidence of in-hospital MACE was 20.3% in Group 1 and 10.8% in Group 2 (P=0.186); the incidence of out of hospital MACE was 9.3% in Group 1 and 23.9% in Group 2 (P=0.037). In Group 1 in-hospital MACE were driven by periprocedural myocardial infarction after the elective procedure, which occurred in 15.6% of patients. Conclusions: Our data show that multivessel, staged PCI in STEMI patients is associated with a low incidence of adverse events at follow-up but with a higher incidence of in-hospital MACE, mainly driven by periprocedural myocardial infarction during the elective procedure. [source] The Challenges of Chronic Total Coronary Occlusions: An Old Problem in a New PerspectiveJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 4 2004DAVID E. KANDZARI M.D. In spite of the remarkable technological innovation and improved outcomes with percutaneous coronary revascularization, chronic coronary artery total occlusions remain a familiar source of procedural frustration and clinical uncertainty. However, considering the recent development of catheter-based technologies specific for chronic total occlusion (CTO) recanalization and the potential for drug-eluting stents to reduce restenosis and reocclusion, this challenging lesion subset is now recognized as the last formidable barrier to percutaneous revascularization success. Further, consistent observations from more recent clinical trials support successful CTO revascularization to avoid subsequent adverse cardiac events and improve long-term overall survival. This review of total coronary occlusions provides an overview of CTO pathophysiology, describes the procedural and clinical outcomes associated with CTO revascularization, and presents future directions for clinical investigation. [source] Coronary heart disease outcomes in patients receiving antidiabetic agents in the PharMetrics database 2000,2007,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 8 2008Alexander M. Walker MD, DrPH Abstract Background The risk of coronary heart disease (CHD) in users of antidiabetic agents must be quantified to permit reasoned therapeutic choices. Objectives To assess the risk of myocardial infarction (MI) and coronary revascularization (CR), in diabetic patients who began rosiglitazone, pioglitazone, metformin, or sulfonylureas. Methods We conducted a retrospective cohort study of MI and CR in the PharMetrics database. We performed head-to-head comparisons using propensity-score-stratified Cox proportional hazards models, examining risks both on-treatment and during total follow-up before regimen switches. Results For the combined outcome (MI and CR), the crude rates per 1000 person years were 9 on monotherapy, 13 on dual therapy, and 21 on therapies combined with insulin. In the absence of insulin, regimens containing thiazolidinediones (TZDs) tended toward lower risk than comparable regimens containing sulfonylureas and higher risk than those containing metformin. The summary hazard ratio for rosiglitazone versus pioglitazone was 1.04 (95%CI: 0.94,1.14) for total follow-up and 1.05 (0.92,1.19) for on-treatment time. For MI, the hazard ratios were 1.07 (0.89,1.27) for total follow-up and 1.21 (0.95,1.54) for on-treatment time. Conclusions The present data indicate that the risk of CHD in patients using TZDs appears to lie between the risks associated with sulfonylureas and metformin. Neither the risk of MI and CR together nor the risk of MI alone was significantly different between rosiglitazone and pioglitazone. A nonsignificant observed excess risk of 21% for MI during on-treatment time will require combination with the results of other studies to provide a reliable assessment. Copyright © 2008 John Wiley & Sons, Ltd. [source] A comparison of pioglitazone and rosiglitazone for hospitalization for acute myocardial infarction in type 2 diabetes,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 10 2007Charles M. Gerrits PharmD Abstract Background Recent studies have raised concerns about potential increased cardiovascular (CV) risk in type 2 diabetes patients treated with some peroxisome proliferator-activated receptor gamma (PPAR-gamma) agonists. Objective To ascertain the risk of hospitalization for acute myocardial infarction (AMI) in type 2 diabetes patients treated with pioglitazone relative to rosiglitazone. Methodology Using data covering 2003,2006 from a large health care insurer in the US, a retrospective cohort study was conducted in patients who initiated treatment with pioglitazone or rosiglitazone. The hazard ratio (HR) of incident hospitalization for AMI after initiation of treatment with these drugs was estimated from multivariate Cox's proportional hazards survival analysis; similarly, the HR was ascertained for hospitalization for the composite endpoint of AMI or coronary revascularization (CR). Results A total of 29,911 eligible patients were identified in the database; 14,807 in the pioglitazone and 15,104 in the rosiglitazone group. Baseline demographics, medical history, and dispensed medications were generally well balanced between groups. The unadjusted HR for hospitalization for AMI was 0.82, 95%CI: 0.67,1.01. After adjustment for baseline covariates the HR was 0.78, 95%CI: 0.63,0.96. The adjusted HR for the composite of AMI or CR was 0.85, 95%CI: 0.75,0.98. Conclusion This retrospective cohort study showed that pioglitazone, in comparison with rosiglitazone, is associated with a 22% relative risk reduction of hospitalization for AMI in patients with type 2 diabetes. Copyright © 2007 John Wiley & Sons, Ltd. [source] Off-pump, minimally invasive and robotic coronary revascularization yield improved outcomes over traditional on-pump CABGTHE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, Issue 1 2009Pavan Atluri Abstract Coronary artery disease is a global health concern, with increasing morbidity and mortality. Surgical coronary artery bypass grafting has been performed on cardiopulmonary bypass for nearly four decades, with excellent long-term durability. Beating-heart coronary surgery has been increasing in frequency in an attempt to decrease cardiopulmonary bypass-related morbidity. Furthermore, with increasing expertise and technology, minimally invasive and robotic techniques have been developed to enhance post-operative recovery, patient satisfaction and cosmesis. Several clinical trials have demonstrated decreased morbidity and more rapid recovery following off-pump, minimally invasive and robotic procedures when compared to on-pump coronary artery bypass grafts (CABGs). An equivalent extent of revascularization and medium-term anastomotic patency has been demonstrated among all approaches. Furthermore, for a large number of patients who do not have anatomy amenable to traditional coronary revascularization, adjunctive molecular therapies may provide alternative myocardial micro-revascularization. Copyright © 2008 John Wiley & Sons, Ltd. [source] Mortality and Revascularization Following Admission for Acute Myocardial Infarction: Implication for Rural VeteransTHE JOURNAL OF RURAL HEALTH, Issue 4 2010Thad E. Abrams MD Abstract Introduction: Annually, over 3,000 rural veterans are admitted to Veterans Health Administration (VA) hospitals for acute myocardial infarction (AMI), yet no studies of AMI have utilized the VA rural definition. Methods: This retrospective cohort study identified 15,870 patients admitted for AMI to all VA hospitals. Rural residence was identified by either Rural-Urban Commuting Area (RUCA) codes or the VA Urban/Rural/Highly Rural (URH) system. Endpoints of mortality and coronary revascularization were adjusted using administrative laboratory and clinical variables. Results: URH codes identified 184 (1%) veterans as highly rural, 6,046 (39%) as rural, and 9,378 (60%) as urban; RUCA codes identified 1,350 (9%) veterans from an isolated town, 3,505 (22%) from a small or large town, and 10,345 (65%) from urban areas. Adjusted mortality analyses demonstrated similar risk of mortality for rural veterans using either URH or RUCA systems. Hazards of revascularization using the URH classification demonstrated no difference for rural (HR, 0.96; 95% CI, 0.94-1.00) and highly rural veterans (HR, 1.13; 0.96-1.31) relative to urban veterans. In contrast, rural (relative to urban) veterans designated by the RUCA system had lower rates of revascularization; this was true for veterans from small or large towns (HR, 0.89; 0.83-0.95) as well as veterans from isolated towns (HR, 0.86; 0.78-0.93). Conclusion: Rural veterans admitted for AMI care have a similar risk of 30-day mortality but the adjusted hazard for receipt of revascularization for rural veterans was dependent upon the rural classification system utilized. These findings suggest potentially lower rates of revascularization for rural veterans. [source] CT01 IMPACT OF COMPLETION ANGIOGRAPHY AFTER SURGICAL CORONARY REVASCULARIZATIONANZ JOURNAL OF SURGERY, Issue 2007S. Kumar Background Coronary revascularization surgery does not traditionally employ angiography to assess procedural success. Early graft failure is reported up to 30% in one year (JAMA Nov 2005) may relate to technical errors or conduit problems. We hypothesize that intra-operative assessment of graft by angiography identifies graft defects and may improve the long term graft survival. Methods We have developed one of the first hybrid operation room in the USA. In one year period 203 consecutive patients (age:63+/,16, M/F:126/39) underwent coronary revascularization with angiography before decannulation. Results Of 436 grafts, 72 angiographic defects were detected in 69 grafts (17% of total grafts). There were 11% conduit defects, 3% anastomotic defects, and 3% target vessel error. Of 72 defects, 25/72 defects required minor revision, 47/72 required either surgical or percutaneous intervention. Intra-operative angiography added an average 20+/,12 minutes to the surgery and 112+/,56 ml contrast. Renal function at 24hours and 48 hours after procedure did not vary significantly between patients who did vs. those did not have revisions. There were no significant differences in cardiopulmonary bypass time, aortic cross clamp time, and length of hospital stay for patients who underwent revision compared to those who did not. Renal function, bleeding complication, transfusion were similar in patients with percutaneous vs. surgical revision. Conclusions Intraoperative graft angiography performed at the time of CABG identifies graft defects, allowing for immediate surgical or percutaneous revision. Long-term study is in progress to assess whether intra-operative completion angiography decreases the rate of early graft failure. [source] Beating-Heart Coronary Artery Bypass Grafting With Miniaturized Cardiopulmonary Bypass Results in a More Complete Revascularization When Compared to Off-Pump GraftingARTIFICIAL ORGANS, Issue 3 2010Delawer Reber Abstract The technique of miniaturized cardiopulmonary bypass (M-CPB) for beating-heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M-CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump-related inflammatory response and organ injury. Finally, this technique combines the advantages of the off-pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M-CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off-pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating-heart CABG, 117 (39%) of them with the use of M-CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra- and early-postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M-CPB patients than in patients in the OPCAB group. Beating-heart CABG with M-CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating-heart CABG with the support of a M-CPB is the operation of choice when total coronary revascularization is needed. [source] Defining the length of stay following percutaneous coronary intervention,CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 7 2009An expert consensus document from the society for cardiovascular angiography, interventions endorsed by the American college of cardiology foundation Abstract Percutaneous coronary intervention (PCI) is the most common method of coronary revascularization. Over time, as operator skills and technical advances have improved procedural outcomes, the length of stay (LOS) has decreased. However, standardization in the definition of LOS following PCI has been challenging due to significant physician, procedural, and patient variables. Given the increased focus on both patient safety as well as the cost of medical care, system process issues are a concern and provide a driving force for standardization while simultaneously maintaining the quality of patient care. This document: (1) provides a summary of the existing published data on same-day patient discharge following PCI, (2) reviews studies that developed methods to predict risk following PCI, and (3) provides clarification of the terms used to define care settings following PCI. In addition, a decision matrix is proposed for the care of patients following PCI. It is intended to provide both the interventional cardiologist as well as the facilities, in which they are associated, a guide to allow for the appropriate LOS for the appropriate patient who could be considered for early discharge or outpatient intervention. © 2009 Wiley-Liss, Inc. [source] PCI versus CABG for multivessel coronary disease in diabetics,CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 1 2009Giuseppe Tarantini MD Abstract Objectives: To explore the clinical performance of a strategy of revascularization by percutaneous coronary intervention (PCI) with drug-eluting stent (DES) in diabetic patients with multivessel disease (MVD) compared with coronary artery bypass graft (CABG), when it is based on clinical judgment. Background: Diabetes mellitus (DM) is a major risk factor for poor outcome after PCI. However, PCI may result in better outcome if the choice of revascularization (PCI versus CABG) is based on the physician decision, rather than randomization. Limited experiences have compared revascularization by DES-PCI versus CABG in DM patients with MVD. Methods: From August 2004 to August 2005, 220 consecutive DM patients with MVD underwent DES-PCI (93) or CABG (127) at our Institution. The type of revascularization was dependent on patient and/or physician choice. Major adverse cardiac and cerebrovascular events (MACCE) included death, myocardial infarction, repeat coronary revascularization, and stroke. Results: Compared with PCI patients, CABG patients had higher prevalence of 3-vessel disease (P < 0.001), significant LAD involvement (P < 0.001), presence of total occlusions (P = 0.04), collateral circulation (P < 0.001). At 2-year follow-up, MACCE were not different between CABG group and DES-PCI group (OR 1.2; P = 0.6) and, only when the clinical judgment on the revascularization choice was excluded at propensity analysis, DES-PCI increased the risk of 24-month MACCE in total population (OR 1.8; P = 0.04). Conclusions: For patients with DM and MVD, a clinical judgment-based revascularization by DES-PCI is not associated with worse 2-year outcome compared with CABG. © 2008 Wiley-Liss, Inc. [source] Real-world bare metal stenting: Identification of patients at low or very low risk of 9-month coronary revascularizationCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 2 2004Stephen G. Ellis MD Abstract The high cost of drug-eluting stents (DESs) has made identification of patients who are at low risk for subsequent revascularization after treatment with bare metal stents (BMSs) highly desirable. Previous reports from randomized trials suffer from biases induced by restricted entry criteria and protocol-mandated angiographic follow-up. Between 1994 and 2001, 5,239 consecutive BMS patients, excluding those with coil stents, technical failure, brachytherapy, staged procedure, or stent thrombosis within 30 days, were prospectively identified from a large single-center tertiary-referral-center prospective registry for long-term follow-up. We sought to identify characteristics of patients with very low (, 4%) or low (4,10%) likelihood of coronary revascularization 9 months after BMS. Nine-month clinical follow-up was obtained in 98.2% of patients. Coronary revascularization was required in 13.4% and did not differ significantly by stent type. On the basis of multivariate analysis identifying 11 independent correlates and previous reports, 20 potential low-risk patient and lesion groups (228 ± 356 patients/groups) were identified (e.g, patients with all of the following: native vessel, de novo, reference diameter , 3.5 mm, lesion length < 5 mm, no diabetes, not ostial in location). Actual and model-based outcomes were analyzed. No group had both predicted and observed 9-month revascularization , 4% (very low risk). Conversely, 19 of 20 groups had a predicted and observed revascularization rate of 4,10% (low risk). In the real-world setting, the need for intermediate-term revascularization after BMS may be lower than expected, but it may be very difficult to identify patients at very low risk. Conversely, if the benefits of DESs are attenuated in routine practice, many groups of patients treated with BMSs may have nearly comparable results. Catheter Cardiovasc Interv 2004;63:135,140. © 2004 Wiley-Liss, Inc. [source] The Brain First or the Heart: The Approach to Revascularizing Severe Co-Existing Carotid and Coronary Artery DiseaseCLINICAL CARDIOLOGY, Issue 8 2009Raed Aqel MD Combined symptomatic severe cerebralvascular disease and significant obstructive coronary artery disease frequently exist.1,2 For the past few decades, clinicians have debated the various treatment strategies for these high-risk patients including staged procedures and hybrid revascularization. While some recommend addressing the more unstable vascular territory first, others prefer to intervene on the carotids prior to performing coronary revascularization. Both surgical and percutaneous options have been explored in various clinical settings, but there are no treatment guidelines to date. Given the frequency and magnitude of this problem, we performed an extensive review of the literature in an attempt to add some much needed clarity. An illustrative case and recommendations are provided. Copyright © 2009 Wiley Periodicals, Inc. [source] Trends in use of herbal and nutritional supplements in cardiovascular patientsCLINICAL CARDIOLOGY, Issue 2 2004Tomasz Stys M.D. Abstract Background: Use of herbs and nutritional supplements (known as naturoceuticals) is increasing in the USA, with about 50% of Americans taking naturoceuticals and spending over $10 billion per year for them. This raises concerns regarding their use instead of proven therapies, their side effects, and drug interaction potential. Hypothesis: The study sought to characterize cardiology patients who used supplements and to examine whether their use was diagnosis or doctor dependent, whether it affected patients' compliance, and what supplements were used. Methods: In all, 187 patients attending our cardiology clinic were interviewed, examined, and followed for up to 1 year. The users and nonusers of naturoceuticals were compared. Results: Supplements were used in 106 patients (an average of 3.1 naturoceutical per patient). There were no significant differences in their use by gender, age, primary care doctor specialty, or cardiovascular medications prescribed (except for statins). Patients with a history of myocardial infarction, coronary revascularization, hyperlipidemia, and a family history of coronary artery disease were more likely to use the supplements. Average low-density lipoprotein (106 vs. 108 mg/dl), average blood pressure (132/77 vs. 138/78 mmHg), and average hemoglobin (Hb)A1c (8.7 vs. 7.7%) showed no statistically significant differences between users and nonusers. Patients most commonly took multivitamins, vitamin E, vitamin C, vitamin B, folate, garlic, calcium, coenzyme Q10, and gingko. Conclusion: This study indicates that naturoceutical use is widespread among cardiovascular patients and it is difficult to predict clinically who the users are. Fortunately, according to our limited compliance measures, it appears that the naturoceutical use has not affected patients' compliance with traditional medications. Also, possibly a detrimental interaction potential between traditional medications and naturoceuticals has been demonstrated. [source] To what degree is amelioration of angina following coronary revascularization associated with improvement in myocardial perfusion?CLINICAL PHYSIOLOGY AND FUNCTIONAL IMAGING, Issue 5 2006Allan Johansen Summary Objective:, To examine the association between changes in chest pain and changes in perfusion following revascularization as assessed by clinical evaluation and myocardial perfusion imaging (MPI) in patients with stable angina. Design:, In a prospective series of 380 patients (58·8 ± 8·8 years) referred to angiography because of known or suspected stable angina, changes in chest discomfort and changes in perfusion after 2 years were assessed in 144 patients, who underwent revascularization, and 236, who did not. The decision to treat invasively was made without knowledge of the result of MPI. Results:, In revascularized patients, the presence of typical/atypical angina was reduced from 93% to 36% and the improvement was associated with improvement in perfusion. A small improvement in perfusion induced a high frequency of change from angina to no pain, whereas a further reduction caused little extra change. In non-revascularized patients the change in chest discomfort was not related to changes in perfusion, which were rarely present. Conclusion:, Alleviation of chest discomfort 2 years after revascularization is associated with improvements in perfusion. This association appeared to be an all-or-nothing phenomenon. Non-revascularized patients also exhibited improvements in chest discomfort despite insignificant changes in perfusion. [source] | ||||||||||||||||||||||