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Second-generation stents fail to BEST CABG

16 Apr, 15 | by Alistair Lindsay

The technology of drug eluting stents for percutaneous coronary intervention (PCI) has improved over time with resultant improvements in patient outcomes.  Although prior studies have demonstrated the benefit of surgical coronary artery bypass grafting (CABG) over transcatheter PCI among patients with multivessel coronary artery disease (CAD), these studies did not incorporate newer generation drug-eluting stents.  The multicenter BEST trial randomized 880 patients with multivessel CAD to PCI with an everolimus-eluting stent or to CABG. The primary end point for this non-inferiority study was a composite of death, myocardial infarction, or target-vessel revascularization at 2 years.  The results of the study non-significantly favored CABG at 2 years of follow-up with the primary end-point occurring in 7.9% of the CABG group and 11% of the PCI group.  more…

Surgical Repair of Moderate Mitral Regurgitation at the Time of CABG Lacks Clear Benefit

17 Feb, 15 | by Alistair Lindsay

Ischemic mitral regurgitation (MR) is common and associated with poor outcomes among patients undergoing bypass surgery.  However, it remains unknown whether repair of ischemic MR concurrent to CABG leads to better patient outcomes.  To address this important clinical question, this multi-center study randomly assigned 301 patients with moderate ischemic MR to CABG alone or CABG plus mitral valve repair.  The primary end-point was the echocardiographic parameter of left ventricular end-systolic volume index (LVESVI) at 1-year, which is a measure of left ventricular remodeling and is a known predictor of poor outcomes. Secondary end-points included major adverse cardiac or cerebrovascular events and functional assessments using the Minnesota heart failure questionnaire. more…

Quality of Life following Coronary Artery Bypass Graft Surgery versus Guideline-based Medical Therapy in Ischemic Cardiomyopathy  

14 Oct, 14 | by Alistair Lindsay

It remains uncertain if surgical revascularization improves patient outcomes in the setting of coronary artery disease with reduced systolic function. This is particularly true in light of the STICH trial, a contemporary randomized control trial of coronary artery bypass graft surgery (CABG) with optimal medical therapy compared to optimal medical therapy alone in patients with ischemic left ventricular dysfunction. The primary results of the STICH trial demonstrated no overall mortality benefit to CABG with medical therapy compared to medical therapy alone. In this study, the trial authors report quality of life outcomes from the STICH trial. The trial randomized 1212 patients with an ejection fraction ≤35% with coronary anatomy suitable for surgical revascularization to either CABG with medical therapy or medical therapy alone. more…

Bilateral internal mammary grafts in diabetics: benefits outweigh perioperative risks

3 Sep, 13 | by Alistair Lindsay

Patients with diabetes have more severe coronary disease at presentation and worse overall outcomes than their non-diabetic counterparts, even following surgical revascularisation. Whilst use of the left internal thoracic artery (LITA) is well established and improves event free survival when anastomosed to the LAD, the use of both right and left internal thoracic arteries in bilateral (BITA) grafting is less well described with concerns remaining over the associated increased risks of sternal wound infection, particularly in diabetics. more…

SYNTAX II: Improved predictive value

18 Mar, 13 | by Alistair Lindsay

The anatomical SYNTAX score is advocated in both US and European guidelines to help establish the best revascularisation approach in patients with complex coronary artery disease.  The purpose of this study was to improve the SYNTAX score further by including prognostically important clinical variables, as opposed to the anatomical variables that are used for the current score. more…

FREEDOM: CABG superior to PCI in diabetics

16 Dec, 12 | by Alistair Lindsay

Diabetes is one of the principle aetiological factors for coronary artery disease with vascular disease in diabetics displaying a particularly aggressive phenotype, often resulting in multivessel disease. Current evidence suggests that CABG is particularly beneficial in these patients as compared with PCI. however, much of this evidence was either gathered in the era before modern drug eluting stents or is from meta-analyses of smaller studies. more…

PCI in centres without surgical backup

4 Jun, 12 | by Alistair Lindsay

As percutaneous coronary intervention (PCI) has advanced, improved technology and increased collective experience have led to a marked reduction in the need for emergency coronary artery bypass surgery (CABG), with only 0.15% of patients requiring emergency surgical intervention in 2002.  In fact, PCI is now commonly practiced in hospitals without on-site cardiothoracic back-up, something that was almost unheard of even a decade ago.  Despite this expansion, the evidence for this approach – patient outcomes in the absence of immediate surgical intervention – remains undefined. more…

EuroSCORE updated

5 Apr, 12 | by Alistair Lindsay

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most widely used cardiac risk models for predicting mortality after cardiac surgery and forms the basis of many pre-operative discussions surrounding risk/benefit ratios and gaining informed consent for a procedure.  First published in 1999 and derived from an international European database, the system has been highly successful, but with time and improvements in cardiothoracic techniques and mortality, it is now clear that model overpredicts risk and is no longer appropriately calibrated. In the EuroSCORE II project the aim was to update this system and make it more relevant to contemporary practice. more…

Stroke following CABG and long term outcomes

3 Oct, 11 | by Alistair Lindsay

Stroke is a potentially devastating complication following cardiothoracic surgery with a reported incidence of between 2 and 10%. While numerous risk factors have been described for stroke, little data are available regarding its temporal relationship to the surgical procedure and whether this predicts long term outcomes. more…

STICH examines the role of CABG in heart failure

11 Jun, 11 | by Alistair Lindsay

While the efficacy of CABG in improving both morbidity and mortality in patients with severe coronary artery disease and angina was established in the 1970’s, the majority of patients who took part in these initial ground-breaking studies had normal or near normal ventricular function.  The role of CABG in treating patients with poor systolic LV function is less well established, especially in light of modern alternatives such as medical and device management. more…

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