Early Outcomes of Closed Versus Open Left Anterior Descending Artery Endarterectomy In Patients Undergoing Coronary Artery Bypass Grafting

Coronary endarterectomy is an old surgical procedure against coronary artery disease which was first described by Baily et al. in 1957. In spite of the first adverse effects, several recent publications have demonstrated that coronary endarterectomy (CE) with coronary artery bypass grafting (CABG) can be done safely with appropriate mortality and morbidity. The main objective of CABG is complete revascularization of coronary vessels and, particularly, left internal mammary artery to left anterior descending artery (LIMA-LAD) anastomosis, Since; patent LIMA-LAD is the single most significant determinant for long-term and eventfree survival. A best evidence topic in cardiac surgery was written according to a structured protocol. The problem was whether LAD artery open endarterectomy (open-CE) with CABG compares favorably with LAD artery closed endarterectomy (closed-CE) with CABG in the myocardial revascularization of patients presenting with diffuse coronary artery disease (DCAD). The purpose of this review is just to determine the safety and feasibility of CE in general and open-CE versus closed-CE particularly. The last search date was December 2019 and the search period was from 1992 till 2019. Open-CE with CABG may carry a lower early mortality rate (range from 2.9% to 8.8%) than closed-CE with CABG (range from 6.8% to 10.9%) and CE + CABG has a significantly higher risk of death than isolated CABG. Internal thoracic artery (ITA) use may enhance mortality, while the saphenous vein (SV) conduit or two CE vessels may worsen the clinical outcome. The main complication of CE can be found in post-operative atrial fibrillation (AF), in our review; the rate ranged from 9% to 29%. Another devastating complication is postoperative myocardial infarction (MI) with a range of 0% to 13.9%.

Coronary endarterectomy in myocardial revascularization

Aim. To compare the immediate outcomes of combined coronary artery bypass grafting (CABG) with coronary endarterectomy (CE) and isolated CABG.Material and methods. This retrospective study included 192 patients with stable angina who underwent myocardial revascularization in the period from January 2016 to August 2018. The patients were divided into 2 groups. Group 1 included patients who underwent combined CABG and CE, while group 2 — patients who underwent isolated CABG. Patients in both groups did not differ in the main preoperative characteristics, with the exception of the incidence of obesity and right coronary artery disease.Results. In-hospital mortality in group 1 was 2,2% (n=2), in group 2 — 2% (n=2). The incidence of perioperative myocardial infarction in group 1 was 1% (n=1) and in group 2 — 0%. There were no significant differences between groups in the following postoperative parameters: in-hospital mortality, perioperative myocardial infarction, need and duration of inotropic support, duration of mechanical ventilation (MV) and need for long-term mechanical ventilation, stroke, arrhythmias, resternotomy for bleeding. In group 1, encephalopathy (11,8%) and respiratory failure (12,9%) were significantly more common.Conclusion. Combined CABG and CE is a safe technique for achieving complete myocardial revascularization in diffuse coronary artery disease, since, in comparison with isolated CABG, there is no increase in the incidence of death and perioperative myocardial infarction. However, in this category of patients, an increase in the incidence of non-lethal, non-disabling cerebral and pulmonary complications should be expected.

Early Postoperative Results of On-Pump Coronary Endarterectomy: Is Gender a Risk Factor?

Background: Coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) is an effective but still controversial surgical strategy for the treatment of diffuse coronary artery disease. In this study, we aimed to investigate the impact of gender differences on operative and early postoperative results of patients who underwent CABG with CE. Methods: This retrospective study included 141 patients who had undergone CE combined with CABG from January 2015 to December 2020, as well as 141 patients without CE as the control group. First, patients with and without CE were compared. Next, patients undergoing CE were divided into 2 groups according to gender (group 1, male patients; group 2, female patients). Results: Of the 141 patients who underwent CE combined with on-pump CABG, 95 (67.3%) were male, and median age was 66 years (range 58 to 71.2). Of the 141 patients who underwent isolated on-pump CABG, 99 (70.2%) were males, and median age was 63 years (range 41 to 80.4). The data for these 2 groups (with and without CE) were compared. Previous percutaneous coronary intervention (PCI), presence of diabetes mellitus, and perfusion time were significantly more common in the CE group. There were 95 patients in group 1, with a median age of 65 years (range 58 to 69), and 46 patients in group 2, with a median age of 66 (64 to 71.2). There were no difference between the groups in terms of age, body mass index, hyperlipidemia, chronic obstructive pulmonary disease, peripheral artery disease, or previous coronary intervention. The need for positive inotropic support and postoperative atrial fibrillation were found to be significantly more common in group 2 (P = .022 and .039, respectively). Defibrillation after releasing the aortic cross clamp was also significantly more common in group 2 (P = .025). Conclusion: In our study, the need for defibrillation after aortic cross-clamp releasing in the perioperative period, the need for inotropic support and the incidence of atrial fibrillation in the post-operative period, increased significantly in the female gender. CE can be performed safely in both genders with acceptable mortality and morbidity rates.

Venoarterial extracorporeal membrane oxygenation for cardiogenic shock after coronary endarterectomy

Background: Clinical outcomes of cardiogenic shock patients who were supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary endarterectomy (CE) have not yet been reported. We conducted a retrospective observational study to evaluate the short-term outcomes of patients supported with VA-ECMO after CE. Methods: Patients ( n = 32) who received VA-ECMO refractory cardiogenic shock after CE between January 2011 and December 2020 at the Beijing Anzhen Hospital were reviewed retrospectively. Multivariable logistic regression analysis was used to identify factors independently associated with in-hospital mortality. Results: Twenty patients (63%) could be weaned from VA-ECMO, and 12 patients (38%) survived to hospital discharge. The median (interquartile range [IQR]) time on VA-ECMO support was 4 (3–6) days. The median (IQR) length of ICU stay and hospital stay were 9 (5–13) and 20 (15–27) days, respectively. Neurological complications were observed in 4 (13%) of the patients. ECMO-related complications occurred in 9 (28%) of the patients. SAVE score was identified as an independent protective factor for in-hospital mortality (OR, 0.70; 95% CI, 0.54–0.91; p = 0.009). The area under the receiver operating characteristic curve for SAVE score was 0.83 (95% CI, 0.67–0.98). SOFA score (0.78; 95% CI, 0.62–0.94) and EuroSCORE (0.79; 95% CI, 0.62–0.97) also exhibited good performances. Conclusions: VA-ECMO is an acceptable technique for the treatment of cardiogenic shock in patients undergoing CE. SAVE score might be a useful tool to predict survival for these patients. Prospective studies are needed to assess long-term outcomes of hospital survivors.

SURGICAL MANAGEMENT OF MULTIPLE INSTENT RESTENOSIS WITH CORONARY ENDARTERECTOMY AND STENTECTOMY

In-stent restenosis remain the most important problem of coronary stent implantation. The number of patients with in-stent restenosis of coronary arteries is increasing in the practice of heart surgeons. We report a successful treatment of a patient with multiple in-stent restenosis of coronary arteries. LAD was treated with long arteriotomy of about 8 sm followed by open coronary endarteriectomy and stentectomy. The arteriotomy was then reconstructed with a venous patch and distal anastomosis with the LIMA then performed. The patient’s postoperative period was uncomplicated. At a 6-month followup examination, the patient is doing well and is asymptomatic. Combined open endarterectomy and stentectomy appears to be an effective alternative surgical treatment of FMJ-LAD and multiple intra-stent restenoses and gives a chance of full revascularization for such patients. Key words: Surgical management, coronary endarterectomy, stentectomy, arteriotomy, patient, FMJ-LAD

Coronary endarterectomy in coronary artery disease: Factors affecting graft patency and survival

Background Coronary endarterectomy aims to improve completeness of revascularization in patients with occluded coronary vessels. The benefits of coronary endarterectomy remain uncertain. The aim of this study was to evaluate short-term surgical outcomes and factors affecting graft patency post-coronary endarterectomy. Methods Between 2009 and 2019, 81 consecutive patients who had coronary endarterectomy done were evaluated for their perioperative and early results. A total of 36 patients with follow-up coronary studies were included in patency analysis. Mortality rates, major adverse cardiac and cerebrovascular events, and graft patency were outcomes of interest. Survival and risk factor analysis were performed with Kaplan–Meier and logistic regression analysis. Results The average age of the cohort was 61.9 ± 9.29 years. Complete revascularization rate was 95.4% post-coronary endarterectomy. The 30-day and 1-year mortality was 2.5 and 6.2%, respectively. One-year major adverse cardiac and cerebrovascular events rate was 11.1%. Periprocedural myocardial infarction rate was 7.4%. Three patients required repeat revascularization within a mean follow-up duration of 49.6 ± 36.5 months. Overall graft patency was 89.2% at 20.2 months and graft patency post-coronary endarterectomy was 85.4%. Arterial grafts showed 100% patency. Vein grafts to endarterectomized obtuse marginal branch had patency rates of 33.3%. Multiple endarterectomies were associated with worse one-year major adverse cardiac and cerebrovascular events (OR: 28.6 ± 1.16; P = 0.003). Conclusions Coronary endarterectomy facilitates completeness of revascularization and does not increase early mortality. Graft patency post-coronary endarterectomy on obtuse marginal artery was suboptimal. Judicious use of coronary endarterectomy should be practiced to balance the need of completeness of revascularization against the risk of myocardial infarction.