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A how-to-do-it message from the strategic surgical command center
Recently, a manuscript arrived on my desk from an accomplished cardiothoracic surgeon, Michael Halkos, from the Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga, with a host of coinvestigators. Their Perspective statement read “Aortic clamping during CABG surgery is associated with cerebral atheroembolism, which is likely responsible for increased periprocedural stroke risk in patients undergoing CABG. The findings of this study support the use of traditional clamping methods during on- or off-pump CABG for patients wit h low-grade aortic disease.” The Emory group has been at the for...
Source: The Journal of Thoracic and Cardiovascular Surgery - May 24, 2017 Category: Cardiovascular & Thoracic Surgery Authors: John W. Hammon Tags: Editorial commentary Source Type: research

Dual antiplatelet therapy at discharge: Antiplatelet practice patterns after coronary artery bypass grafting, surgical anecdote is driving standard of care
Thrombosis and platelet aggregation are key pathogenic mechanisms in acute coronary syndromes (ACS). Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor has been demonstrated to reduce death from cardiovascular causes, nonfatal myocardial infarction, and stroke after ACS.1-3 These large randomized controlled trials studied heterogeneous populations of patients with ACS treated with medical therapy, percutaneous coronary intervention, or coronary bypass grafting (CABG). The data supporting DAPT after CABG are less robust and limited to observational studies, subgroup analyses, and smaller randomized studies ...
Source: The Journal of Thoracic and Cardiovascular Surgery - November 8, 2017 Category: Cardiovascular & Thoracic Surgery Authors: Mark Helmers, Pavan Atluri Tags: Editorial commentary Source Type: research

The importance of atrial fibrillation at the time of coronary artery bypass grafting: Join in the chorus
In this issue of the Journal, Saxena and colleagues1 apply the cumulative influence of a 12-paper meta-analysis to further illustrate the importance of preoperative atrial fibrillation (AF) on mortality after coronary artery bypass grafting (CABG). Preoperative AF in patients undergoing CABG was associated with increased major morbidity, such as stroke and renal failure, as well as an increased risk of early and late mortality (odds ratio, 1.64, and hazard ratio [HR], 1.74, respectively). These increased rates of AF-associated mortality and complications were similar irrespective of on-pump or off-pump revascularization.
Source: The Journal of Thoracic and Cardiovascular Surgery - December 9, 2017 Category: Cardiovascular & Thoracic Surgery Authors: Chris C. Cook, J. Scott Rankin, Vinay Badhwar Tags: Editorial commentary Source Type: research

We don't know what we need to know about atrial fibrillation
Atrial fibrillation (AF) is encountered in older patients and sometimes preoperatively in patients undergoing coronary artery bypass (CAB). Prior single-center studies, Society of Thoracic Surgeons database studies, and a Cochrane review indicate that AF is associated with increased risk for these patients.1-3 The meta-analysis from Saxena and colleagues4 confirms these prior reports and notes an association of preoperative AF with higher stroke, renal failure, reoperation for bleeding, prolonged ventilation, and higher early and late mortality.
Source: The Journal of Thoracic and Cardiovascular Surgery - January 5, 2018 Category: Cardiovascular & Thoracic Surgery Authors: Patrick M. McCarthy Tags: Editorial commentary Source Type: research

Clampless facilitated anastomosis with HEARSTRING to reduce cerebral damage during off-pump coronary bypass grafting. Don't forget it: Easy to use!
In their prospective randomized study, Halkos and colleagues1 highlight a strategy to reduce the risk of cerebral embolism during on-pump and off-pump aortic coronary bypass grafting (CABG) surgery. The authors compared 4 groups of patients according to the surgical technique used. Because of the low number of patients in each group, the main purpose of the study was to detect the high-intensity transient signals (HITS) by transcranial Doppler ultrasonography instead of the incidence of major neurologic events such as cerebral stroke.
Source: The Journal of Thoracic and Cardiovascular Surgery - April 11, 2018 Category: Cardiovascular & Thoracic Surgery Authors: Francesco Formica, Stefano D'Alessandro, Luigi Amerigo Messina Tags: Adult: Coronary: Letter to the editor Source Type: research

Preoperative renal impairment and off-pump coronary artery bypass grafting: The jury is still out
The superiority of off-pump or on-pump coronary artery bypass grafting (CABG) remains to be demonstrated. Through the years, retrospective and prospective studies have suggested that off-pump CABG is associated with improved outcomes, such as reduced renal injury, reduced bleeding and need for transfusion, and shortened hospital stay. The Randomized On/Off Bypass trial, however, demonstrated that off-pump CABG led to lower 5-year survival and event-free survival than did on-pump CABG.1 The more robust CABG Off or On Pump Revascularization Study, in contrast, showed that the rate of the composite outcome of death, stroke, m...
Source: The Journal of Thoracic and Cardiovascular Surgery - April 7, 2018 Category: Cardiovascular & Thoracic Surgery Authors: Mustafa Zakkar, Gianni D. Angelini Tags: Editorial commentary Source Type: research

The limitations of observational data in assessing surgical left atrial appendage ligation
We read with interest the study by Juo and colleagues, which examined outcomes in a cohort of patients with atrial fibrillation who underwent surgical left atrial appendage (LAA) ligation concomitantly with coronary artery bypass grafting. The authors evaluated the short-term efficacy and safety of LAA ligation in 20,664 patients among a sample of 234,642 patients from the Nationwide Inpatient Sample, and reported no significant differences in postoperative stroke, mortality, bleeding, and pericardial complications.
Source: The Journal of Thoracic and Cardiovascular Surgery - June 14, 2018 Category: Cardiovascular & Thoracic Surgery Authors: Saurabh Gupta, Emilie P. Belley-C ôté, Richard P. Whitlock Tags: Letter to the editor Source Type: research

Multivessel coronary artery disease and poor left ventricle function: It is consistent and clear, coronary artery bypass grafting wins again
Superiority of coronary artery bypass grafting (CABG) to medical therapy in patients with impaired ventricular function (ie, ejection fraction  ≤ 35%) has been shown in clinical trials.1,2 Observational studies have also demonstrated greater survival in patients with an impaired left ventricle undergoing CABG compared with those that are treated with percutaneous coronary intervention (PCI).3,4 Although these studies unanimously demons trated that the incidence of early stroke, renal failure, and other complications were higher in the CABG group, having a better survival rate favors CABG over PCI in the treatment of pa...
Source: The Journal of Thoracic and Cardiovascular Surgery - May 28, 2018 Category: Cardiovascular & Thoracic Surgery Authors: Saina Attaran, William S. Weintraub, Vinod H. Thourani Tags: Editorial commentary Source Type: research

Commentary: Off-pump surgery —Choice, not religion
For more than 2  decades, we have examined the value of off-pump coronary artery bypass grafting surgery. It has been the subject of single-institution and single-surgeon reports, randomized trials, and observational studies that have used a myriad of statistical adjustment strategies in attempts to allow comparis ons with a variety of on-pump strategies. The most common question addressed has been “Should off-pump surgery be the standard strategy used by most surgeons for most patients undergoing coronary artery bypass grafting surgery?” As their stories have unfolded, the largest studies involving heter ogeneous gro...
Source: The Journal of Thoracic and Cardiovascular Surgery - April 23, 2019 Category: Cardiovascular & Thoracic Surgery Authors: Bruce Lytle Tags: Commentary Source Type: research

Commentary: Reinventing the wheel: Off- versus on-pump redo coronary artery bypass grafting
The use of off-pump techniques for coronary artery bypass grafting (CABG) peaked in the 1990s but continues to decline. In 2016, only 13% of all CABG surgery were performed off-pump.1 It was originally introduced to avoid the adverse effects of cardiopulmonary bypass and minimize aortic manipulation. However, multiple trials have failed to show a clear advantage for the off-pump CABG. The CABG Off- or On-Pump Revascularization Study (CORONARY) did not show a significant difference in the composite outcome of death, stroke, renal failure, myocardial infarction, and the need for repeat revascularization up to 5  years.
Source: The Journal of Thoracic and Cardiovascular Surgery - May 22, 2019 Category: Cardiovascular & Thoracic Surgery Authors: Tamer Attia, Michael E. Halkos Tags: Commentary Source Type: research

Commentary: Nuisance or nemesis? Postoperative atrial fibrillation increases long-term mortality regardless of sex
Postoperative atrial fibrillation (POAF) complicates approximately 30% of coronary artery bypass grafting (CABG) procedures.1 POAF has been associated with perioperative adverse outcomes including stroke, reoperation for bleeding, myocardial infarction, and pacemaker use.1,2 Patients with POAF are known to have a significantly increased risk of mortality in short-term, midterm, and long-term follow-up. POAF also lengthens hospital stay by 3 to 5  days and increases hospitalization cost from $10,000 to $20,000 per patient.
Source: The Journal of Thoracic and Cardiovascular Surgery - June 5, 2019 Category: Cardiovascular & Thoracic Surgery Authors: Malak Elbatarny, Derrick Y. Tam, Stephen E. Fremes Tags: Commentary Source Type: research

Commentary: Silent brain lesions after coronary artery bypass grafting —Reexamining the sound of silence
Stroke remains one of the most feared complications after coronary artery bypass grafting (CABG) and is associated with as much as 10 times greater in-hospital mortality.1 Although large series have investigated clinical cerebrovascular events and identified risk factors, such as history of cerebrovascular disease or prolonged cardiopulmonary bypass time, subclinical neurologic events and their long-term impact remain poorly understood.2,3 These so-called silent infarcts refer to new brain lesions on postoperative imaging in patients without any correlating focal neurologic findings.
Source: The Journal of Thoracic and Cardiovascular Surgery - November 13, 2019 Category: Cardiovascular & Thoracic Surgery Authors: Andrew M. Vekstein, Shu S. Lin Tags: Commentary Source Type: research

Commentary: ART: Let it rest in peace
The Arterial Revascularization Trial (ART) was a multicenter, prospective trial consisting of 3102 patients who underwent coronary artery bypass graft (CABG) randomized to receive either bilateral internal thoracic artery (BITA) or single internal thoracic artery (SITA) grafts along with guideline-directed medical therapy (GDMT).1 Both groups received saphenous vein grafts (SVGs), and 21.8% of the SITA and 19.4% of the BITA patients also received a radial artery (RA) graft. After 10  years, there was no significant difference between the groups in mortality from any cause, or the composite endpoint of death, myocardial in...
Source: The Journal of Thoracic and Cardiovascular Surgery - April 27, 2020 Category: Cardiovascular & Thoracic Surgery Authors: Harold L. Lazar Tags: Commentary Source Type: research

Commentary: The left main controversy: Is this a real subgroup requiring custom clinical recommendations?
For 3  decades, coronary artery bypass grafting (CABG) has been the standard of care for patients with left main coronary artery stenosis (LMCAS), a practice based on trials that showed improved survival compared with medical management.1 The Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) trial was the first large trial to compare percutaneous coronary intervention (PCI) with CABG in the treatment of coronary artery disease.2 The SYNTAX protocol included a prespecified exploratory analysis in the subgroup of patients with LMCAS that was underpowered for t he primary composite en...
Source: The Journal of Thoracic and Cardiovascular Surgery - May 4, 2020 Category: Cardiovascular & Thoracic Surgery Authors: Mario Gaudino, Domenico Pagano, Nick Freemantle Tags: Commentary Source Type: research

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