Shahzad Gull Raja

Background: Effective opioid-sparing analgesia after median sternotomy remains an unmet need in cardiac surgery. We evaluated whether bilateral intercostal cryoanalgesia, added to standard multimodal analgesia, was associated with postoperative pain, opioid consumption, recovery and early hospital-resource use after isolated coronary artery bypass grafting (CABG). Methods: This single-centre, non-randomised comparative service evaluation included 60 patients undergoing isolated CABG through median sternotomy between 1 November 2025 and 30 May 2026 (30 cryoanalgesia; 30 standard care). The prespecified primary endpoint was cumulative movement-evoked pain burden, quantified as the area under the curve (AUC) for scores recorded on postoperative days 1–3. Secondary endpoints included rest-pain AUC, opioid consumption expressed as oral morphine equivalents (OME), time to first bowel opening, postoperative length of stay and an exploratory break-even calculation. Results: Cryoanalgesia was associated with lower movement-pain AUC (adjusted mean difference −3.56 score-days, 95% confidence interval [CI] −4.62 to −2.50; p < 0.001) and rest-pain AUC (−3.16 score-days, 95% CI −4.19 to −2.14; p < 0.001). Total observed opioid consumption was lower by 112.9 mg OME (95% CI −192.8 to −33.1; p = 0.006), length of stay by 1.32 days (95% CI −1.93 to −0.71; p < 0.001), and time to first bowel opening by 0.49 days (95% CI −0.92 to −0.06; p = 0.027). Conclusions: In this small non-randomised evaluation, bilateral intercostal cryoanalgesia was associated with lower early pain and opioid exposure and faster recovery. Selection, temporal and residual confounding preclude causal or cost-effectiveness conclusions. Prospective randomised evaluation with fixed observation periods and longer-term safety follow-up is required.

Objectives: The optimal conduit strategy for coronary artery bypass grafting (CABG) in patients with moderate left ventricular dysfunction (LVEF 30–49%) remains debated. While total arterial grafting (TAG) has shown benefits in broader populations, its role in this higher-risk subgroup is unclear. This study aimed to compare short-term outcomes and long-term survival between single arterial grafting (SAG) and TAG in patients with moderate LV dysfunction undergoing CABG. Methods: A retrospective analysis of 1866 patients was performed, with 640 patients matched using propensity scores (320 SAG vs. 320 TAG). Preoperative, intraoperative, and postoperative variables were assessed. Survival was evaluated using Kaplan–Meier analysis and Cox regression. Results: Matched cohorts were well balanced across baseline characteristics. Long-term survival at 10 and 15 years was numerically higher in the TAG group (85.8% and 79.7%) compared to SAG (81.7% and 74.2%), though not statistically significant (log-rank p = 0.862). Multivariate Cox regression identified age (HR 1.045, p < 0.001), NYHA class (NYHA III HR 0.610, p = 0.003), previous cardiac surgery (HR 0.501, p = 0.006), and off-pump CABG (HR 1.521, p < 0.001) as independent predictors of mortality. Grafting strategy (TAG vs. SAG) was not independently associated with long-term mortality (HR 1.005, p = 0.966). Conclusion: TAG is safe and feasible in patients with moderate LV dysfunction undergoing isolated CABG, with comparable short-term outcomes. Although unadjusted analyses suggested improved long-term survival, this difference was not observed after propensity matching or multivariable adjustment, and grafting strategy was not independently associated with mortality.

Background: Multiple arterial grafting (MAG) is associated with superior long-term outcomes in coronary artery bypass grafting (CABG). The influence of prior myocardial infarction (MI) on outcomes following MAG remains uncertain. This study evaluates in-hospital outcomes and long-term survival of MAG in patients with and without previous MI. Methods: A retrospective single-center observational analysis of 2468 patients undergoing MAG was performed. Propensity score matching yielded 911 pairs based on preoperative variables. Kaplan–Meier survival analysis and Cox regression were used to assess long-term survival and predictors of mortality. Results: In the unmatched cohort, patients with prior MI had significantly higher rates of diabetes (30.6% vs. 23.9%, p < 0.001), smoking history (p < 0.001), and impaired left ventricular function (fair/poor LVEF: 32.4% vs. 11.1%, p < 0.001), along with higher logistic EuroSCORE (3.81 vs. 3.11, p < 0.001). After matching, baseline characteristics were balanced. In-hospital outcomes, including 30-day mortality (1.5% vs. 1.9%, p = 0.587), stroke, reoperation, and renal complications, were similar. Long-term survival at 10, 15, and 20 years was comparable (log-rank p = 0.814). Multivariate Cox regression identified age (HR 1.065, p < 0.001), NYHA class, diabetes (HR 0.779, p = 0.008), and off-pump CABG (HR 1.444, p < 0.001) as independent predictors of mortality. Prior MI was not associated with increased long-term mortality (HR 0.872, p = 0.105). Conclusions: Despite worse baseline risk profiles, patients with prior MI undergoing MAG had equivalent in-hospital outcomes and long-term survival. MAG remains a robust revascularization strategy irrespective of MI history, supporting its broader use in CABG. These findings should be interpreted in the context of a single-center experience from a high-volume arterial grafting program.

Background and Objective: Multiple arterial grafting (MAG), particularly bilateral internal thoracic artery (BITA) use, has demonstrated superior long-term outcomes in coronary artery bypass grafting (CABG). However, its benefit in elderly patients remains debated, with age thresholds proposed to guide conduit selection. This review aims to synthesize current evidence on age-related efficacy of MAG and explore technical, physiological, and methodological factors influencing its application. Methods: A literature search was conducted using PubMed and Embase for studies published between January 1990 and August 2025. Search terms included “multiple arterial grafting”, “bilateral internal thoracic artery”, “coronary artery bypass”, “age threshold”, “frailty”, and “surgical outcomes”. Only studies available in English were considered. Titles and abstracts were screened for relevance to age‑related outcomes in MAG, and full texts of eligible studies were reviewed. Key findings were extracted and synthesized, with particular attention to methodological approaches, statistical models, and clinical endpoints to ensure a critical and contextually informed appraisal of the evidence. Key Content and Findings: Early observational studies suggested diminished BITA benefit beyond 60–70 years, but recent registry analyses challenge this notion, showing survival advantages even in older cohorts. Technical refinements—such as skeletonized harvesting, composite grafting, and radial artery integration—have expanded MAG’s feasibility. Frailty and comorbidity burden are increasingly recognized as more predictive than chronological age. Emerging tools, including artificial intelligence-based risk models and decision aids, may further personalize conduit strategy. Conclusions: Chronological age alone is insufficient to guide MAG decisions. Individualized assessment incorporating physiologic reserve, surgical expertise, and patient preferences is essential. Future research should prioritize age-stratified trials, functional outcomes, and implementation strategies to optimize MAG use across the age spectrum.

Background: Right ventricular failure (RVF) remains a major determinant of morbidity and mortality following left ventricular assist device (LVAD) implantation. In its most severe form, RVF necessitates right ventricular assist device (RVAD) support, which is associated with markedly worse early and long-term outcomes. While numerous studies have examined predictors of post-LVAD RVF, few have focused specifically on RVAD implantation as a discrete and clinically decisive endpoint. We therefore performed a systematic review and meta-analysis to identify robust preoperative predictors of RVAD requirement following LVAD implantation. Methods: A systematic literature search of MEDLINE, EMBASE, SCOPUS, and PubMed was conducted from inception to August 2025 in accordance with PRISMA guidelines. Studies enrolling adult patients undergoing durable or temporary LVAD implantation and reporting preoperative predictors of postoperative RVAD requirement were included. Pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed using the I2 statistic, with predefined sensitivity and subgroup analyses based on LVAD era and study size. Results: Twenty studies met inclusion criteria, of which nineteen comprising 31,591 patients were included in the meta-analysis. Several consistent preoperative predictors of RVAD requirement were identified across clinical, haemodynamic, echocardiographic, and laboratory domains. Patients requiring RVAD were younger (MD –3.57 years) and more frequently female, had a higher likelihood of prior cardiac surgery, INTERMACS Profile 1 status, and need for preoperative mechanical support including ventilation and intra-aortic balloon pump. Haemodynamic predictors included elevated central venous pressure, higher CVP/PCWP ratio, lower cardiac index, and reduced right ventricular stroke work index. Echocardiographic predictors included severe tricuspid regurgitation and lower tricuspid annular plane systolic excursion. Laboratory markers of hepatic dysfunction, coagulopathy, malnutrition, anaemia, thrombocytopenia, and elevated natriuretic peptides were also significantly associated with RVAD implantation. Subgroup analyses demonstrated consistent direction of effects across LVAD eras and study sizes. Conclusion: RVAD requirement after LVAD implantation is driven by a constellation of high clinical acuity, haemodynamic compromise, and end-organ dysfunction rather than any single isolated variable. A comprehensive, multi-parameter preoperative assessment is essential to identify patients at highest risk and to guide patient selection, preoperative optimisation, and consideration of planned biventricular support strategies.

Off-pump coronary artery bypass grafting (OPCAB) represents one of the most significant technical innovations in contemporary cardiac surgery. Developed as an alternative to conventional on-pump coronary artery bypass grafting (ONCAB), OPCAB avoids cardiopulmonary bypass and its associated systemic inflammatory response, aiming to reduce perioperative morbidity and improve recovery. Over the past three decades, advances in stabilization devices, intracoronary shunts, anesthetic management, and surgical training have refined the procedure, making it safer and more reproducible. Despite these developments, OPCAB adoption remains inconsistent worldwide, reflecting ongoing debate about its relative benefits and limitations. Evidence from randomized controlled trials, meta-analyses, and large registries suggests that OPCAB achieves comparable early mortality to ONCAB, with potential advantages in reducing renal dysfunction, neurocognitive decline, and perioperative bleeding. These benefits appear most pronounced in high-risk subgroups, including elderly patients and those with significant comorbidities. However, concerns persist regarding long-term graft patency, completeness of revascularization, and variability in outcomes depending on surgeon experience and institutional expertise. Cost-effectiveness analyses have suggested potential resource savings, but these are offset by training requirements and the technical complexity of the procedure. Global practice variation highlights the influence of surgical culture, guideline ambiguity, and institutional resources. Barriers to universal adoption include technical challenges, inconsistent long-term outcomes, and limited exposure in training programs. In the future, robotic and minimally invasive OPCAB, as well as hybrid revascularization strategies, may expand its role. This review synthesizes current evidence, explores barriers to widespread implementation, and outlines future directions for integrating OPCAB into balanced, evidence-based clinical practice.