Orr Sela

Background/Objectives: Revascularization of the left anterior descending (LAD) artery can be achieved by either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Minimally invasive direct CABG (MIDCAB) enables LAD revascularization via a small thoracotomy without sternotomy or cardiopulmonary bypass. To compare long-term survival following LAD revascularization by MIDCAB or following PCI using drug-eluting stents (DES), of the historic cohort we reported in 2006. Methods: Data were assessed of 272 patients who underwent LAD PCI with DES, and 104 patients who underwent MIDCAB using the left internal thoracic artery (LITA) to LAD, in two major centers, between May 2002 and December 2003. Matching for age, sex, and extent of coronary disease yielded two balanced groups of 83 patients each. Results: Baseline characteristics were similar with a mean age ± standardized difference (SD) of 64.70 ± 12.52 of the MIDCAB group vs. 63.59 ± 12.06 of the Cypher group and an identical male to female ratio of 66 to 83 (79.5%), except for a higher prevalence of EF < 35% in the MIDCAB group and prior PCI in the DES group. Thirty-day mortality was 1.1% after MIDCAB and 0% after DES-PCI (p = 0.11). At 2 years, the proportion of recurrent angina was lower after MIDCAB (8.4% vs. 35%; p < 0.001), as was the proportion of re-interventions (3.6% vs. 16.8%; p = 0.005). Over a mean follow-up of 16 years, 10-year survival was 77.1 ± 4.6% for the MIDCAB and 81.0 ± 4.3% for the DES group (p = 0.48). The rates of 20-year survival were 60.2 ± 5.4% and 56.1 ± 5.5%, respectively (p = 0.73). In multivariable analysis, advanced age and prior myocardial infarction independently predicted mortality while treatment with MIDCAB showed a trend toward improved survival (p = 0.053). Conclusions: Long-term survival rates after LAD revascularization with MIDCAB and after DES-PCI were comparable. MIDCAB demonstrated a non-significant trend toward lower mortality. Limitations include the retrospective design and lack of detailed late event adjudication.

Objective: To evaluate the outcome of single vs. bilateral internal thoracic artery (SITA vs. BITA) revascularization in patients with multivessel coronary disease referred for coronary artery bypass graft (CABG) while on chronic dialysis. Methods: This retrospective analysis included all the patients with multivessel disease on chronic dialysis who underwent isolated CABG in our center during 1996–2021, utilizing SITA or BITA revascularization. We further matched the groups according to patient age and EuroSCORE II ±0.5. Results: Of the 7547 patients with multivessel disease who underwent CABG, 77 were on chronic dialysis. Of these, 2 had incomplete follow-up data, 58 underwent SITA, and 17 BITA revascularization. Comparing the SITA group with the BITA, the mean age was higher (67.8 vs. 58.6 years, standardized mean difference 1.035); the median (interquartile range) EuroSCORE II was higher (3.73 (1.78–6.23) vs. 1.78 (1.38–3.50), standardized mean difference 0.934); and comorbidities were more prevalent. Early mortality did not differ between the BITA and SITA groups in the unmatched cohort (11.8% vs. 15.5%, p > 0.999) or in the matched cohort (12.5% vs. 6.3%, p = 0.999). Other early adverse events such as early stroke, myocardial infarction, and bleeding requiring re-exploration were also similar. The median survival was 1.22 ± 0.5 years for the SITA and 5.64 ± 1.50 years for the BITA group. The respective five-year survival rates were 22.5 ± 5.9% and 58.35 ± 13.80%, p = 0.005. For the matched cohort, comprising 16 patient pairs, the five-year survival did not differ between the groups (27.8 ± 11.7% vs. 54.7 ± 14.7%, p = 0.258). In multivariable analysis, adjusted to EuroSCORE II and age, the hazard ratio (95% confidence interval) for BITA revascularization was insignificant, 0.638 (95% CI 0.25–1.62), p = 0.343. The hazard ratios for age and EuroSCORE II were 1.061 (95% CI 1.023–1.101), p = 0.002 and 1.155 (95% CI 1.070–1.246), p < 0.001. Conclusions: Despite a trend in favor of BITA utilization, no clear long-term survival benefit was demonstrated for BITA revascularization in patients on chronic dialysis after CABG.

Background: as transcatheter technologies have advanced, the patient population that is referred to open heart surgeries has shifted. This study’s objective was to evaluate recent trends in the characteristics of patients undergo surgical valvular interventions and coronary revascularizations (CABG) in our center over a period of 14 years. Methods: this is a retrospective analysis of ecological trends in the age, sex, and risk profile (Charlson comorbidity index—CCI) of patients who, from January 2010 to December 2023, underwent CABG, aortic valve replacement (AVR), or mitral valve repair or replacement (with or without tricuspid valve intervention). The data were extracted from electronic clinical files using MD-Clone software. Results: for the CABG procedures, the respective data for 2010 and 2023 were: mean ages 68.0 and 64.6 years; 79.7% and 83.1% males; and mean CCI scores 3.16 and 2.51. The p-values for the cumulative differences over the study period were 0.001, 0.005, and 0.013, respectively. The respective data for isolated AVR were mean ages of 69.2 and 62.9 years; 64.1% and 59.1% males; mean CCI 3.64 and 2.32; p-values: p-values: 0.84, 0.422, and 0.318. Conclusions: over a 14-year period, changes were evident in the age, sex distribution, and CCI for operations performed in our center. These changes most likely resulted from accumulated data regarding the advantages and detriments of treatment strategies, mostly of CABG vs. percutaneous coronary intervention; major advancements in transcatheter technologies, mostly in transcatheter AVR; and clinical guidelines facilitating a more collaborative decision-making, open-minded, and personalized approach.

Objective: The optimal surgical approach for critically ill patients with complex coronary disease remains uncertain. We compared outcomes of bilateral internal thoracic artery (BITA) versus single ITA (SITA) revascularization in critical patients. Methods: We evaluated 394 consecutive critical patients with multi-vessel disease who underwent CABG during 1996–2001. Outcomes measured were early mortality, strokes, myocardial-infarctions, sternal infections, revisions for bleeding, and late survival. The critical preoperative state was acknowledged concisely by one or more of the following: preoperative ventricular tachycardia/fibrillation, aborted sudden cardiac death, or the need for mechanical ventilation or for preoperative insertion of intra-aortic-balloon counter-pulsation. Results: During the study period, 193 of our patients who underwent SITA and 201 who underwent BITA were in critical condition. The SITA group was older (mean 68.0 vs. 63.3 years, p = 0.001) and higher proportions were females (28.5% vs. 18.9% p = 0.025), after recent-MI (69.9% vs. 57.2% p = 0.009) and with left-main disease (38.3% vs. 49.3% p = .029); the median logistic EuroSCORE was higher (0.2898 vs. 0.1597, p0.99, respectively). Long-term survival (median follow-up of 15 years, interquartile-range: 13.57–15) was better in the BITA group (median 14.39 vs. 9.31± 0.9 years, p = 0.001). Propensity-score matching (132 matched pairs) also yielded similar early outcomes and improved long-term survival (median follow-up of 15 years, interquartile-range: 13.56–15) for the BITA group (median 12.49±1.71 vs. 7.63±0.99 years, p = 0.002). In multivariable analysis, BITA revascularization was found to be a predictor for improved survival (hazard-ratio of 0.419, 95%CI 0.23–0.76, p = 0.004). Conclusions: This study demonstrated long-term survival benefit for BITA revascularization in patients in a critical pre-operative state who presented for surgical revascularization.