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Journal and News Scan
Long-term survival following coronary artery bypass grafting: off-pump versus on-pump strategies
JACC - Journal of the American College of Cardiology, 04/18/2014 Evidence Based Medicine Clinical Article
Although several large–scale clinical trials have compared the surgical outcomes between off–pump and on–pump CABG, the long–term survival has not been compared between the two surgical strategies in a reasonably sized cohort. To compare long–term survival after off–pump and on–pump coronary artery bypass grafting (CABG). In patients undergoing elective isolated CABG, on–pump strategy conferred a long–term survival advantage compared with off–pump strategy.
- Authors evaluated long–term survival data in 5203 patients (aged 62.9±9.1 years, 1340 females) who underwent elective isolated CABG (off–pump, n=2333; on–pump, n=2870) from 1989 through 2012.
- Vital statuses were validated from Korean National Registry of Vital Statistics.
- Long–term survival was compared with the use of propensity scores and inverse–probability–weighting to adjust selection bias.
- Patients undergoing on–pump CABG had higher number of distal anastomoses than those undergoing off–pump CABG (3.7±1.2 vs. 3.0±1.1, P<0.001).
- Survival data were complete in 5167 patients (99.3%) with a median follow–up duration of 6.4 years (inter–quartile range, 3.7–10.5 years; maximum 23.1 years).
- During follow–up, 1181 patients (22.7%) died.
- After adjustment, both groups of patients showed a similar risk of death at 30–day (odds ratio, 0.70; 95% CI, 0.35–1.40; P=0.31) and up to one year (HR, 1.11; 95% CI, 0.74–1.65; P=0.62).
- For overall mortality, however, patients undergoing off–pump CABG were at a significantly higher risk of death (HR, 1.43; 95% CI 1.19–1.71; P<0.0001) compared with those undergoing on–pump CABG.
- In subgroup analyses, on–pump CABG conferred survival benefits in most demographic, clinical and anatomic subgroups compared with off–pump CABG
The authors, well-known experts in critical care medicine, provide a detailed and usedful overview of critical illness polyneuropathy. This affects 25% to 100% of ICU patients and is associated with impaired recovery after cricial illness.
A brief case presentation is followed by an operative video detailing the technique for performing an aortic valve replacement in the setting of endocarditis. In this particular video, a pericardial patch is used to reconstruct the area of the commissure between the right and left coronary sinuses. A prosthetic tissue valve is then implanted. (Please see the companion video as well showing the operative technique for aortic root replacement in the setting of endocarditis: http://www.youtube.com/watch?v=5vPzaX... )
This article on Type A Aortic Dissection was selected as a top article from 2013 by the 2014 Circulation editors.
The original article is here:
The outcome of aortic valve replacement for patients with low gradient severe aortic stenosis and preserved ejection fraction is debated. The aim of the current study was to evaluate the effect of aortic valve intervention on survival in that group. The findings suggest that aortic valve intervention is associated with improved survival among patients with low gradient severe aortic stenosis and preserved left ventricle function. The presence of either a low or normal stroke volume index did not affect the mortality benefit.
Ischaemic heart disease is a major risk factor for heart failure. However, long–term benefit of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in those patients has not been well elucidated. In patients with heart failure with advanced coronary artery disease, CABG was a better option than PCI because CABG was associated with better survival benefit, particularly in more complex coronary lesions stratified by the SYNTAX score.
In this promising investigation, authors have found changes associated with airway cancerization in large airways in lung cancer patients, while these changes are absent in cancer-free smokers. And in addition, with shorter distance from tumors, airway cancerization expression increases statistically.
This study evaluated the use of ultrasound to assess diaphragm thickening, rather than diaphragm motion, to predict extubation success. Measurements were made in 63 ventilated patients, end-expiration and end-inspiration differences in thickness during spontaneous breathing were calculated, and the outcome was extubation within 48 hr. The ROC AUC was 0.79 for assessing weaning success (79% accuracy).
There are few instruments to assess patient-centered outcomes after lung transplant. The authors developed and validated a shortened version of the valued life activities disability scale for this population. The scale was devised using 140 lung transplant participants and was validated in 84 patients before and after transplant. The instrument takes only 3 min to complete, has good correlation with longer scales, has good internal consistency, correlates with physiologic parameters, and demonstrates expected improvement comparing before and after transplant states.
This manuscript reports on the 5-year outcomes in the 705 patients with left main (LM) lesions enrolled in the randomized arm of the SYNTAX trial. Follow-up data to 5 years were available in 96.9% of patients who underwent PCI and 92.5% of patients randomized to CABG. Total MACCE at 5 years was 36.9% in patients who received PCI compared with 31.0% in CABG patients (hazard ratio 1.23 [0.95, 1.59]; P=0.12) which was mainly related to differences in repeat revascularization. In the group of patients with high SYNTAX Scores (≥33), MACCE, as well as cardiac death, and revascularization were all significantly increased in patients receiving PCI; whereas stroke and MI occurred at similar rates between treatment arms. The findings suggest that PCI can provide equivalent long-term (to 5 years) death/stroke or MI to CABG, in particular in the subset of LM subjects with SYNTAX Scores <33.