Hybrid minimally invasive multivessel coronary artery bypass grafting to achieve complete myocardial revascularisation: the first clinical case

<p><strong>Aim</strong>. To report the first clinical case of the hybrid procedure combining off-pump minimally invasive multivessel coronary artery bypass grafting (MICS-CABG) and percutaneous coronary intervention (PCI) of the obtuse marginal (OM) artery to achieve complete myocardial revascularisation.</p><p><strong>Clinical case</strong>. Bilateral in situ skeletonised left internal mammary artery (IMA) grafting to the left anterior descending artery was performed, and a Y-shape anastomosis was created from the left IMA-right IMA to the circumflex branch. At 2 hours postoperatively, graft failure caused by subtotal stenosis at the graft was diagnosed. Reconstruction of the anastomosis improved the transit time flow measurement by 3.5 hours postoperatively. Acute myocardial infarction did not develop. On postoperative day 1, graft patency was assessed, and then the OM stent was placed. On postoperative day 8, the patient was discharged and referred to the outpatient centre for further treatment and rehabilitation. Hybrid revascularisation offers the advantages of both CABG and PCI; however, the technical complexity is a major limitation for its widespread use. This case reports the development of adverse events during the surgeon's training to perform this nonstandard technology. Timely diagnosis of the initial graft failure and surgical revision led to a successful and complication-free outcome and avoided prolonged patient rehabilitation.</p><p><strong>Conclusion</strong>. Hybrid revascularisation combining MICS-CABG and PCI with new-generation drug-eluting stents can be a worthwhile alternative to conventional multivessel CABG with minimal invasiveness and complete revascularisation.</p><p>Received 5 June 2020. Revised 10 September 2020. Accepted 15 September 2020.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p>

Intra-aortic balloon counterpulsation: current evidence-based and unresolved issues

<p>This literature review provides the current evidence-based research regarding the role of intra-aortic balloon counterpulsation in the treatment of patients in various clinical situations. These include patients with acute coronary syndrome, complicated or uncomplicated by cardiogenic shock, accompanied by high-risk percutaneous coronary interventions, accompanying patients in need of coronary artery bypass surgery in various conditions as a ‘bridge’ to decision-making or treatment. Because the introduction of intra-aortic balloon counterpulsation into clinical practice, it has been the most common method of hemodynamic support in high-risk patients. The classical strategy for the treatment of acute myocardial infarction has evolved over the last decade from a thrombolysis scenario to a primary coronary revascularisation scenario, which resulted in a larger patient cohort. The currently available data, however, do not support the routine use of intra-aortic balloon counterpulsation by most of this population. Current studies have shown that the use of intra-aortic balloon counterpulsation did not lead to a decrease in 30-day mortality in patients with acute coronary syndrome and cardiogenic shock who received therapy with the strategy of early myocardial revascularisation as the planned primary goal. The expediency of using high-risk percutaneous coronary intervention as an accompanying method is ambiguous, whereas the use of the method as a ‘bridge’ to surgical myocardial revascularisation may be justified and requires additional research. The article provides the current recommendations for the treatment of patients. Research results and unresolved issues are being discussed.</p><p>Received 3 June 2020. Revised 4 August 2020. Accepted 24 August 2020.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p>

Perioperative predictors of early silent coronary graft occlusion after direct myocardial revascularisation

<p><strong>Background.</strong> The condition of the coronary grafts is the most important determinant of prognosis after direct myocardial revascularisation. Previous studies mainly aimed at exploring the long-term patency and causes of coronary graft occlusions; identification of patients at risk for asymptomatic graft occlusion in the early postoperative period remains an unresolved issue.<br /><strong>Aim.</strong> The purpose of this study was to define perioperative predictors of early asymptomatic coronary graft occlusion after direct myocardial revascularisation.<br /><strong>Methods.</strong> This retrospective study included 201 patients with coronary artery disease who underwent microscope-assisted coronary artery (CA) bypass surgery in 2013–2018. All patients underwent 64-slice computed tomography angiography 7 days after surgery. The patients were categorised into two groups: those with confirmed patency of all coronary grafts (n = 153; group I) and those with occlusion of at least one graft (n = 48; group II). The perioperative predictors of early asymptomatic coronary graft occlusion were analysed using logistic regression.<br /><strong>Results.</strong> The total graft patency was 91.7% among a total of 650 coronary grafts that were examined. The frequencies of mammary and venous graft occlusions were comparable (8.4% and 8.2%, respectively). No differences were noted in the conduit types or the revascularised areas of the myocardium between the two groups. Multivariate regression analysis revealed that diffuse CA lesions (odds ratio [OR], 2.74; 95% confidence interval [CI], 1.36–5.52; p = 0.005), lesion diameter of CA of &lt;1.5 mm (OR, 2.86; 95% CI, 1.34–6.71; p = 0.007) and hyperglycaemia (glucose &gt;7.8 mmol/l) during the first postoperative day (OR, 4.22; 95% CI, 1.70–10.5; p = 0.002) were independent predictors of early coronary graft occlusion. History of percutaneous coronary intervention (OR, 0.32; 95% CI, 0.11–0.97; p = 0.045) and increased baseline glomerular filtration rate (OR, 0.96; 95% CI, 0.93–0.98; p = 0.002) were associated with a reduced risk of early graft occlusion.<br /><strong>Conclusion.</strong> The frequency of early asymptomatic occlusion after microscope-assisted coronary artery bypass surgery was comparable between the venous and mammary grafts and did not depend on the anatomical zone of myocardial revascularisation. Diffuse CA lesions, target CA diameter of &lt;1.5 mm and hyperglycaemia (&gt;7.8 mmol/L) during the first postoperative day were associated with an increased risk of early silent graft occlusion, whereas increased baseline glomerular filtration rate and history of percutaneous coronary intervention were protective for the early patency of coronary bypass grafts.</p><p>Received 24 June 2019. Revised 23 August 2019. Accepted 29 August 2019.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p>

RESULTS OF STAGED ENDOVASCULAR MYOCARDIAL REVASCULARISATION IN PATIENTS TREATED FOR ACUTE CORONARY SYNDROME WITH ST-SEGMENT ELEVATION AND MULTIVESSEL DISEASE

Aim. To evaluate the results of complete functional endovascular myocardial revascularisation which is performed early after stenting the culprit artery (within 90 days) with third-generation sirolimus-eluting stents in patients treated for acute coronary syndrome (ACS) with ST-segment elevation and multivessel disease. Materials and methods. We analysed the results of a 2-year follow-up treatment period of patients suffering from ACS with ST-segment elevation and multivessel disease who had undergone urgent stenting of culprit artery. Within 90 days after stenting, a complete functional endovascular myocardial revascularisation was performed using third-generation sirolimus-eluting stents. The efficacy and safety of the procedure was evaluated according to the non-inferiority criteria in comparison with the literature data on myocardial revascularisation by coronary artery bypass surgery. Results. In the course of follow-up treatment, 1 lethal myocardial infarction (after 18 months from complete revascularisation) and 2 non-lethal myocardial infarctions were registered. The symptoms of angina returned in 7 patients, 6 of whom had undergone unplanned re-revascularisation within 6 to 12 months following complete revascularisation. The MACCE rate was 0.143 [95% confidence interval: 0.0770; 0.2497]. Conclusion. In patients having ACS with ST-segment elevation and multivessel disease, endovascular myocardial revascularisation performed early after stenting the culprit artery is equivalent to coronary artery bypass surgery in terms of cardiovascular mortality rates, as well as incidence of non-fatal cardiovascular events. However, such an approach underperforms compared to coronary artery bypass surgery in terms of a composite endpoint of MACCE and the number of required re-interventions.