Bilateral Internal Mammary Artery Grafting Enhances Survival in Diabetic Patients: A 30-Year Follow-Up of Propensity Score–Matched Cohorts Circulation Editors’ Picks Most Read Articles in Cardiovascular Surgery

Summary: The prevalence of diabetes mellitus is increasing at an unprecedented rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over inter-ventional revascularization in this group of patients, perhaps because of the diffuse nature of coronary atherosclerosis in this population. Similarly, multiple studies have shown the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery (SIMA) grafting in select populations. However, concerns about sternal wound infection have discouraged the use of BIMA grafting in diabetics. Therefore, we studied the long-term results of BIMA versus single internal mammary artery grafting in a large population of diabetic patients in whom BIMA grafting was broadly applied. Because of the uncontrolled surgical selection process for single internal mammary artery versus BIMA grafting, we applied propensity score matching to create matched sets of single internal mammary artery and BIMA patients among 1107 consecutive coronary artery bypass graft patients. Although there was no difference in operative mortality, morbidity, or sternal wound infection between groups, there was a clear long-term survival benefit, even among matched patients, for BIMA over single internal mammary artery grafting. Given the increasingly prevalence of diabetes mellitus, the high incidence of extensive coronary artery disease in diabetics, and the proven benefit of coronary artery bypass graft surgery as a strategy for revascularization, these findings address an issue of high clinical impact. Because the findings are compelling and radically alter current clinical practice, this research is novel and warrants serious attention from both future researchers and clinical decision makers. Conclusions: Compared with SIMA grafting, BIMA grafting in pro- pensity score–matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality. 1 Effective revascularization has not been reported previously in a study of post-CABG graft patency. This study is the first randomized study of off-pump versus on-pump CABG to indicate that both graft patency and effective revascularization are clearly worse with off-pump CABG. FitzGibbon graft patency was worse for arterial, left internal mammary artery pedicle, and vein graft conduits. In addition, every coronary territory was revascularized less effectively with off-pump CABG. At the 1-year follow-up angiography, ≈ 50% of off-pump CABG patients had at least 1 coronary territory that was at risk for ischemia. Those patients with less effective revascularization had significantly more adverse cardiac events by 1 year after CABG. Conclusions: Off-pump CABG resulted in significantly lower FitzGibbon A patency for arterial and saphenous vein graft conduits and less effective revascularization than on-pump CABG. At 1 year, patients with less effective revascularization had higher adverse event rates. 4 online registry. This analysis of early results confirm that, in the United Kingdom, national results of f-EVAR are comparable to those from single-center series. This finding justifies the continued use and evaluation of the f-EVAR by means of a prospective multicenter study. Conclusions: In this national sample, fenestrated endovascular repair has been performed with a high degree of technical and clinical success. Late survival and target vessel patency are satisfactory. These results support continued use and evaluation of this technique for juxtarenal aneurysms, but illustrate the need for a more robust evidence base. long-term after estimate after for a whom Conclusions: risk predicted the risk of after coronary artery bypass graft surgery and can be used for informed consent and as an aid in determining treatment choice. stratification surgical Conclusions: Preoperative BNP associated with postoperative high-risk patients undergoing cardiac surgery. If confirmed in other types of patients and surgeries, preoperative BNP may be a valuable component of future efforts to improve preoperative risk stratification and discrimination among surgical candidates. Marfan syndrome and aortic diameter between 45 and 49 mm. Aortic diameter of 50 mm appears to be a reasonable threshold for prophylactic surgery. Summary: Readmissions are common after coronary artery bypass grafting surgery and account for a large proportion of hospital health-care costs in this patient population. Readmission rates vary widely among hospitals, but the reasons for this variability are unknown. The top 2 reasons for readmission after coronary artery bypass grafting in this cohort in California were heart failure and infection. Patient demographic and clinical risk factors, rather than the hospital charac- teristics that were measured for this study accounted for most of the observed hospital-level variation in coronary artery bypass grafting readmissions. Conclusions: California hospitals performing CABG surgery vary widely in 30-day readmission rates. Patient demographic and clinical risk factors, rather than measured hospital characteristics, accounted for most of the observed hospital-level variation in CABG readmissions. 12 Summary: Coronary artery bypass graft and percutaneous coronary intervention (PCI) are alternative revascularization procedures for patients with multivessel or left main coronary artery disease. The relative benefits of coronary artery bypass graft and percutaneous coronary intervention on patient outcomes (mortality, myocardial infarction, stroke, and repeat procedures) vary according to the presence or absence of diabetes mellitus, but previous studies provide conflicting data on long-term outcome. In this study, risk-adjusted long-term rates of mortality and serious composite outcomes are not different after percutaneous coronary intervention and coronary artery bypass graft both in diabetic and in nondiabetic patients with multivessel or left main coronary artery disease. However, the rate of repeat revascularization was higher in the percutaneous coronary intervention group. Due to the nonrandomized nature of data, these results are hypothesis generating and should be confirmed through large, randomized clinical trials. Conclusions: For multivessel or left main disease, the long-term risks of mortality and composite serious outcomes were not different between PCI and coronary artery bypass grafting in diabetic and non- diabetic patients, but PCI was associated with higher risk of repeat revascularization. These relative treatment effects were not modified by diabetic status. These results are hypothesis generating and should be addressed in a randomized trial. 13 revas- revascularization, CABG had better angina relief at than treated with PCI, with an adjusted between-group difference similar to the treatment effect in the overall population. These findings suggest that some of the antianginal benefits of CABG may result from mechanisms unrelated to relief of myo- cardial ischemia (eg, denervation, placebo effects). The strength of association between repeat revascularization and angina was greater among patients treated with CABG as compared with those treated with PCI, indicating that the end point of repeat revascularization has a different clinical impact based on the original treatment and thus should play a limited role as an indirect measure of health outcomes between these 2 revascularization strategies. Conclusions: Among patients with multivessel coronary artery dis- ease treated with PCI or CABG, the occurrence of repeat revascularization follow-up not the antianginal benefit of in the overall The differential association between repeat revascularization and anginal status, according to the type of initial revascularization procedure, end point should play a limited role in any direct comparison of the treatment Summary: In patients with left ventricular dysfunction undergoing cardiac surgery, the presence of pulmonary hypertension (PH) may adversely affect the outcome. Although left heart disease is the most common cause of PH, very few data on the pathophysiology and treatment of out-of-proportion PH due to left heart disease are avail- able. Several previous studies have focused on either inhaled nitric oxide (iNO) or oral sildenafil administration in patients with PH. The combined use of these agents in patients with out-of-proportion PH due to left heart disease is not well documented. To our knowledge, this study is the first that evaluates the effects of oral sildenafil and iNO on hemodynamic and gas exchange when administered immedi- ately postoperatively either alone or in combination in postoperative patients with out-of-proportion PH due to left valvular heart disease who underwent valve replacement surgery. The combination of sildenafil and iNO has an additive effect in decreasing pulmonary vascu- lar pressure and resistance more than either alone. Further evidence of the salutary effect of this combination is that, in contrast to iNO alone, sildenafil unloaded the left ventricle, reducing both preload and afterload, whereas the iNO added to the sildenafil improved ventilation/perfusion mismatch (eliminated the decreased PaO 2 /FiO 2 ratio) induced by sildenafil alone. The findings of our study may suggest improved outcome of these patients and thus a new therapeutic approach, an insight that has to be confirmed by larger studies. Conclusions: In this study, the postoperative coadministration of iNO and oral sildenafil in patients with out-of-proportion pulmonary hypertension undergoing cardiac surgery is safe and results in an additive favorable effect on pulmonary arterial pressure and pulmonary vascular resistance, without systemic hypotension and ventila- tion/perfusion mismatch. 15 thromboembolism after cardiac surgery, including chemical and mechanical prophylaxis, but controversy exists regarding th