Complex Issues in Coronary Surgery*

Activity: 103rd Annual Meeting
*Aya Saito Moderator
Yokohama City University
kanagawa
Japan
 - Contact Me

Dr Saito studied medicine at Yokohama City University School of Medicine.  During her fourth year at medical school lecture on artificial organ and cardiac transplantation inspired her and she discovered her passion for heart surgery.  After completing her general, thoracic, and cardiac surgery training in Yokohama, she moved to Tokyo and practiced adult cardiac, pediatric cardiac and vascular surgery at the University of Tokyo, Faculty of Medicine. In 2002, she entered to postdoctoral course to earn PhD, and made several basic and clinical investigations on cryopreserved heart-valve and vascular allograft and completed her work. She became a staff surgeon at the University of Tokyo and worked in adult cardiac surgery area in 2006. In the same year she founded Women in Thoracic Surgery (WTS) in Japan with a great support by Women in Thoracic Surgery (USA).  In 2007, she joined the clinical fellowship at Division of Cardiac Surgery and Multi Organ Transplant Unit, London Health Sciences Centre, University of Western Ontario, Canada and spent her passion on clinical & basic practice on cardiac transplantation as well as adult cardiac surgery including minimally invasive and robotic surgery. She came back to the University of Tokyo in 2009 and started as assistant professor at Department of Cardiothoracic Surgery and became lecturer in 2011.  In 2014 she moved to Toho University Sakura Medical Center as associate professor at Division of Cardiac Surgery and also director of Division of Medical Engineering. She has been organizing annual meetings for Women in Thoracic Surgery in Japan since 2006, serving herself to promote mentor-mentee relationship among both female and male surgeons across the country.  She serves on several national/international profession organization committees and boards.  Today she serves herself energetically for a full spectrum of adult cardiac surgical care, and also enjoys the privilege of teaching the next generation of cardiac surgeons.

*Todd Rosengart Moderator
Baylor College of Medicine
Houston, TX 
United States
 - Contact Me

Dr. Todd K. Rosengart is professor and chair of the Michael E. DeBakey Department of Surgery at Baylor College of Medicine. He is the DeBakey-Bard Chair of Surgery and is professor of heart and vascular disease at the Texas Heart Institute. He is past president of the Society of Surgical Chairs and a member of the board of directors of the American Association for Thoracic Surgery.

Dr. Rosengart continues to run an NIH-funded laboratory with over 20 years of NIH support in the fields of angiogenesis and cellular reprogramming. In 1997, he and his team at Cornell performed the world’s first viral-based cardiac gene transfer procedure, part of a landmark NIH and FDA-approved first-in-man angiogenesis trial for “no option” patients with end stage coronary artery disease. He is PI of a cardiovascular surgery NIH T32 training grant, recipient of $20 million in total research grants, holds thirteen U.S. patents and is author of over 200 peer-reviewed articles and other publications with an h-index of 60.  He has mentored nearly 100 research and cardiac surgery trainees over the past 30 years.

Dr. Rosengart is past chair of the NIH Bioengineering, Technology and Surgical Sciences Study Section, chair of a new American College of Surgeons National Surgeon Scientist Study Section and a member of the Scientific Advisory Committee for the Leducq Foundation. He was editor of Seminars in Thoracic and Cardiovascular Surgery from 2013 to 2020. Amongst other affiliations, he is a member of the American Surgical Association, the Southern Surgical Society, the Society of Thoracic Surgeons, the Southern Thoracic Surgical Society and the Texas Surgical Society.

Dr. Rosengart is co-founder of Vitals.com (MDx, LLC), a web-based medical consumerism and physician search company and co-founder of XyloCor Therapeutics, a gene therapy company leading an FDA Fast Track designated Phase I/II national trial of angiogenic gene therapy for treating patients with end stage coronary artery disease.

Saturday, May 6, 2023: 9:45 AM - 11:30 AM
Los Angeles Convention Center 
Posted Room Name: 515A 

Track

Adult Cardiac
103rd Annual Meeting

Presentations

Why is Multi Arterial Grafting So Hard to Adopt

Total Time: 15 Minutes 

Speaker

*Jennifer Lawton, Johns Hopkins Univerity  - Contact Me Baltimore, MD 
United States

37. Females and Patients with Low Socioeconomic Status Are Less Likely to Undergo Multi-Arterial Grafting

Total Time: 15 Minutes 
Objective: Females and patients with low socioeconomic status have poorer healthcare access with greater outcome inequities. We examined association of female sex and low socioeconomic status with rate of multiarterial grafting (MAG) during coronary artery bypass grafting (CABG) to advance quality for these priority populations.

Methods: Patients undergoing isolated CABG with two or more bypass grafts from 2011 to 2022 were evaluated in a statewide collaborative database. Patients with a history of mediastinal radiation, prior cardiac surgery, emergent/salvage status, and subclavian stenosis were excluded. Patients were stratified by the distressed community index (DCI) score, a socioeconomic ranking by zip code (scale of 0-100, 100 being the most distressed). Hierarchical regression modeling was performed to associate DCI and sex with MAG, incorporating patient factors (e.g., age, BMI, diabetes, creatinine) and surgery year, with hospital and surgeon as random effects.

Results: A total of 39,004 patients underwent CABG at 33 centers. The mean age was 66±10 years and 24% (n=9,388) were female. Compared to males, females lived in zip codes associated with higher median DCI (51 [IQR 24, 72] vs 42 [IQR 17, 66]), p<0.001). The overall rate of MAG was 15% and was lower among females (10% versus 17%, p<0.001). Overall adjusted odds of receiving MAG increased throughout the study period (2012 vs 2018, OR 0.20 [95% CI 0.17-0.22], p<0.001). After multivariable adjustment, females were less likely to receive MAG compared to males (OR 0.51 [95% CI 0.45-0.58], p<0.001) (Figure). Similarly, patients living in zip codes with a higher DCI score had lower adjusted odds of receiving MAG (OR 0.90 per 10-point increase [95% CI 0.87-0.94], p<0.001). There was no association between Black race (vs White race) and MAG (OR 0.88 [95% CI 0.76-1.02] p=0.24). The impact of DCI and sex on MAG did not change by surgery-year (p>0.05) suggesting these effects did not change over time.

Conclusions: After risk adjustment, females are half as likely to undergo MAG during CABG than males. Similarly, patients from low socioeconomic status are less likely to receive MAG, even after accounting for risk and hospital. These disparity gaps persisted even though the overall rate of MAG increased over time. Increased attention to identify and address barriers to MAG in these populations is required to provide more equitable surgical revascularization practices. 

View Submission


Invited Discussant

*Marc Ruel, University of Ottawa Heart Institute  - Contact Me Ottawa, ON 
Canada

Abstract Presenter

Catherine Wagner, Michigan Medicine  - Contact Me Ann Arbor, MI 
United States

38. Ticagrelor Removal With Intraoperative Polymer Bead Hemoadsorption in Patients Undergoing Urgent Coronary Artery Bypass Grafting

Total Time: 15 Minutes 
Background: Patients on ticagrelor undergoing urgent cardiac surgery are at high risk for perioperative bleeding complications. We measured ticagrelor levels before and after cardiopulmonary bypass (CPB) to determine whether intraoperative hemoadsorption can actively remove ticagrelor in patients undergoing urgent cardiac surgery.
Methods: The hemoadsorption cartridge was incorporated in the CPB circuit and remained active for the duration of the pump run. Blood samples were collected before and after CPB. The main objective of the current analysis was to compare mean total plasma ticagrelor levels (ng/mL) at baseline with ticagrelor levels obtained at the end of CPB. Plasma ticagrelor levels were measured at a certified outside laboratory (Altascience, Laval, QC, Canada). Data are presented as mean ± SD.
Results: A total of 11 patients undergoing urgent CABG at 3 institutions were included (mean age 67.9±9.8 years, 91% male, mean EuroSCORE-II of 3.0±3.3% (range: 0.7-12.4%). Mean intraoperative hemoadsorption duration was 97.1±43.4min with a mean flow rate through the device of 422.9±40.3mL/min. Mean ticagrelor levels pre-CPB were 103.5±63.8ng/mL compared with mean post-CPB levels of 34.0±17.5ng/ml, representing a highly significant 67.1% reduction (P<0.001, Figure). Sites reported that the intraoperative integration of the device was simple and safe without any device-related adverse events reported.
Conclusions: This is the first in vivo report demonstrating that intraoperative hemoadsorption can efficiently remove ticagrelor and significantly reduce circulating drug levels. Whether active ticagrelor removal can reduce serious perioperative bleeding in patients undergoing urgent cardiac surgery is currently evaluated in the double blind, randomized Safe and Timely Antithrombotic Removal – Ticagrelor (STAR-T) trial. 

View Submission


Invited Discussant

*Mario Gaudino, Weill Cornell Medicine/NYP Hospital  - Contact Me New York, NY 
United States

Abstract Presenter

Michael Schmoeckel, Asklepios Klinik St. Georg  - Contact Me Hamburg, Germany 
United States

39. The Fate of Concomitant Tricuspid Regurgitation in Patients Undergoing Coronary Artery Bypass Grafting

Total Time: 15 Minutes 
Objective: Due to lack of supportive data, tricuspid regurgitation (TR) is usually not addressed for patient undergoing coronary artery bypass grafting (CABG). Here we evaluate changes in degree of TR over time and its impact on survival in patient undergoing CABG.
Methods: We reviewed data of 10183 patients who underwent isolated CABG between January 2000 and January 2021. Patients were stratified by severity of preoperative TR and divided into two groups: non-significant TR (none-trivial, mild) and significant TR (moderate, severe). We excluded patients who had undergone previous tricuspid valve surgery and underwent concomitant valve or ablative surgery. Propensity score matching and Cox proportional hazards models were used to determine association between grade of TR and the primary endpoint of all-cause mortality. The secondary endpoint was the change of TR severity on postoperative echocardiography.
Results: After propensity score matching, 826 patients were identified (413 in each group). At baseline, 290 (70.2%) and 123 (29.8%) patients had none-trivial and mild TR in non-significant TR group, respectively. Similarly, 388 (93.9%) and 25 (6.1%) patients had moderate and severe TR in significant TR group, respectively. On postoperative echo TR improved in 6.3% of patient in the non-significant group and 25.7% in the significant group (Figure 1). The Kaplan-Meier survival curve demonstrated a significant survival difference between patient with preoperative non-significant and significant TR (p < 0.001). But after adjusting for significant confounders (age, sex, preoperative diabetes mellitus, preoperative atrial fibrillation, left ventricular function and pulmonary artery systolic pressure), the significant TR group did not show any worse survival as compared to the non-significant group (HR 1.13; 95% CI, 0.88-1.5; p = 0.38). While age (HR 1.05; 95% CI, 1.03-1.1; p < 0.001), preoperative diabetes mellitus (HR 1.74; 95% CI, 1.38-2.2; p < 0.001), and pulmonary artery systolic pressure (HR 1.01; 95% CI, 1.00-1.02; p = 0.009) were significantly associated with increased risk of mortality.
Conclusions: Significant (moderate or severe) preoperative TR improves in 25.7% patient after isolated CABG, while non-significant (trace or mild) TR can worsen in 39.7%. But more importantly after adjusting for other factors significant TR does not seem to affect long-term survival after isolated CABG. 

View Submission


Invited Discussant

♦Patrick Myers, CHUV  - Contact Me Lausanne, - 
Switzerland

Abstract Presenter

Daisuke Kaneyuki, NewYork- Presbyterian/Columbia University Medical Center  - Contact Me New York, NY 
United States

40. Urgent/Emergent CABG Outcomes are Adversely Impacted by COVID Infection, But Not Altered Processes of Care: An N3C and NSQIP Analysis

Total Time: 15 Minutes 
Objective: The differential effects of COVID-19 active viral infection, viral convalescence, and altered care processes on emergency CABG (eCABG) outcomes have not been studied. We sought to evaluate whether the altered processes of care due to the pandemic's burden on healthcare institutions negatively impacted eCABG outcomes.
Methods: The National COVID Cohort Collaborative (N3C) contains clinical observation, lab, medication, and procedural data from 6.5 million COVID+ (15.9 million total) patients from 76 US centers. We queried N3C (Feb. 2020 to Aug. 2022; Concept ID 4336464) to include adult patients undergoing eCABG. Patients were divided into 3 groups according to COVID test results: negative result (C-Neg), positive result <2 weeks before CABG (C-Active), or positive result >2 weeks before CABG (C-Conv). The National Surgical Quality Improvement Program (NSQIP) database was utilized for pre-COVID controls from 2016-2018. Propensity matching was performed using inverse probability of treatment weighting based on: age, gender, comorbidity score, race, social determinants of health and COVID status. Statistical analysis was performed using standardized mean difference, t-test and Chi-square test.
Results: In N3C, 16,757 patients underwent eCABG (16,262 C-Neg, 125 C-Active, 370 C-Conv); there were 546 eCABG in NSQIP pre-COVID group (Table 1). The incidence of hospital mortality, 30-day mortality, infectious complications, and renal impairment were significantly higher in C-Active compared to C-Neg and C-Conv. Compared to pre-COVID, C-Active had increased hospital and 30-day mortality. CVA and bleeding complications did not differ. After propensity matching, length of stay (LOS) (OR 1.5), in-hospital death (OR 2.3), death within 30 and 90 days of discharge (OR 3.8, 3.8), renal impairment (OR 1.1), infectious complications (OR 3.4) and pneumonia (OR 3.8) were significantly greater in C-Active compared to C-Neg. Compared to C-Conv, C-Active had increased LOS (OR 2.7) and incidence of death (OR 6.1).
Conclusions: Traditional processes of care were altered during the COVID-19 pandemic. We conclude that eCABG in C-Active patients is associated with significantly increased mortality, LOS, and renal and infectious morbidity. Equivalent mortality in C-Neg and pre-COVID patients indicates that COVID associated changes in processes of care did not impact eCABG outcomes. Additional research into optimal timing of eCABG after COVID positivity is warranted. 

View Submission


Invited Discussant

*Rakesh Arora, Cleveland University Hospitals  - Contact Me Cleveland, OH 
United States

Abstract Presenter

Emily Grimsley, University of South Florida  - Contact Me Tampa, FL 
United States

41. Use of Perioperative Mechanical Circulatory Support in Patients with Ischemic Cardiomyopathy Undergoing Surgical Revascularization

Total Time: 15 Minutes 
Objective: We aimed to explore optimal patient selection and perioperative mechanical circulatory support (MCS) in patients with reduced ejection fraction (EF) who undergo surgical revascularization.
Methods: Patients with reduced EF (<35%) undergoing isolated coronary artery bypass grafting (CABG) from 2015-2021 were identified. Requirement of preoperative MCS (pre-MCS) and postoperative MCS (post-MCS) were noted, defined as use of intra-aortic balloon pump (IABP), ECMO, or Impella. Primary outcomes of interest were in-hospital mortality and long-term survival. Logistic regression was used to identify risk factors for MCS requirement.
Results: A total of 378 patients were included. Median STS predicted risk of mortality was 2.4% (IQR 1.3-4.4%). Sixty-five percent (n=246) of patients had previous myocardial infarction, of which 75% were within 21 days of CABG. Twenty-one patients (5.5%) presented in cardiogenic shock, of which 15 were in shock at the time of CABG. Thirty-nine patients (10.3%) required pre-MCS; compared to patients that did not require pre-MCS, those that did had lower pulmonary artery saturation (57.8% vs 63%, p=0.01) and cardiac index (2.0 vs 2.5, p=0.01) on preop catheterization and lower LV end diastolic diameter (50mm vs 55mm, p=0.01) on echo. Of patients that required pre-MCS, 8 (20.5%) required post-MCS (2 IABP, 4 ECMO, 1 Impella, 1 Centrimag). Of patients that did not require pre-MCS, 22 (6.4%) required post-MCS (14 IABP, 5 ECMO, 3 Impella). Independent risk factors for requiring post-MCS were low preop EF (OR 0.91, 95%CI 0.85-0.99, p=0.02), presence of mild MR compared to no MR preop (OR 3.37, 95%CI 1.17-9.73, p=0.03), and cross-clamp time (OR 1.02, 95%CI 1.01-1.04, p=0.02). Overall, in-hospital mortality was 2.9% and 3-year survival was 95.2%. Compared to those who did not require perioperative MCS, those that required pre-MCS had similar in-hospital mortality (3.2% vs 1.6%, p=.50) and 3-year survival (96.8% vs 96.8%, p=.98). However, patients who required post-MCS had significantly worse in-hospital mortality and 3-year survival (16.7% and 76.7% respectively, p <0.001).
Conclusion: In a large series of patients with reduced EF who underwent surgical revascularization, we report favorable outcomes with selective use of MCS. Despite worse severity of illness, patients requiring pre-MCS have similar outcomes to those that do not require perioperative MCS, while patients requiring post-MCS have worse short- and long-term survival. 

View Submission


Invited Discussant

*Leora Yarboro, University of Virginia  - Contact Me Charlottesville, VA 
United States

Abstract Presenter

Alice Vinogradsky, Columbia University  - Contact Me New York City, NY 
United States

Specialty Coronary Training: Reality or Overkill?

Total Time: 15 Minutes 

Speaker

*Stephen Fremes, MD, MSc, Sunnybrook Health Sciences Centre  - Contact Me Toronto, ON 
Canada