: The arguments are discussed as to whether or not to proceed with multivessel percutaneous coronary intervention, with or without a drug-eluting stent, in patients with diabetes mellitus (DM), including (1) surgeons unable to complete revascularization because of smaller native arteries; and (2) diabetic patients being sicker and having higher operative mortality rates than nondiabetic patients (non-DM), particularly with the conventional coronary artery bypass surgery (on-pump) technique. To support or dispute the claims, a retrospective review of 480 consecutive patients at a single institution (195 DM and 285 non-DM) was carried out. Observations were made to see whether diabetes is a predictor of poor outcomes.: The preoperative comorbidity, intraoperative measurement of the size of the artery at the site of anastomosis with different gauged probes, and the number of grafts per patient were recorded. Intraoperative and postoperative variables between two groups were compared. The observed number of grafts (O) after surgery was compared with the number of grafts predicted (P) before surgery. The O/P ratio or "completion index" of ≥1 signifies complete revascularization. Logistic regression analysis was used to test the possibility that diabetes is a predictor of poor outcomes.: Diabetic patients were older, with more comorbidity (congestive heart failure, peripheral vascular diseases, dialysis-dependent). The number of grafts per patient was 4.2 ± 1.3 (DM) and 4.2 ± 1.3 (non-DM). The size of 742 DM and 949 non-DM arteries were gauged. There was no statistical difference in size between DM and non-DM (in millimeters) at each artery. All ratios ranged from 0.9 to 1.2, indicating similarity between DM and non-DM. The only significant risk factor for operative death was low left ventricular ejection fraction (P = 0.001).: Patients with DM were sicker but tolerated off-pump coronary artery bypass grafting as well as non-DM patients. The number of grafts per patient and O/P ratio signify the ability to perform complete revascularization. We are able to bypass the small target vessels, as anticipated. Diabetes is not a predictor of the outcomes.
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Introduction The objective of this study is to determine the efficacy of intramyocardial angiogenic cell precursors (ACPs) injection in ischemic cardiomyopathy (ICM). Methods Twenty-five ICM patients (cell group) underwent intramyocardial ACPs injection. Seventeen ICM patients (control group) treated by medical means were matched with cell group. There was no statistically significant difference between cell and control groups in relation to left ventricular ejection fraction (LVEF) and comorbidities. In the cell group, mean age was 58.4 ± 13.7 years. Mean LVEF was 26.1% ± 7.4%. New York Heart Association (NYHA) class was 2.9 ± 0.6. The ACPs were derived and expanded from autologous blood. The number of cells before injection was 27.4 ± 18.8 million cells. The cells were injected into the nonviable myocardium and hypokinetic segments in the cell group. Results There was no new ventricular arrhythmia. NYHA was improved by 0.9 ± 1.0 (P < 0.001) at 229.9 ± 98.8 days. Six-minute walk test and quality of life assessed by short form-36 improved in the cell group. LVEF was improved in 72% of patients (18 of 25). LVEF improved by 6.4 ± 9.9 points % (P = 0.003) at 290.4 ± 210.3 days. The percentage of infarction area decreased 21.9 ± 17.4 points % at 159 ± 54 days postoperatively. There was no significant improvement of NYHA and LVEF in the control group. Conclusions For this efficacy study, the NYHA class, quality of life, and six-minute walk test were improved after cell transplantation. The LVEF was also significantly improved in the cell treated group.
OBJECTIVES:To report midterm results and assess clinical markers which can predict intramyocardial angiogenic cell precursors (ACPs) injection for cardiomyopathy outcomes.METHODS:Between May 2005 and April 2010, 143 consecutive cardiomyopathy patients underwent intramyocardial ACPs injection. Sixty patients were dilated cardiomyopathy (DCM) and 83 were ischemic cardiomyopathy (ICM). Mean age was 59.6 ± 12.1 years. ACPs were isolated from patient’s own blood and cultured. Number of cells prior to injection was 47.3 ± 36.8 million cells. ACPs were injected into non-viable myocardium and hypokinetic segments. Combined coronary artery surgery and cell injection were performed in 34.9% of ICM. Kaplan-Meier was used to estimate survival time. Cox proportional hazard model was applied by fitting data which included age, gender, diagnosis, diabetes, hypertension, hypercholesterolemia, pulmonary hypertension, renal failure, NYHA class, serum creatinine, preop LVEF, type of operations and number of ACPs into the model to identify predictors of death.RESULTS:There was no new ventricular arrhythmia. Thirty-day mortality rate was 3.3% (2/60) for DCM and 8.4% (7/83) for ICM. Overall death rate was 14.5/1000/month (95%CI: 10.6-19.5). Overall survival probability at 12, 24, 36 and 48 months was 79.9% (95%CI: 72.1-85.8), 67.9% (95%CI: 58.5-75.6), 62.9% (95%CI: 52.4-71.7), 55.4% (95%CI: 43.0-66.2), respectively. LVEF improved by 3.6±12.3% (P=0.04) for DCM and 7.6±10.1% (P<0.001) for ICM. ICM patients with combined coronary artery surgery and cell injection showed more LVEF improvement. (11.8±11.6% vs 4.9±8.0%, P=0.007). Cox regression analyses suggested only preop LVEF (hazard ratio 0.91, 95% CI 0.87-0.95, P<0.001) was associated with decreased survival.CONCLUSIONS:Intramyocardial ACPs injection improved LVEF in both DCM and ICM. Preop LVEF was a significant survival predictor
Objective: The left internal thoracic artery (LITA), when grafted to the left anterior descending artery (LAD), is generally accepted as the conduit of choice for coronary artery bypass grafting (CABG). In contrast, the role and efficacy of the right internal thoracic artery (RITA), despite its long-term use as a coronary artery graft, is relatively less understood. Accordingly, in this study, we sought to assess the utility of the RITA as a coronary conduit by examining the long-term patency of both in situ and free RITA grafts and analyzing the association between intraoperative graft and coronary artery variables. Methods: Nine hundred and sixty-two patients (LITA 962, RITA 432) who had CABG between 1985 and 1998 and underwent re-angiography for evidence of myocardial ischemia were included in this observational analysis. The diameter of the internal thoracic artery (ITA), the presence of a proximal anastomosis with the aorta, the location of the anastomosis with the coronary artery, and the coronary artery diameter, were recorded at the initial procedure. The follow-up was 67.0±39.4 months (mean±SD, range 0.1–169.5). The relationship between intraoperative variables and graft patency was assessed using Cox proportional hazard models. Results: Highest RITA failure rates were associated with grafting a native coronary artery with a stenosis of less than 60% compared with 80–100% (RR 3.8 (95% CI, 1.9–7.2) P=0.0001). Grafts to non-LAD arteries had a higher risk of failure, the highest risk ratio being associated with grafting the right coronary artery (RR 4.0 (95% CI, 0.9–17.4) P=0.06)). Free compared with in situ grafts were also associated with a higher risk of failure with this result bordering on statistical significance (RR 1.9 (95% CI, 1.0–6.0) P=0.06)) Conclusion: Preference should be given to grafting arteries with a high grade stenosis or occlusion, to grafting left rather than right coronary arteries, and to using in situ rather than free ITA grafts. Passing the RITA to the left, either anterior to the aorta or through the transverse sinus, did not influence patency.
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