Introduction: The SYNergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery (SYNTAX) score quantifies complexity of coronary artery disease (CAD) using angiographic data to objectively guide mode of revascularization. Recent studies evaluating complexity of CAD by the anatomical SYNTAX score (SS1) and impact on clinical outcomes following CABG have been inconclusive. Hypothesis: We sought to investigate the prognostic value of SS1 in predicting survival and incidence of major adverse cardiac events (MACE) following CABG in the REGROUP trial (ClinicalTrials.gov number NCT01850082.) Methods: This was a pre-planned sub-analysis of the REGROUP trial which randomized patients undergoing isolated CABG to endoscopic versus open vein harvest at 16 U. S. Veterans Affairs Medical Centers between 2014-2017; The median follow-up was 4.7 years (interquartile range 3.84-5.45). SS1 was extracted for all patients and stratified by terciles. Time-to-event survival analysis was performed for MACE defined as death from any cause, nonfatal myocardial infarction, or repeat revascularization over the study follow-up. Results: The mean SS1 for this cohort (N=1,145) was 28.5±11.5 (median 27). Mean age was 66.4±6.90 years, 50.2% were diabetics and 99.5% were males reflecting the Veterans population. According to SS1 terciles, low (<23), intermediate (23-32) and high (>32) SS1 groups comprised 383, 393 and 369 patients, respectively. Over study follow-up, SS1 terciles were associated with all-cause death (log-rank, p=0.012), which occurred in 8.6%, 14.2% and 15.2% of patients respectively (p=0.013). However, SS1 was not associated with higher rates of the composite MACE which occurred in 20.4%, 22.6% and 25.5% of patients (p=0.247). Conclusions: Over the REGROUP study follow-up, complexity of CAD evaluated by the SS1 is significantly associated with all-cause death, but not MACE.
An 80‐year‐old woman with severe symptomatic heart failure (ejection fraction of 13%), and left bundle branch block (QRS duration of 160 ms) underwent cardiac resynchronization therapy (CRT). She had significant baseline dyssynchrony with a septal to posterior wall delay of 160 ms by echocardiographic tissue synchronization imaging (TSI). Despite exhaustive efforts, a stable posterior‐lateral coronary vein lead position could not be achieved with the standard percutaneous approach, resulting in anterior coronary vein lead placement. This resulted in no improvement in the patient's symptoms or ventricular function. Follow‐up TSI revealed earlier activation of the anteroseptal site and worsened dyssynchrony with septal to posterior wall delay of now 290 ms. This information prompted surgical revision of the left ventricular (LV) lead position via limited thoracotomy and posterior‐lateral epicardial lead implantation. Pacing at the new lead site resulted in a 30% increase in stroke volume and symptomatic improvement. TSI in this case redirected lead position in a clinical nonresponder, resulting in a favorable response to CRT.
In this long and complicated case, Dr. Marco Zenati performs a full, biatrial Cox-MAZE IV procedure with coronary artery bypass grafting (CABG) and a mitral valve replacement (MVR), moving between the three procedures as necessary to minimize time on the ischemic heart. The patient suffers from congestive heart failure that recently escalated from class II to class III.
We hypothesized that a high-quality anastomosis between the left internal thoracic artery and the left anterior descending coronary artery could be constructed off-pump using a 4-degrees-of-freedom robotic telemanipulation system, endoscopic myocardial stabilization, and two-dimensional visualization. Nine swine were used. Three ports were created on the left chest for the endoscope and the two robotic arms, and another port was created on the right chest for the endostabilizer. Quality of anastomosis was assessed by angiography, analysis of flow, survival after proximal coronary ligation, and histopathology. All nine anastomoses were completed successfully in 22 ± 3.6 minutes without the need for repair stitches. Left internal thoracic artery flow was 21.6 ± 2.5 ml/min with diastolic dominant pattern. Eight animals (89%) survived for 60 minutes with the proximal left anterior descending coronary ligated. Angiographic patency was 100% with Fitzgibbon grade A in all. Histopathology of the anastomosis demonstrated minor changes in the integrity of the endothelium and the internal elastic lamina and absence of medial necrosis. We have demonstrated in our robotic off-pump coronary bypass model that a high-quality anastomosis can be constructed between the left internal thoracic artery and the left anterior descending coronary artery. These results support continued research towards robotic endoscopic off-pump CABG.
We introduce an intelligent system to optimize a team composition based on the team's historical outcomes and apply this system to compose a surgical team. The system relies on a record of the procedures performed in the past. The optimal team composition is the one with the lowest probability of unfavorable outcome. We use the theory of probability and the inclusion exclusion principle to model the probability of team outcome for a given composition. A probability value is assigned to each person of database and the probability of a team composition is calculated from them. The model allows to determine the probability of all possible team compositions even if there is no recoded procedure for some team compositions. From an analytical perspective, assembling an optimal team is equivalent to minimizing the overlap of team members who have a recurring tendency to be involved with procedures of unfavorable results. A conceptual example shows the accuracy of the proposed system on obtaining the optimal team.
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