Background: The efficacy of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD) has been well-defined by randomized controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction <35%; EF) were under-represented in these trials. We sought to compare the outcomes of patients with multivessel CAD and EF<35% undergoing CABG vs. PCI. Methods: We used APPROACH, a clinical data collection initiative, capturing all patients undergoing cardiac catheterization and revascularization in the province of Alberta, Canada, to identify 2477 patients with multivessel CAD and EF<35% undergoing CABG (n=1242) or PCI (n=1235) between 1995 and 2008. Results: Patients undergoing CABG were slightly older (65.8 vs. 65.3 years; p=0.269), more likely to have three vessel CAD (62% vs. 56%; p<0.001), male gender (85% vs. 77%; p<0.001), diabetes (39% vs. 27%; p<0.001), peripheral vascular disease (PVD; 14% vs. 8%, p<0.001), congestive heart failure (CHF; 46% vs. 41%, p=0.012), and COPD (21% vs. 16%, p=0.005). Unadjusted survival at 1, 5, and 12 years in the CABG vs. PCI groups was 90% vs. 86%, 75% vs 71%, and 47% vs. 48%, respectively (p=0.394). After controlling for differences in baseline risk factors, CABG was associated with improved long term outcomes. Multivariable logistic regression identified PCI was significantly associated with a higher risk of death compared to CABG (adjusted hazard ratio, 1.20; 95% CI, 1.03 to 1.40). Other significant predictors of poor long-term survival included COPD (adjusted hazard ratio, 1.19; 95% CI, 1.01 to 1.40), renal failure (adjusted hazard ratio, 2.33; 95% CI, 1.80 to 3.04), CHF (adjusted hazard ratio, 1.19; 95% CI, 1.04 to 1.37), diabetes (adjusted hazard ratio, 1.21; 95% CI, 1.06 to 1.40), PVD (adjusted hazard ratio, 1.31; 95% CI, 1.09 to 1.59), and prior CABG (adjusted hazard ratio, 1.30; 95% CI, 1.04 to 1.62). Conclusion: In patients with multivessel CAD and left ventricular dysfunction, CABG was associated with better survival than PCI after adjustment for baseline risk profile differences. Further research exploring the factors leading to use of a particular revascularization modality is required.
Mesothelial / monocytic incidental cardiac excrescence (Cardiac MICE) is a rare benign cardiac lesion. MICEs are usually incidental findings during cardiac surgery, but can also be identified in the endomyocardial biopsy setting. Grossly, MICEs mimic thrombus and microscopically, they contain mesothelial and monocytic cells with fibrin, and empty spaces. The pathogenesis of MICE remains unknown. We propose a new theory that the empty spaces are air microbubbles and these contribute to the formation of MICE. We present two cases of MICE: the first case was a previously formed MICE incidentally found in the left atrium of a patient during valve replacement. Histologically, many variable - sized empty spaces were lined by macrophages and these empty spaces probably represent air microbubbles. The second case was a recently formed MICE found in an endomyocardial biopsy which contained fresh air microbubbles without lining cells in the thrombus admixed with mesothelial cells.
The study aim was to evaluate the hemodynamic performance of the St. Jude Medical Epic Supra bioprosthesis during the early six-month follow up period, and to confirm the safety and efficacy of the valve by collecting details of adverse events and NYHA functional classification.Fifty-seven patients undergoing aortic valve replacement (AVR) with the Epic Supra valve between September 2007 and January 2009 at three centers in Canada were evaluated for the study. The subjects were monitored preoperatively, at discharge, and at six months postoperatively. Echocardiographic data were available from 50 subjects at the six-month follow up. In order to prevent observer variability, all echocardiograms were sent to an independent Echocardiography Core Laboratory (ECL) for interpretation of the data.The mean subject age was 74 years. Concomitant coronary artery bypass grafting (CABG) was performed in 44% of the procedures. The mean pressure gradients were 11.2, 12.5, 10.8, 8.4 and 11.3 mmHg, respectively, for valves sized 19 mm (n = 2), 21 mm (n = 20), 23 mm (n = 22), 25 mm (n = 5) and 27 mm (n = 1). The average effective orifice areas (EOAs) were 1.44, 1.57, 1.69, 1.93 and 1.81 cm2 for the .valves sized 19, 21, 23, 25 and 27 mm, respectively.The results of the six-month echocardiographic follow up indicated that the Epic Supra valve offered excellent hemodynamic performance in the 21, 23 and 25 mm sizes. However, additional data are still required for the 19 and 27 mm valves to characterize their performance. The mean gradients and EOA-values were comparable to those of other supra-annular stented tissue valves. The EOA index indicated an absence of prosthesis-patient mismatch, with values in all subjects at or near 0.85 cm2/m2. The percentage of subjects without aortic insufficiency (AI) at follow up was 92%; only four subjects showed trivial AI.
