Focusing on Patient Subcategories: When Could We Expect a Suboptimal Late Result after Coronary Endarterectomy?

Reply by the Authors of the Original Article

We read with very interest the paper from Bitan et al,[1] in which they optimally described their experience in the treatment of complex coronary patients by means of coronary artery bypass grafting and adjunctive coronary endarterectomy (CE) on the left anterior descending (LAD) or patch angioplasty. With a detailed follow-up, they have reported a satisfactory 5-year survival and a good freedom from repeated revascularization. These data strongly confirmed our recent published clinical experience.[2] Although we did not perform an angiographic follow-up of 72 patients undergoing CE (2006–2013), we focused on the results based on single versus double antiplatelet protocols. At 7 years, freedom from death of any cause, including operative mortality was respectively in the single and dual antiplatelet groups of patients 73 ± 9% versus 81 ± 5%, while freedom from cardiac death was 84 ± 9% versus 85 ± 5%. These results showed that different antiplatelet therapies does not make difference in the early and late outcomes. We were really interested in achieving a complete understanding of which risk factors could influence survival, and at the Cox regression analysis we identified as independent predictors of late survival the age older than 70 years (odds ratio [OR]: 1.29; p = 0.003) and the presence of chronic obstructive pulmonary disease (COPD) (OR: 23.8; p = 0.033). As far as we are concerned, patients with diffusive coronary artery disease represent a very complex category, in which both cardiac and noncardiac factors can play a crucial role. COPD was already been considered as a detrimental factor for coronary surgical patients.[3] We believe that the presence of COPD and older age could be therefore considered as potential risk factors to guide revascularization strategy in a specific direction, that is, avoiding CE in older and COPD patients, and taking into account alternative strategies of revascularization, that is, hybrid or, when feasible, percutaneous.

The study by Bitan et al gives us the opportunity to study not only clinical results of CE but also patch angioplasty. We would be really interested in knowing the authors' opinion regarding the potential role of risk factors, both cardiac and extracardiac, that could influence in their experience the late results. What could we learn more from your excellent follow-up?

• References

• 1 Bitan O, Pirundini PA, Leshem E. , et al. Coronary endarterectomy or patch angioplasty for diffuse left anterior descending artery disease. Thorac Cardiovasc Surg 2017; (e-pub ahead of print). DOI: 10.1055/s-0037-1600918.
• 2 Russo M, Nardi P, Saitto G. , et al. Single versus double antiplatelet therapy in patients undergoing coronary artery bypass grafting with coronary endarterectomy: mid-term results and clinical implications. Interact Cardiovasc Thorac Surg 2017; 24 (02) 203-208
• 3 Angouras DC, Anagnostopoulos CE, Chamogeorgakis TP. , et al. Postoperative and long-term outcome of patients with chronic obstructive pulmonary disease undergoing coronary artery bypass grafting. Ann Thorac Surg 2010; 89 (04) 1112-1118