Background Valve replacement combined with coronary artery bypass graft (CABG) operation (VR + CABG) is usually associated with higher mortality and complication rates. Currently, angiography remains the most commonly used approach to guide CABG. The aim of this study is to investigate whether a quantitative flow ratio (QFR)-guided strategy can improve the clinical outcomes of VR + CABG. Methods Patients ( n = 536) treated by VR + CABG between January 2018 and December 2021 were retrospectively assessed. In 116 patients, all lesions were revascularized entirely based on QFR (the QFR-guided group), whereas in 420 patients, all lesions were revascularized entirely based on angiography (the angiography-guided group). To minimize selection bias between the 2 groups, propensity score matching was performed at a ratio of 1:2. The primary endpoint of the study was the rate of major adverse cardiac and cerebrovascular events (MACCE) at 1-year, which was defined as a composite of cardiac mortality, myocardial infarction (MI), any repeat revascularization, and stroke. Results No statistically significant differences were observed in the baseline clinical characteristics between the QFR-guided and angiography-guided groups after propensity score matching. The mean age of all patients was 66.2 years [standard deviation (SD) = 8.3], 370 (69%) were men, the mean body-mass index of the population was 24.8 kg/m 2 (SD = 4.5), 129 (24%) had diabetes, and 229 (43%) had angina symptoms. When compared with the angiography-guided group, the QFR-guided group had a significantly shorter operative time (323 ± 60 min vs. 343 ± 71 min, P = 0.010), extra corporal circulation time (137 ± 38 min vs. 155 ± 62 min, P = 0.004), clamp time (73 ± 19 min vs. 81 ± 18 min, P < 0.001), and less intraoperative bleeding volume (640 ± 148 ml vs. 682 ± 166 ml, P = 0.022). Compared with the angiography-guided group, the 1-year MACCE was significantly lower in the QFR-guided group (6.9% vs. 14.7%, P = 0.036, hazard ratio = 0.455, 95% confidence interval: 0.211–0.982). Conclusion Our results raise the hypothesis that among patients who undergo VR + CABG, QFR-guided strategy is associated with optimized surgical procedure and a superior clinical outcome, as evidenced by a lower rate of MACCE at 1-year compared with conventional angiography-guided strategy.

BACKGROUND For patients with intermediate coronary stenoses, the prognostic value of coronary artery bypass grafting (CABG) remains controversial. The prognostic impact of CABG may be different according to Murray law-based quantitative flow ratio (μQFR) and angiography-derived microcirculatory resistance (AMR) in patients with intermediate coronary stenoses. METHODS AND RESULTS Clinical data of 1411 cases who were diagnosed with multivessel coronary artery disease and had coronary artery intermediate stenoses (50% to 70% by visual assessment) between January 2013 and January 2020 were collected. Patients were categorized into CABG and defer groups based on the decision to bypass intermediate stenoses. These patients were further divided into different subgroups based on μQFR and AMR. The primary outcome was the major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of cardiac death, target vessel myocardial infarction, target vessel revascularization and stroke. Multivariable analysis showed AMR (HR = 1.68, 95% CI 1.18-4.14, P = 0.008) was independent factor associated with MACCE in all patients. On receiver-operating characteristic (ROC) curve analysis, the estimated area under the curve was 0.75 (95% CI: 0.72-0.79) for MACCE. Using the maximum Youden’s index, the optimal cutoff value for AMR to predict MACCE was 2.50 mmHg*s/cm. In defer group, MACCE was significantly lower in patients with both μQFR > 0.80 and AMR < 2.50 mmHg*s/cm as compared with patients with μQFR > 0.80 (13.2% vs 22.0%, P = 0.031) or AMR < 2.50 mmHg*s/cm (13.2% vs 23.6%, P = 0.012) alone. Compared with patients with both normal μQFR and AMR, patients with both abnormal μQFR and AMR carried the highest risk for MACCE (HR = 3.46, 95% CI 2.10-5.71, P < 0.001). CABG was associated with a lower risk of MACCE compared with the deferral strategy when both μQFR and AMR were abnormal. In contrast, at normal μQFR and AMR, patients in both CABG and defer groups had similar MACCE outcomes. CONCLUSIONS In patients with intermediate coronary stenoses, the prognostic value of treatment strategy differed according to μQFR and AMR, with a significant interaction. The combination of μQFR and AMR can help stratify risk and guide treatment strategies for patients with intermediate coronary stenoses.

Abstract Background: Compared with isolated mitral valve replacement (MVR) or isolated coronary artery bypass grafting (CABG), MVR + CABG surgery is associated with higher mortality and complication rate. This study investigated the safety and efficacy of the myocardial protection technique to short cardioplegic arrest time in patients who underwent MVR + CABG. Methods:This study enrolled patients diagnosed with mitral valve disease and coronary artery disease who underwent MVR + CABG between January 2014 and January 2022. The patients were divided into the CABG without cardioplegic arrest (CA) group (novel group) and CABG with CA group (conventional group) according to surgical methods. The baseline data of the two groups of patients were corrected by the propensity score matching (PSM) method. Endpoints assessed were operative mortality (OM), major morbidity (MM)and 5-year follow-up clinical outcomes. Results: 810 patients (256 in the novel group and 554 in the conventional group) were enrolled in this study. PSM resulted in a total of 460 patients (230 pairs). There was no significant difference in OM between the two groups (6.5% vs 10.8%, P= 0.098). The MM was significantly lower in the novel group than the conventional group (24.3% vs 33.9%, P= 0.024). Mean operation time (285 ± 55 vs 298 ± 60 minutes, P= 0.016), cardiopulmonary bypass (CPB) time (115 ± 33 vs 139 ± 38 minutes, P < 0.001), CA time (66 ± 11 vs 85 ± 16 minutes, P < 0.001), intensive care unit stay time (33.6 ± 12.3 vs 36.6 ± 14.5 hours, P = 0.017) and post-operative length of stay (11.1 ± 3.6 vs 11.9 ± 4.1 days, P = 0.027) were significantly shorter in the novel group than in the conventional group. There was no significant difference between the novel group and the conventional group in terms of death from any cause, valve-related complications, myocardial infarction and any repeat revascularisation in 5 years follow-up. Conclusions: The novel group is associated with excellent short-term outcomes and comparable medium-term outcomes for patients undergoing MVR + CABG. Myocardial protection strategy to short cardioplegic arrest time in patients undergoing MVR + CABG was surgically feasible, reproducible, and safe.

To compare early and medium-term outcomes between robotic and sternotomy approaches for mitral valve replacement (MVR). Clinical data of 1393 cases who underwent MVR between January 2014 and January 2023 were collected and stratified into robotic MVR (n = 186) and conventional sternotomy MVR (n = 1207) groups. The baseline data of the two groups of patients were corrected by the propensity score matching (PSM) method. After matching, the baseline characteristics were not significant different between the two groups (standardized mean difference < 10%). Moreover, the rates of operative mortality (P = 0.663), permanent stroke (P = 0.914), renal failure (P = 0.758), pneumonia (P = 0.722), and reoperation (P = 0.509) were not significantly different. Operation, CPB and cross-clamp time were shorter in the sternotomy group. On the other hand, ICU stay time, post-operative LOS, intraoperative transfusion, and intraoperative blood loss were shorter or less in the robot group. Operation, CPB, and cross-clamp time in robot group were all remarkably improved with experience. Finally, all-cause mortality (P = 0.633), redo mitral valve surgery (P = 0.739), and valve-related complications (P = 0.866) in 5 years of follow-up were not different between the two groups. Robotic MVR is safe, feasible, and reproducible for carefully selected patients with good operative outcomes and medium-term clinical outcomes.