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1.  Acute Coronary Syndrome in Patients with Prior Coronary Artery Bypass Surgery: Observations from a 20-Year Registry in a Middle-Eastern Country 
PLoS ONE  2012;7(7):e40571.
Clinical characteristics and trends in the outcome of acute coronary syndrome (ACS) in patients with prior coronary artery bypass graft surgery (CABG) are unclear. The aim of this study was to evaluate clinical characteristics, in-hospital treatment, and outcomes in patients presented with ACS with or without a history of prior CABG over 2 decades.
Data were derived from hospital-based study for collected data from 1991 through 2010 of patients hospitalized with ACS in Doha, Qatar. Data were analyzed according to their history of prior CABG. Baseline clinical characteristics, in-hospital treatment, and outcome were compared.
A total 16,750 consecutive patients with ACS were studied, of which 693 (4.1%) had prior CABG. Patients with prior CABG were older (mean 60.5±11 vs. 53±12 years; P = 0.001), more likely to be females and have more cardiovascular risk factors than the non-CABG group. Prior CABG patients had larger infarct size, were less likely to receive reperfusion therapy, early invasive therapy and more likely to receive evidence-based therapies when compared to non-CABG patients. In-hospital mortality and stroke rates were comparable between the 2 groups. Over 2 decades, there was reduction in the in-hospital mortality rates and stroke rates in both groups (CABG, death; 13.2% to 4%, stroke; 1.9% to 0.0%, non-CABG, death; 10% to 3.2%, stroke 1.0% to 0.1%; all, p = 0.001).
Significant reduction in-hospital morbidity and mortality among ACS patients with prior CABG over a 20-year period.
PMCID: PMC3399890  PMID: 22815766
2.  Does prior coronary artery bypass surgery alter the gender gap in patients presenting with acute coronary syndrome? A 20-year retrospective cohort study 
BMJ Open  2012;2(6):e001969.
Previous studies demonstrated women presenting with acute coronary syndrome (ACS) have poor outcomes when compared with men ‘the gender gap phenomenon’. The impact of prior coronary artery bypass graft (CABG) on women presenting with ACS is unknown. We hypothesised that the gender gap is altered in ACS patients with prior CABG. The aim of this study was to evaluate patients presenting with ACS according to their gender and history of prior CABG.
Retrospective, observational (cohort) study.
Data were collected from hospital-based registry of patients hospitalised with ACS in Doha, Qatar, from 1991 through 2010. The data were analysed according to their gender and history of prior CABG.
A total of 16 750 consecutive patients with ACS were studied. In total, 693 (4.3%) patients had prior CABG; among them 125 (18%) patients were women.
Primary and secondary outcome measures
Comparisons of clinical characteristics, inhospital treatment, and outcomes, including inhospital mortality and stroke were made.
Women with or without prior CABG were older, less likely to be smokers, but more likely to have diabetes mellitus (DM), hypertension and renal impairment than men (p=0.001). Women were less likely to receive reperfusion and early invasive therapies. When compared with men, women without prior CABG carried higher inhospital mortality (11% vs 4.9%; p=0.001) and stroke rates (0.9% vs 0.3%; p=0.001). Female gender was independent predictor of poor outcome. Among prior CABG patients, despite the fact that women had worse baseline characteristics and were less likely to receive evidence-based therapy, there were no significant differences in mortality or stroke rates between the two groups.
Consistent with the world literature, women presenting with ACS and without prior CABG had higher death rates compared with men. Patients with prior CABG had comparable death rates regardless of the gender status.
PMCID: PMC3533054  PMID: 23194954
acute coronary syndrome; coronary artery bypass surgery; gender gap; outcome
3.  Patient-Centered Research Abstracts 
Journal of General Internal Medicine  2000;15(Suppl 2):4-5.
Timing of coronary artery bypass grafting (CABG) following acute myocardial infarction (AMI) has changed, and optimal timing is unclear. There is little population-based data on current practice or its outcomes. Our objectives were to establish: 1) current practice patterns, 2) in-hospital mortality, and 3) clinical, demographic and systems determinants of early CABG (defined as a CABG performed during the same hospitalization following an AMI).
Data are from the Healthcare Cost and Utilization Project at AHRQ. The analytic dataset includes all CABGs (DRG 106/107) performed in short-stay, non-federal hospitals in CA, MA, NJ and WI from 1989–1996. CABGs are coded as early if an AMI (ICD-9 410*1) was the principal diagnosis. Cases were further narrowed to CABGs performed on days 3–8 to exclude unstable and post-operative AMI, and atypical cases after day 9. In-hospital mortality rates were calculated following early CABG. Independent impact of early CABG on in-hospital mortality is determined using multivariate logistic models, adjusting for demographic (age >70, gender, race), clinical (severity, comorbidity, PTCA performed), payer (public, private, HMO) hospital (teaching, volume) and state factors. The independent influence of state and payer on likelihood of receiving an early CABG are established using multivariate logistic models, adjusting for the same factors.
There were 367,387 CABGs performed across 4 states over 8 years. In 1989, 5–12% of CABGS were performed early following AMI. By 1996, 17–21% of CABGS were performed early following AMI, representing a 2–4 fold increase. In 1996, there were 12,616 CABGS performed day 3–8 in the 4 states; 413 or 3.33% died in-hospital. The death rate for early CABG versus other CABG (without AMI) was no different (3.37% vs. 3.31%). Using logistic regression, in-hospital death was not affected by timing, state or payer, but was twice as likely with age>71, coded comorbidity or complications. Use of early CABG was 50-60% less likely in CA (adjusted OR = 0.50), NJ (OR = .39) and WI (OR = .59) as compared to MA, 22% less likely in teaching hospitals (OR = .78), and 15–50% less likely with coded comorbidity or severity. Use of early CABG was 15% more likely in high volume hospitals, 16% more likely with private as compared to HMO insurance, and twice as likely following angioplasty.
Early CABG represents as much as one-fifth of all CABGs performed in 4 states by 1996. Although mortality does not appear to be affected by timing, use of early CABG is influenced by state, hospital and payer characteristics. These findings provide evidence that market factors play a significant role in the timing of CABG following AMI. Future studies will examine which market factors, including physician, payer and hospital competition, are most important.
PMCID: PMC1495760
4.  Mid-term outcomes of patients with PCI prior to CABG in comparison to patients with primary CABG 
The number of percutaneous coronary interventions (PCI) prior to coronary artery bypass grafting (CABG) increased drastically during the last decade. Patients are referred for CABG with more severe coronary pathology, which may influence postoperative outcome. Outcomes of 200 CABG patients, collected consecutively in an observational study, were compared (mean follow-up: 5 years). Group A (n = 100, mean age 63 years, 20 women) had prior PCI before CABG, and group B (n = 100, mean age 66, 20 women) underwent primary CABG. In group A, the mean number of administered stents was 2. Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 54 vs 34 (P = 0.007), distribution of CAD (P < 0.0001), unstable angina: 27 vs 5 (P < 0.0001). For intraoperative data, the total number of established bypasses was 2.43 ± 1.08 vs 2.08 ± 1.08 (P = 0.017), with the number of arterial bypass grafts being: 1.26 ± 0.82 vs 1.07 ± 0.54 (P = 0.006). Regarding the postoperative course, significant results could be demonstrated for: adrenaline dosage (0.83 vs 0.41 mg/h; [p is not significant (ns)]) administered in 67 group A vs 47 group B patients (P = 0.006), and noradrenaline dosage (0.82 vs 0.87 mg/h; ns) administered in 46 group A vs 63 group B patients (P = 0.023), CK/troponine I (P = 0.002; P < 0.001), postoperative resuscitation (6 vs 0; P = 0.029), intra aortic balloon pump 12 vs 1 (P = 0.003), and 30-day mortality (9% in group A vs 1% in group B; P = 0.018). Clopidogrel was administered in 35% of patients with prior PCI and in 19% of patients without prior PCI (P = 0.016). Patients with prior PCI presented for CABG with more severe CAD. Morbidity, mortality and reoperation rate during mid term were significantly higher in patients with prior PCI.
PMCID: PMC2922310  PMID: 20730065
CABG; CABG and PCI; CAD; outcome
5.  Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk 
Journal of vascular surgery  2012;56(3):668-676.
Although carotid artery stenosis and coronary artery disease often coexist, many debate which patients are best served by combined concurrent revascularization (carotid endarterectomy [CEA]/coronary artery bypass graft [CABG]). We studied the use of CEA/CABG in New England and compared indications and outcomes, including stratification by risk, symptoms, and performing center.
Using data from the Vascular Study Group of New England from 2003 to 2009, we studied all patients who underwent combined CEA/CABG across six centers in New England. Our main outcome measure was in-hospital stroke or death. We compared outcomes between all patients undergoing combined CEA/CABG to a baseline CEA risk group comprised of patients undergoing isolated CEA at non-CEA/CABG centers. Further, we compared in-hospital stroke and death rates between high and low neurologic risk patients, defining high neurologic risk patients as those who had at least one of the following clinical or anatomic features: (1) symptomatic carotid disease, (2) bilateral carotid stenosis > 70%, (3) ipsilateral stenosis >70% and contralateral occlusion, or (4) ipsilateral or bilateral occlusion.
Overall, compared to patients undergoing isolated CEA at non-CEA/CABG centers (n = 1563), patients undergoing CEA/CABG (n =109) were more likely to have diabetes (44% vs 29%; P =.001), creatinine >1.8 mg/dL (11% vs 5%; P =.007), and congestive heart failure (23% vs 10%; P < .001). Patients undergoing CEA/CABG were also more likely to take preoperative beta-blockers (94% vs 75%; P < .001) and less likely to take preoperative clopidogrel (7% vs 25%; P < .001). Patients undergoing CEA/CABG had higher rates of contralateral carotid occlusion (13% vs 5%; P = .001) and were more likely to undergo an urgent/emergent procedure (30% vs 15%; P < .001). The risk of complications was higher in CEA/CABG compared to isolated CEA, including increased risk of stroke (5.5% vs 1.2%; P < .001), death (5.5% vs 0.3%; P < .001), and return to the operating room for any reason (7.6% vs 1.2%; P <.001). Of 109 patients undergoing CEA/CABG, 61 (56%) were low neurologic risk and 48 (44%) were high neurologic risk but showed no demonstrable difference in stroke (4.9% vs 6.3%; P =.76), death, (4.9 vs 6.3%; P =.76), or return to the operating room (10.2% vs 4.3%; P = .25).
Although practice patterns in the use of CEA/CABG vary across our region, the risk of complications with CEA/CABG remains significantly higher than in isolated CEA. Future work to improve patient selection in CEA/CABG is needed to improve perioperative results with combined coronary and carotid revascularization.
PMCID: PMC3574812  PMID: 22560308
6.  Coronary Revascularization Alone or with Mitral Valve Repair 
Texas Heart Institute Journal  2009;36(5):416-424.
We sought to evaluate retrospectively the outcomes of patients at our hospital who had moderate ischemic mitral regurgitation and who underwent coronary artery bypass grafting (CABG) alone or with concomitant mitral valve repair (CABG+MVr).
A total of 83 patients had a reduced left ventricular ejection fraction and moderate mitral regurgitation: 28 patients underwent CABG+MVr, and 55 underwent CABG alone. Changes in mitral regurgitation, functional class, and left ventricular ejection fraction were compared in both groups.
The mean follow-up was 5.1 ± 3.6 years (range, 0.1–15.1 yr). Reduction of 2 mitral-regurgitation grades was found in 85% of CABG+MVr patients versus 14% of CABG-only patients (P < 0.0001) at 1 year, and in 56% versus 14% at 5 years, respectively (P = 0.1), as well as improvements in left ventricular ejection fraction and functional class. One- and 5-year survival rates were similar in the CABG+MVr and CABG-only groups: 96% ± 3% versus 96% ± 4%, and 87% ± 5% versus 81% ± 8%, respectively (P = NS). Propensity analysis showed similar results. Recurrent (3+ or 4+) mitral regurgitation was found in 22% and 47% at late follow-up, respectively.
In patients with moderate ischemic mitral regurgitation, either surgical approach led to an improvement in functional class. Early and intermediate-term mortality rates were low with either CABG or CABG+MVr. However, an increased rate of late recurrent mitral regurgitation in the CABG+MVr group was observed.
PMCID: PMC2763474  PMID: 19876417
Cardiac surgical procedures; coronary artery bypass; coronary disease/complications/surgery; disease-free survival/trends; matched-pair analysis; mitral valve insufficiency/physiopathology/surgery; multivariate analysis; myocardial ischemia/complications/surgery; myocardial revascularization/methods/statistics & numerical data; postoperative period; recurrence; risk assessment
7.  Short- and Long-Term Patient Outcomes From Combined Coronary Endarterectomy and Coronary Artery Bypass Grafting 
Medicine  2015;94(41):e1781.
This meta-analysis aimed to compare the short- and long-term outcomes in patients undergoing combined coronary endarterectomy and coronary artery bypass grafting (CE + CABG) versus isolated CABG, and particularly to examine subgroup patients with high-risk profile and patients with diffuse disease in the left anterior descending artery (LAD).
Studies published between January 1, 1970 and May 31, 2015 were searched in the literature databases, including Ovid Medline, Embase, PubMed, and ISI Web of Science.
A total of 30 eligible studies including 63,730 patients were analyzed.
Five authors extracted data from the included studies independently.
Meta-analysis on the total patients revealed that CE + CABG was associated with significantly increased 30-day postoperative all-cause mortality compared with isolated CABG (OR = 1.86, 95% CI: 1.66–2.08, z = 10.99, P < 0.0001). Subgroup analysis on patients with high-risk profile and patients with diffuse disease in the LAD showed that 30-day mortality after CE + CABG was 2.6 folds (OR = 2.60, 95% CI: 1.39–4.86, z = 2.99, P = 0.003) and 3.93 folds (OR = 3.93, 95% CI: 1.40–11.0, z = 2.60, P = 0.009) of that after isolated CABG in the respective subgroup. In contrast, the mortality was comparable in CE + off-pump CABG and CE + on-pump CABG groups (OR = 0.53, 95% CI: 0.18–1.55, z = 1.16, P = 0.248). In addition, the incidences of perioperative myocardial infarction (MI) and 30-day postoperative complications, including low output syndrome (LOS), MI, ventricular tachycardia (VT), and renal dysfunction after CE + CABG were significantly higher than those after isolated CABG (all P < 0.05). In high-risk patient subgroup, CE + CABG significantly increased the incidences of postoperative LOS, MI, and renal function compared with isolated CABG (all P < 0.05). The incidence of perioperative myocardial after CE + CABG was 2.86 and 2.92 times of that after isolated CABG in high-risk patients and patients with diffuse disease in LAD, respectively. Analysis on the recent reports (published later than 2000) showed consistent results as the analysis including all the eligible reports. Long-term survival was comparable in CE + CABG and isolated CABG groups (hazardous ratio = 1.16, 95% CI: 0.32–4.22, z = 0.23, P = 0.819).
CE + CABG appears to be associated with poor short-term outcomes, particularly in high-risk patients and patients with diffuse disease in the LAD.
PMCID: PMC4616783  PMID: 26469920
8.  Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy 
OBJECTIVES—To evaluate whether coronary artery bypass graft (CABG) surgery is equally provided among different socioeconomic status (SES) groups in accordance with need. To estimate the association between SES and mortality occurring 30 days after CABG surgery.
DESIGN—Individual socioeconomic index assigned with respect to the characteristics of the census tract of residence (level I = highest SES; level IV = lowest SES). Comparison of age adjusted hospital admission rates of ischaemic heart disease (IHD) and CABG surgery among four SES groups. Retrospective cohort study of all patients who underwent CABG surgery during 1996-97.
SETTING—Rome (2 685 890 inhabitants) and the seven cardiac surgery units in the city.
PARTICIPANTS—All residents in Rome aged 35 years or more. A cohort of 1875 CABG patients aged 35 years or more.
MAIN OUTCOME MEASURES—Age adjusted hospitalisation rates for CABG and IHD and rate of CABG per 100 IHD hospitalisations by SES group, taking level I as the reference group. Odds ratios of 30 day mortality after CABG surgery, adjusted for age, gender, illness severity at admission, and type of hospital where CABG was performed.
RESULTS—People in the lowest SES level experienced an excess in the age adjusted IHD hospitalisation rates compared with the highest SES level (an excess of 57% among men, and of 94% among women), but the rate of CABG per 100 IHD hospitalisations was lower, among men, in the most socially disadvantaged level (8.9 CABG procedures per 100 IHD hospital admissions in level IV versus 14.1 in level I rate ratio= 0.63; 95% CI 0.44, 0.89). The most socially disadvantaged SES group experienced a higher risk of 30 day mortality after CABG surgery (8.1%) than those in the highest SES group (4.8%); this excess in mortality was confirmed even when initial illness severity was taken into account (odds ratio= 2.89; 95% CI 1.44, 5.80).
CONCLUSIONS—The universal coverage of the National Health Service in Italy does not guarantee equitable access to CABG surgery for IHD patients. Factors related to SES are likely to influence poor prognosis after CABG surgery.

Keywords: coronary artery bypass graft; ischaemic heart disease; socioeconomic status
PMCID: PMC1731596  PMID: 11076990
9.  Initial and long-term results of coronary angioplasty and coronary bypass surgery in patients of 75 or older. 
British Heart Journal  1993;70(2):122-125.
OBJECTIVE--To evaluate clinical outcome after percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients of 75 or older who underwent either procedure between 1980 and 1987. SUBJECTS--93 patients aged 75-89 with angina pectoris class III-IV (Canadian Cardiovascular Society) who underwent PTCA and 81 patients aged 75-84 with angina class III-IV who underwent CABG. Follow up was 8.2 years in the PTCA group and 8.3 years in the CABG group. MAIN OUTCOME MEASURES--In-hospital complications and survival at follow up. RESULTS--Primary success rate for PTCA was 84% (78/93). Two patients died, two had emergency CABG, three had a myocardial infarction, and one had a cerebrovascular accident. PTCA failed in seven patients (five underwent elective CABG and two were treated conservatively). Median hospital stay was 4.3 days. Primary success rate for CABG was 63% (53/81). Six patients died, two had a cerebrovascular accident, eight had a myocardial infarction, 10 had a rethoracotomy, and four the adult respiratory distress syndrome. Median hospital stay was 14.2 days. In the PTCA group during follow up eight patients died, three had a non-fatal myocardial infarction, two had elective CABG, 10 had repeat PTCA, and four had recurrence of angina. Sixty four patients were free of angina (69%). In the CABG group during follow up eight patients died, one had a non-fatal myocardial infarction, six had PTCA, and three had recurrence of angina. Fifty seven patients were free of angina AP (70%). Actuarial survival after 10 years was 92% for PTCA and 91% for CABG. CONCLUSIONS--PTCA is safe in elderly patients. The complication rate is lower and hospital stay significantly shorter compared with CABG (p < 0.05). Long-term follow up showed no significant difference between PTCA and CABG.
PMCID: PMC1025270  PMID: 8038020
10.  Influence of concomitant coronary artery bypass graft on outcome of surgery of the ascending aorta/arch 
Heart  2006;93(2):232-237.
Surgery of the ascending aorta with or without arch is being performed in an increasingly elderly population with risks of coexisting coronary artery disease.
To define specific groups requiring coronary artery bypass graft (CABG) and to analyse the influence of concomitant CABG on outcome.
Over a 10‐year period in a single institution, 296 consecutive procedures on the ascending aorta with or without arch were carried out in 291 patients. CABG was required in 42 (14.2%) procedures. In 24 (57%) patients, CABG was planned preoperatively and in 18 (43%) patients, on a salvage basis.
In‐hospital mortality for patients undergoing concomitant CABG was higher (21.4% v 11%, p<0.06). Adjusting for baseline and operative characteristics, this was attributable to operative priority, and was not a consequence of concomitant CABG (adjusted OR 0.30, 95% CI 1.1 to 8.31; p = 0.48). However, in‐hospital mortality was significantly higher when CABG was performed as salvage rather than as a planned procedure (38.9% v 8.9%, p = 0.025), and this difference remained after adjusting for confounding variables (adjusted OR 16.2, 95% CI 1.03 to >200; p = 0.047). The 3‐year survival was significantly lower with concomitant CABG (59% v 81.9%, p<0.001).
In association with surgery of the ascending aorta with or without arch planned concomitant CABG did not entail any added operative risk. However, salvage CABG, which occurred almost exclusively in association with emergency cases, was associated with a higher early mortality. Patients needing concomitant CABG had worse survival at 3 years compared with those requiring isolated surgery of the ascending aorta with or without arch.
PMCID: PMC1861367  PMID: 16914487
11.  Management of Post-Operative Atrial Fibrillation and Subsequent Outcomes in Contemporary Patients Undergoing Cardiac Surgery: Insights from the CAPS-Care STS AF Registry 
Clinical cardiology  2013;37(1):7-13.
Post-operative atrial fibrillation (POAF) is a well-recognized complication of cardiac surgery, however, its management remains a challenge and the implementation and outcomes of various strategies in clinical practice remain unclear.
We compared patient characteristics, operative procedures, post-operative management, and outcomes between patients with and without POAF following coronary artery bypass grafting (CABG) in the Society for Thoracic Surgery multicenter CAPS-Care registry (2004–2005).
Of 2,390 patients who underwent CABG, 676 (28%) had POAF. Compared with patients without POAF, those with POAF were older (median age 74 vs. 71, p<0.0001), more likely to have hypertension (86% vs. 83%, p=0.04), and impaired renal function (median estimated glomerular filtration rate, 56.9 vs. 58.6 mL/min/1.73m2, p=0.0001). A majority of patients with POAF were treated with amiodarone (77%) and beta-blockers (68%); few underwent cardioversion (9.9%). Patients with POAF were more likely to experience complications (57% vs.41%, p<0.0001), including acute limb ischemia (1.0% vs. 0.4%, p=0.03), stroke (4% vs. 1.9%, p=0.002), and reoperation (13% vs. 7.9%, p<0.0001). Length of stay (median 8 days vs. 6 days, p<0.0001), in-hospital mortality (6.8% vs. 3.7%, p=0.001), and 30-day mortality (7.8 vs. 3.9, p<0.0001) were all worse for patients with POAF. In adjusted analyses, POAF remained associated with increased length of stay following surgery (adjusted ratio of the mean 1.27, 95% CI 1.2–1.34, p<0.0001).
In conclusion, post-operative AF is common following CABG, and such patients continue to have higher rates of post-operative complications. Post-operative AF is significantly associated with increased length of stay following surgery.
PMCID: PMC3975246  PMID: 24353215
atrial fibrillation; coronary artery bypass surgery; postoperative care; outcomes
12.  Impact of Drug-Eluting Stents on the Comparative Effectiveness of Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention 
American heart journal  2014;169(1):149-154.
Drug-eluting stents (DES) have largely replaced bare-metal stents (BMS) for percutaneous coronary intervention (PCI). It is uncertain, however, whether introduction of DES had a significant impact the comparative effectiveness of PCI versus coronary artery bypass graft surgery (CABG) for death and myocardial infarction (MI).
We identified Medicare beneficiaries 66 years of age and older who underwent multivessel CABG or multivessel PCI, and matched PCI and CABG patients on propensity score. We defined the BMS era as January 1999 through April 2003 and the DES era as May 2003 through December 2006. We compared five-year outcomes of CABG and PCI using Cox proportional hazards models, adjusting for baseline characteristics and year of procedure, and tested for an interaction (Pint) of DES era with treatment (CABG or PCI).
Five-year survival improved from the BMS era to the DES era by 1.2% for PCI and by 1.1% for CABG, and the CABG:PCI hazard ratio was unchanged (0.90 vs. 0.90, Pint = 0.96). Five-year MIfree survival improved by 1.4% for PCI and 1.1% for CABG, with no change in the CABG:PCI hazard ratio (0.81 vs. 0.82, Pint = 0.63). By contrast, survival-free of MI or repeat coronary revascularization improved from the BMS era to the DES era by 5.7% for PCI and 0.9% for CABG, and the CABG:PCI hazard ratio changed significantly (0.50 vs. 0.57, Pint ≤ 0.0001).
The introduction of drug-eluting stents did not alter the comparative effectiveness of CABG and PCI with respect to hard cardiac outcomes.
PMCID: PMC4268548  PMID: 25497260
comparative effectiveness research; outcomes research; percutaneous coronary intervention; coronary artery bypass
13.  Impact of invasive treatment strategy on health-related quality of life six months after non-ST-elevation acute coronary syndrome 
Few studies have compared change in the health-related quality of life (HRQL) following treatment of non-ST-elevation acute coronary syndrome (NSTE-ACS) with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). This study is to compare changes in HRQL six months after hospital discharge between NSTE-ACS patients who underwent either PCI or CABG.
HRQL was assessed using the Seattle angina questionnaire at admission and six months after discharge in 1012 consecutive patients with NSTE-ACS. To assess associations of PCI and CABG with HRQL changes, logistic regression models were constructed treating changes in the score of each dimension of the Seattle angina questionnaire as dependent variables.
Although both the PCI and CABG groups experienced angina relief and other improvements at 6-month follow-up (P < 0.001), the CABG relative to PCI group showed more significant improvements in angina frequency (P = 0.044) and quality of life (P = 0.028). In multivariable logistic analysis, CABG also was an independent predictor for both improvement of angina frequency (OR: 1.62, 95%CI: 1.09−4.63, P = 0.042) and quality of life (OR: 2.04, 95%CI: 1.26−6.92, P = 0.038) relative to PCI.
In patients with NSTE-ACS, both PCI and CABG provide great improvement in disease-specific health status at six months, with that of CABG being more prominent in terms of angina frequency and quality of life.
PMCID: PMC4178511  PMID: 25278968
Non-ST elevation acute coronary syndrome; Quality of life; Therapeutic strategy
14.  A case study of hospital closure and centralization of coronary revascularization procedures 
Despite nation-wide efforts to reduce health care costs through hospital closures and centralization of services, little is known about the impact of such actions. We conducted this study to determine the effect of a hospital closure in Calgary and the resultant centralization of coronary revascularization procedures from 2 facilities to a single location.
Administrative data were used to identify patients who underwent coronary artery bypass grafting (CABG), including those who had combined CABG and valve procedures, and patients who underwent percutaneous transluminal angioplasty (PTCA) in the Calgary Regional Health Authority from July 1994 to March 1998. This period represents the 21 months preceding and the 24 months following the March 1996 hospital closure. Measures, including mean number of discharges, length of hospital stay, burden of comorbidity and in-hospital death rates, were compared before and after the hospital closure for CABG and PTCA patients. Multivariate analyses were used to derive risk-adjustment models to control for sociodemographic variables and comorbidity.
The number of patients undergoing CABG was higher in the year following than in the year preceding the hospital closure (51.6 per 100 000 before v. 67.3 per 100 000 after the closure); the same was true for the number of patients undergoing PTCA (129.8 v. 143.6 per 100 000). The burden of comorbidity was significantly higher after than before the closure, both for CABG patients (comorbidity index 1.3 before v. 1.5 after closure, p < 0.001) and for PTCA patients (comorbidity index 1.0 before v. 1.1 after, p = 0.04). After adjustment for comorbidity, the mean length of hospital stay was significantly lower after than before the closure for CABG patients (by 1.3 days) and for PTCA patients (by 1.0 days). The adjusted rates of death were slightly lower after than before the closure in the CABG group. The adjusted rates of death or CABG in the PTCA group did not differ significantly between the 2 periods.
Hospital closure and the centralization of coronary revascularization procedures in Calgary was associated with increased population rates of procedures being performed, on sicker patients, with shorter hospital stays, and, for CABG patients, a trend toward more favourable short-term outcomes. Our findings indicate that controversial changes to the structure of the health care system can occur without loss of efficiency and reduction in quality of care.
PMCID: PMC81069  PMID: 11387915
15.  Early and Midterm Outcome of Redo Coronary Artery Bypass Grafting: On-Pump versus Off-Pump Bypass 
Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality as compared to the first-time operation. Further, the application of the off-pump technique to redo CABG is limited due to technical difficulties. The aim of this retrospective study was to analyze early and midterm results after redo CABG and compare the outcome of redo on-pump and off-pump CABG.
From June 1996 to October 2011, elective redo CABG was performed in 32 patients. Mean age was 64.8 years (on pump 64.3 years vs. off pump 65.5 years; p=0.658), and 21 patients were male. Among these patients, 14 (43.8%) underwent on-pump CABG, and 18 (56.2%) underwent off-pump CABG.
Internal thoracic artery was used in 22 patients (68.8%), and total arterial revascularization was achieved in 17 patients (53.1%). The average number of distal anastomoses was 2.13, and the rate of incomplete revascularization was 43.8%. The rate of total arterial revascularization was higher in the off-pump group (14.3% vs. 83.3%, p<0.001), and the use of saphenous vein graft was more in the on-pump group (78.6% vs. 16.7%, p<0.001). Overall hospital mortality was 3.1% (n=1) and was comparable in both groups (on pump 7.1% vs. off pump 0%; p=0.249). Postoperative complications occurred in 9 patients (64.2%), and the rate of complications was high in the on-pump group without statistical significance (64.2% vs. 33.3%, p=0.082). The mean follow-up duration was 5.4 years, and overall survival at 10 years was 86.0%±10.5%. There was no significant difference in the 10-year survival rate between the two groups (79.6% vs. 100%, p=0.225).
Redo CABG can be safely performed with acceptable mortality. Redo off-pump coronary artery bypass is feasible with low mortality and morbidity, comparable target vessel bypass grafting, and long-term survival. The off-pump technique might be considered a safe option for redo CABG in high-risk patients.
PMCID: PMC4157472  PMID: 25207219
1. Reoperation; 2. Coronary artery bypass; 3. Coronary artery bypass, off-pump
16.  Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction 
The New England journal of medicine  2011;364(17):1607-1616.
The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established.
Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes.
The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P = 0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P = 0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG.
In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH number, NCT00023595.)
PMCID: PMC3415273  PMID: 21463150
17.  Early outcome of Coronary Artery Bypass Graft Surgery in patients with significant Left Main Stem stenosis at a tertiary cardiac care center 
Primary objective of this study was to evaluate the impact of significant left main stem (LMS) stenosis on the early outcome of coronary artery bypass graft (CABG) surgery.
A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two (2602) patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I (n=2088): without significant LMS disease and Group II (n=514): with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student’s t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ≤ 0.05 was considered as significant difference.
Out of two thousand six hundred two, 2088 patients were in Non.LMS group (Control Group) and five hundred fourteen were in LMS Group (Study Group). Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 (9.7%) of patients were unstable in LMS group and they needed urgent surgery (p-value <0.0001). Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group (p-value <0.0001, 0.002, 0.003 respectively). Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group (p-value 0.005 and 0.001 respectively). Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen (2.5%) as compared to just 17 out of two thousand eighty eight (0.8%) in control group.
This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery.
PMCID: PMC4590371  PMID: 26430428
Coronary Artery Bypass Grafting; Left Main Stem disease
18.  Survival enhancing indications for coronary artery bypass graft surgery in California 
Coronary artery bypass graft (CABG) surgery is performed because of anticipated survival benefit, improvement in quality of life, or both. We performed this study to explore variations in clinical indications for CABG surgery among California hospitals and surgeons.
Using California CABG Outcomes Reporting Program data, we classified all isolated CABG cases in 2003–2004 as having "probable survival enhancing indications (SEIs)", "possible SEIs" or "non-SEIs." Patient and hospital characteristics associated with SEIs were examined.
While 82.9% of CABG were performed for probable SEIs, the range extended from 68% to 96% among hospitals and 51% to 100% among surgeons. SEI rates were higher among patients aged ≥ 65 compared with those aged 18–64 (Adjusted Odds Ratio [AOR] > 1.29 for age groups 65–69, 70–74 and ≥ 75; all p < 0.001), among Asians and Native Americans compared with Caucasians (AOR 1.22 and 1.15, p < 0.001); and among patients with hypertension, peripheral vascular disease, diabetes, cerebrovascular disease and congestive heart failure compared to patients without these conditions (AOR > 1.09, all p < 0.001). Variations in indications for surgery were more strongly related to patient mix than to surgeon or hospital effects (intraclass correlation [ICC] = 0.04 for hospital; ICC = 0.01 for surgeon).
California hospitals and surgeons vary in their distribution of indications for CABG surgery. Further research is required to identify the roles of market factors, referral patterns, patient preferences, and local clinical culture in producing the observed variations.
PMCID: PMC2621199  PMID: 19087305
19.  Dementia and Depression with Ischemic Heart Disease: A Population-Based Longitudinal Study Comparing Interventional Approaches to Medical Management 
PLoS ONE  2011;6(2):e17457.
We compared the proportion of ischemic heart disease (IHD) patients newly diagnosed with dementia and depression across three treatment groups: percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical management alone (IHD-medical).
Methods and Findings
De-identified, individual-level administrative records of health service use for the population of Manitoba, Canada (approximately 1.1 million) were examined. From April 1, 1993 to March 31, 1998, patients were identified with a diagnosis of IHD (ICD-9-CM codes). Index events of CABG or PCI were identified from April 1, 1998 to March 31, 2003. Outcomes were depression or dementia after the index event. Patients were followed forward to March 31, 2006 or until censored. Proportional hazards regression analysis was undertaken. Independent variables examined were age, sex, diabetes, hypertension and income quintile, medical management alone for IHD, or intervention by PCI or CABG. Age, sex, diabetes, and presence of hypertension were all strongly associated with the diagnosis of depression and dementia. There was no association with income quintile. Dementia was less frequent with PCI compared to medical management; (HR = 0.65; p = 0.017). CABG did not provide the same protective effect compared to medical management (HR = 0.90; p = 0.372). New diagnosis depression was more frequent with interventional approaches: PCI (n = 626; hazard ratio = 1.25; p = 0.028) and CABG (n = 1124, HR = 1.32; p = 0.0001) than non-interventional patients (n = 34,508). Subsequent CABG was nearly 16-fold higher (p<0.0001) and subsequent PCI was 22-fold higher (p<0.0001) for PCI-managed than CABG-managed patients.
Patients managed with PCI had the lowest likelihood of dementia—only 65% of the risk for medical management alone. Both interventional approaches were associated with a higher risk of new diagnosed depression compared to medical management. Long-term myocardial revascularization was superior with CABG. These findings suggest that PCI may confer a long-term protective effect from dementia. The mechanism(s) of dementia protection requires elucidation.
PMCID: PMC3046165  PMID: 21387018
20.  Impact of waiting time on the quality of life of patients awaiting coronary artery bypass grafting 
A lack of resources has created waiting lists for many elective surgical procedures within Canada's universal health care system. Coronary artery bypass grafting (CABG) for the treatment of atherosclerotic ischemic heart disease is one of these affected surgical procedures. We studied the impact of waiting times on the quality of life of patients awaiting CABG.
A prospective cohort of 266 patients from 3 hospitals in Montreal was used. Patients who gave informed consent were followed from the time they were registered for CABG until 6 months after surgery; recruitment began in November 1993, and the last follow-up was completed in July 1995. Patient groups were classified according to the duration of the wait for CABG (≤ 97 days or >> 97 days). We measured the following outcomes: quality of life (using the Medical Outcomes Study 36-item Short Form [SF-36]), incidence of chest pain (using the New York Heart Association angina classification), frequency of symptoms (using the Cardiac Symptom Inventory) and rates of complications and death before and after surgery.
There were no differences in quality of life at baseline between the 2 groups. Immediately before surgery, compared with patients who waited 97 days or less, those who waited longer had significantly reduced physical functioning (change from baseline SF-36 score 0 v. –4 respectively, p = 0.001), vitality (change from baseline score –0.1 v. –1.3, p = 0.01), social functioning (change from baseline score 0.4 v. –0.4, p = 0.03) and general health (change from baseline score 1.1 v. –1.7, p = 0.001). At 6 months after surgery, compared with patients who waited 97 days or less for CABG, those who waited longer had reduced physical functioning (change from baseline SF-36 score 4.0 v. –0.1 respectively, p = 0.001), physical role (change from baseline score 0.8 v. 0.0, p = 0.001), vitality (change from baseline score 2.2 v. 0.9, p = 0.001), mental health (change from baseline score 1.2 v. 0.0, p = 0.001) and general health (change from baseline score 1.8 v. –0.3, p = 0.001). The incidence of postoperative adverse events was significantly greater among the patients with longer waits for CABG than among those with shorter waits (32 v. 14 events respectively, p = 0.005). Longer waits before CABG were associated with an increased likelihood of not returning to work after surgery (p = 0.08): 10 (53%) of the 19 patients with longer waiting times remained employed after CABG, as compared with 17 (85%) of the 20 with shorter waiting times.
The significant decrease in physical and social functioning, both before and after surgery, for patients waiting more than 3 months for CABG is an important observation. Longer waiting times were also associated with increased postoperative adverse events. By decreasing waiting times for CABG, we may improve patients' quality of life and decrease the psychological morbidity associated with CABG.
PMCID: PMC81367  PMID: 11531051
21.  Predictors and outcomes of early coronary angiography in patients with prior coronary artery bypass surgery presenting with non-ST elevation myocardial infarction 
Open Heart  2014;1(1):e000059.
The best strategy in patients with prior coronary artery bypass graft surgery (CABG) who present with non-ST elevation myocardial infarction (NSTEMI) remains less well defined. We compare the characteristics, therapeutic interventions and outcomes of patients with prior CABG presenting with NSTEMI.
All patients who presented to our hospital during 2007–2012 with available electronic records were analysed retrospectively. Outcomes were compared between patients who underwent coronary angiography or percutaneous coronary intervention (PCI) versus those who were treated medically.
A total of 117 patients were analysed. Of that, 79 patients were managed medically while 38 underwent early angiography, of which only 11 (9.5%) received PCI. Patients treated medically (did not undergo angiography) were older (74±10 vs70±8; p=0.05). ECG changes were the only independent predictor for early angiography (OR 0.4, 95% CI 0.15 to 0.99; p=0.05) while recurrent chest pain (OR 0.2, 95% CI 0.05 to 0.97; p=0.05) predicted PCI on multivariate analysis. The PCI group had higher Global Registry of Acute Cardiac Events (GRACE) score (176±29 vs 150±31; p=0.01). No significant difference was found in readmission rates, morbidity (unstable angina pectoris, NSTEMI, ST elevation myocardial infarction (STEMI), or combination) or mortality at 12 months between the groups who underwent angiography, PCI, or treated medically on univariate and multivariate analysis.
The opportunity to intervene in prior CABG patients presenting with NSTEMI is often low. Initial medical management may be a reasonable option in carefully selected patients particularly in the absence of ongoing symptoms, ECG changes or very high GRACE scores. Further studies are required to evaluate the safety of non-invasive strategies in managing this population.
PMCID: PMC4195928  PMID: 25332800
22.  The Impact of Coronary Artery Endarterectomy on Outcomes During Coronary Artery Bypass Grafting 
Journal of cardiac surgery  2011;26(3):247-253.
The impact of coronary artery endarterectomy during coronary artery bypass grafting (CABG) has been debated. We examined the early and late outcomes of CABG with endarterectomy (CE) compared to CABG alone.
Patients undergoing isolated CABG operations from 2003 to 2008 were retrospectively reviewed. We identified 99 patients who underwent CE and 3:1 propensity matched them to 297 CABG-alone patients based upon clinical factors: Society of Thoracic Surgeons (STS) predicted risk of mortality, age, gender, year of surgery, and ejection fraction. Patient risk factors as well as short-and long-term outcomes were compared by univariate and Kaplan-Meier analysis.
Preoperative risk factors were similar between patients undergoing CE or CABG alone. Cross-clamp times (95.6 vs. 71.8 minutes, p = 0.0001) and perfusion times (121.8 vs. 92.7 minutes, p = 0.0001) were longer in patients undergoing CE. Operative mortality (4.0% vs. 1.3%, p = 0.112) and postoperative complications were not significantly different between groups. Patients undergoing coronary endarterectomy incurred longer ICU (75.06 vs. 48.64 hours, p = 0.001) and hospital stays (9.01 vs. 7.7 days, p = 0.034). Long-term mortality (mean follow-up = 27.7 ± 17.7 months) was equivalent despite revascularization technique (p = 0.13); however, patients undergoing CE encountered worse overall freedom from myocardial infarction (MI) (p = 0.03).
Patients undergoing CABG with coronary CE required longer ventilatory support and ICU stay yet have comparable operative mortality, major complication rates, and long-term survival to isolated CABG. Coronary endarterectomy should be considered an acceptable adjunct to CABG for patients with extensive coronary artery disease to achieve complete revascularization.
PMCID: PMC3117196  PMID: 21477101
23.  Comparison of pathology of chronic total occlusion with and without coronary artery bypass graft 
European Heart Journal  2013;35(25):1683-1693.
The aim of our study was to investigate chronic total occlusion (CTO) in human coronary arteries to clarify the difference between CTO with prior coronary artery bypass graft (CABG) and those without prior CABG.
Methods and results
A total of 95 CTO lesions from 82 patients (61.6 ± 14.0 years, male 87.8%) were divided into the following three groups: CTO with CABG (n = 34) (CTO+CABG), CTO without CABG—of long-duration (n = 49) (LD-CTO) and short-duration (n = 12) (SD-CTO). A histopathological comparison of the plaque characteristics of CTO, proximal and distal lumen morphology, and negative remodelling between groups was performed. A total of 1127 sections were evaluated. Differences in plaque characteristics were observed between groups as follows: necrotic core area was highest in SD-CTO (18.6%) (LD-CTO: 7.8%; CTO+CABG: 4.5%; P = 0.02); calcified area was greatest in CTO+CABG (29.2%) (LD-CTO: 16.8%; SD-CTO: 12.1%; P = 0.009); and negative remodelling was least in SD-CTO [remodelling index (RI) 0.86] [CTO+CABG (RI): 0.72 and LD-CTO (RI): 0.68; P < 0.001]. Approximately 50% of proximal lumens showed characteristics of abrupt closure, whereas the majority of distal lumen patterns were tapered (79%) (P < 0.0001).
These pathological differences in calcification, negative remodelling, and presence of necrotic core along with proximal and distal tapering, which has been associated with greater success, help explain the differences in success rates of percutaneous coronary intervention in CTO patients with and without CABG.
PMCID: PMC4076662  PMID: 24126875
Chronic total occlusion; Coronary artery bypass graft; Percutaneous coronary intervention; Negative remodelling; Calcification
24.  Comparison of Economic and Patient Outcomes With Minimally Invasive Versus Traditional Off-Pump Coronary Artery Bypass Grafting Techniques 
Annals of surgery  2008;248(4):638-646.
Minimally invasive coronary artery bypass grafting (miniCABG) decreases in-hospital morbidity versus traditional sternotomy CABG. We performed a prospective cohort study (NCT00481806) to assess the impact of miniCABG on costs and metrics that influence quality of life after hospital discharge.
One hundred consecutive miniCABG cases performed using IMA grafting ± coronary stenting were compared with a matched group of 100 sternotomy CABG patients using IMA and saphenous veins, both treating equivalent number of target coronaries (2.7 vs. 2.9), off-pump. We compared perioperative costs, time to return to work/normal activity, and risk of major adverse cardiac/cerebrovascular events (MACCE) at 1 year: myocardial infarction (elevated troponin or EKG changes), target vessel occlusion (CT angiography at 1 year), stroke, or death.
For miniCABG, robotic instruments and stents increased intraoperative costs; postoperative costs were decreased from significantly less intubation time (4.80 ± 6.35 vs. 12.24 ± 6.24 hours), hospital stay (3.77 ± 1.51 vs. 6.38 ± 2.23 days), and transfusion (0.16 ± 0.37 vs. 1.37 ± 1.35 U) leading to no significant differences in total costs. Undergoing miniCABG independently predicted earlier return to work after adjusting for confounders (t = − 2.15; P = 0.04), whereas sternotomy CABG increased MACCE (HR, 3.9; 95% CI, 1.4 –7.6), largely from lower target-vessel patency.
MiniCABG shortens patient recovery time, minimizes MACCE risk at 1 year, and showed superior quality and outcome metrics versus standard-of-care CABG. These findings occurred without increasing costs and with superior target vessel graft patency.
PMCID: PMC2649713  PMID: 18936577
25.  Long-term outcomes of isolated aortic valve replacement and concomitant AVR and coronary artery bypass grafting 
Netherlands Heart Journal  2012;20(3):110-117.
It is well established that concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) has a higher operative mortality rate than isolated AVR. However, studies report conflicting results on the long-term mortality. The aim of this prospective study was to explore and compare the outcomes and risk factors of isolated AVR and concomitant AVR and CABG in a consecutive Dutch patient population.
From January 2001 through January 2010, 332 consecutive patients underwent AVR with or without CABG at a single institution (197 isolated AVR and 135 concomitant AVR and CABG). A multivariate Cox proportional hazard analysis was performed to determine the independent risk factors for long-term mortality after aortic valve replacement.
All 332 consecutive, referred patients who underwent aortic valve surgery were followed for up to 10 years. Median follow-up length was 48 months. The population had a median age of 73 years (IQR 65–78) and predominantly consisted of males (62%). Patients in the combined AVR and CABG group were older, had worse cardiac risk profiles and had worse preoperative cardiac statuses than those receiving isolated AVR. Five-year survival was 85% in AVR and 73% in AVR-CABG (p-value 0.012). Independent risk factors for mortality were higher creatinine values, previous CABG and increasing age.
Unselected, consecutive patients who underwent aortic valve replacement surgery and who received concomitant bypass surgery between 2001–2010 had higher 5-year mortality than their counterparts without CABG. Prior CABG, renal function, age but not concomitant CABG remained independently associated with increased mortality. Finally, the observed mortality rate in this consecutive patient group compared favourably with preoperative risk assessment using the EuroSCORE.
PMCID: PMC3286529  PMID: 22311176
Aortic valve replacement; Coronary artery bypass grafting; Long term; Outcome; Survival; EuroSCORE; Concomitant; Valve; Surgery; AVR; CABG

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