151
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Multiple arterial grafting: Stay the course. J Thorac Cardiovasc Surg 2015; 150:452-3. [DOI: 10.1016/j.jtcvs.2015.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 06/05/2015] [Indexed: 11/20/2022]
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152
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Medalion B, Mohr R, Ben-Gal Y, Nesher N, Kramer A, Eliyahu S, Pevni D. Arterial coronary artery bypass grafting is safe and effective in elderly patients. J Thorac Cardiovasc Surg 2015; 150:607-12. [DOI: 10.1016/j.jtcvs.2015.06.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 06/09/2015] [Accepted: 06/13/2015] [Indexed: 10/23/2022]
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Abstract
Stable coronary artery disease is the most common clinical manifestation of ischaemic heart disease and a leading cause of mortality worldwide. Myocardial revascularisation is a mainstay in the treatment of symptomatic patients or those with ischaemia-producing coronary lesions, and reduces ischaemia to a greater extent than medical treatment. Documentation of ischaemia and plaque burden is fundamental in the risk stratification of patients with stable coronary artery disease, and several invasive and non-invasive techniques are available (eg, fractional flow reserve or intravascular ultrasound) or being validated (eg, instantaneous wave-free ratio and optical coherence tomography). The use of new-generation drug-eluting stents and arterial conduits greatly improve clinical outcome in patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). PCI is feasible, safe, and effective in many patients with stable coronary artery disease who remain symptomatic despite medical treatment. In patients with multivessel and left main coronary artery disease, the decision between PCI or CABG is guided by the local Heart Team (team of different cardiovascular specialists, including non-invasive and invasive cardiologists, and cardiac surgeons), who carefully judge the possible benefits and risks inherent to PCI and CABG. In specific subsets, such as patients with diabetes and advanced, multivessel coronary artery disease, CABG remains the standard of care in view of improved protection against recurrent ischaemic adverse events.
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Affiliation(s)
- Raffaele Piccolo
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Gennaro Giustino
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roxana Mehran
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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154
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Calafiore AM, Iacò AL, Di Mauro M. Spending 30 minutes to add years to a patient's life: Why is the last step so difficult? J Thorac Cardiovasc Surg 2015; 150:321-2. [DOI: 10.1016/j.jtcvs.2015.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
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155
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Gatti G, Maschietto L, Dell'Angela L, Benussi B, Forti G, Dreas L, Soso P, Russo M, Sinagra G, Pappalardo A. Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction. Heart Vessels 2015; 31:1045-55. [PMID: 26174428 DOI: 10.1007/s00380-015-0714-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/03/2015] [Indexed: 01/14/2023]
Abstract
Despite encouraging improvements, outcomes of coronary artery bypass grafting (CABG) in the presence of left ventricular (LV) dysfunction remain poor. In the present study, the authors' experience on this subject was reviewed to establish the predictors of immediate and long-term results of surgery. Out of 4383 consecutive patients with multivessel coronary artery disease who underwent primary isolated CABG at the authors' institution from January 1999 throughout September 2014, 300 patients (mean age 66.1 ± 9.6 years) suffered preoperatively from LV dysfunction (defined as LV ejection fraction ≤35 %). The mean expected operative risk (EuroSCORE II) was 10.3 ± 13 %. Hospital deaths and perioperative complications were analyzed retrospectively. Outcomes were evaluated during a mean follow-up of 6.2 ± 4 years. None, one or both internal thoracic arteries (ITAs) were used in 6.3, 29 and 64.7 % of cases, respectively. There were 16 (5.3 %) hospital deaths. Prolonged invasive ventilation (17.7 %), acute kidney injury (14.7 %) and multiple blood transfusion (21.3 %) were the most frequent major postoperative complications. The 10-year non-parametric estimates of freedom from all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were 47.8 [95 % confidence interval (CI) 44.1-51.5], 65.3 (95 % CI 61.4-69.2), and 42.3 % (95 % CI 38.3-46.3), respectively. Shared predictors of decreased late survival and MACCEs were old age (P < 0.04), chronic lung disease (P < 0.01), chronic dialysis (P < 0.0001) and extracardiac arteriopathy (P < 0.045). After adjustment for corresponding risk factors, freedom from cardiac death was higher when both ITAs were used but only for patients with significant increase of LV ejection fraction early after surgery (P = 0.04). In patients with LV dysfunction, CABG may be performed with acceptable hospital mortality and long-term survival. Late outcomes depend mainly on preoperative characteristics of the patients. The use of both ITAs for myocardial revascularization may give long-term survival benefits but only for patients whose LV function improves significantly early after surgery.
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Affiliation(s)
- Giuseppe Gatti
- Divisions of Cardiac Surgery, Ospedale di Cattinara, Ospedali Riuniti and University of Trieste, via P. Valdoni, 7, 34148, Trieste, Italy.
| | - Luca Maschietto
- Divisions of Cardiac Surgery, Ospedale di Cattinara, Ospedali Riuniti and University of Trieste, via P. Valdoni, 7, 34148, Trieste, Italy
| | - Luca Dell'Angela
- Divisions of Cardiology, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Bernardo Benussi
- Divisions of Cardiac Surgery, Ospedale di Cattinara, Ospedali Riuniti and University of Trieste, via P. Valdoni, 7, 34148, Trieste, Italy
| | - Gabriella Forti
- Divisions of Cardiac Surgery, Ospedale di Cattinara, Ospedali Riuniti and University of Trieste, via P. Valdoni, 7, 34148, Trieste, Italy
| | - Lorella Dreas
- Divisions of Cardiac Surgery, Ospedale di Cattinara, Ospedali Riuniti and University of Trieste, via P. Valdoni, 7, 34148, Trieste, Italy
| | - Petar Soso
- Divisions of Cardiac Surgery, Ospedale di Cattinara, Ospedali Riuniti and University of Trieste, via P. Valdoni, 7, 34148, Trieste, Italy
| | - Marco Russo
- Divisions of Cardiology, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Divisions of Cardiology, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Aniello Pappalardo
- Divisions of Cardiac Surgery, Ospedale di Cattinara, Ospedali Riuniti and University of Trieste, via P. Valdoni, 7, 34148, Trieste, Italy
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Valooran GJ, Nair SK, Chandrasekharan K. Strategies for the coronary surgeon to remain "competitive and co-operative" in the PCI era. Indian Heart J 2015; 67:351-8. [PMID: 26304568 PMCID: PMC4561793 DOI: 10.1016/j.ihj.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 04/09/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong. METHODS Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization. RESULTS The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature. CONCLUSIONS Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.
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Affiliation(s)
- George Jose Valooran
- Consultant, Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, India
| | - Shiv Kumar Nair
- Senior Consultant and HOD, Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, India.
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157
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Gardner TJ. Once more with emphasis: Two internal thoracic artery grafts are even better than one! J Thorac Cardiovasc Surg 2015; 150:454-5. [PMID: 26071971 DOI: 10.1016/j.jtcvs.2015.05.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Timothy J Gardner
- Department of Surgery, The Stanley Kimmel Medical College of Jefferson University, Philadelphia, Pa; Center for Heart and Vascular Health, Christiana Care Health System, Newark, Del; Value Institute at Christiana Care Health System, Newark, Del.
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158
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Affiliation(s)
- O P Yadava
- C.E.O. & Chief Cardiac Surgeon, National Heart Institute, New Delhi, India.
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159
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Gatti G, Dell'Angela L, Barbati G, Benussi B, Forti G, Gabrielli M, Rauber E, Luzzati R, Sinagra G, Pappalardo A. A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting. Eur J Cardiothorac Surg 2015; 49:910-7. [DOI: 10.1093/ejcts/ezv208] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/04/2015] [Indexed: 11/12/2022] Open
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LaPar DJ, Crosby IK, Rich JB, Quader MA, Speir AM, Kern JA, Tribble C, Kron IL, Ailawadi G. Bilateral Internal Mammary Artery Use for Coronary Artery Bypass Grafting Remains Underutilized: A Propensity-Matched Multi-Institution Analysis. Ann Thorac Surg 2015; 100:8-14; discussion 14-5. [PMID: 26002440 DOI: 10.1016/j.athoracsur.2015.02.088] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/19/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bilateral internal mammary arterial (BIMA) grafts have repeatedly demonstrated superior outcomes compared with single IMA (SIMA) after coronary artery bypass grafting (CABG). Despite known survival benefits with BIMA use, perceived perioperative challenges often preclude BIMA use. We hypothesized that the use of BIMA remains underutilized, even in low-risk patients. METHODS A total of 43,823 primary, isolated CABG patients in a regional Society of Thoracic Surgeons Database were evaluated. Patients were stratified by BIMA versus SIMA use. Surgical candidates considered "low risk" for BIMA use included the following: age less than 70 years; no or mild chronic lung disease; body mass index less than 30; and absence of diabetes. The BIMA patients (n = 1,333) were 1:1 propensity matched to SIMA patients (n = 1,333) and outcomes were compared. RESULTS Overall, BIMA use was 3%; 24% (n = 10,327) of patients met "low-risk" criteria for BIMA use. Among "low-risk" patients, BIMA utilization was 6%. Propensity-matched comparisons revealed similar preoperative risk profiles between BIMA and SIMA patients (Predicted Risk of Mortality [PROM] 1.1% vs 1.1%, p > 0.05). The BIMA use was associated with longer cross-clamp time (71 vs 62 minutes, p < 0.05). Importantly, BIMA use was not associated with increased postoperative mortality, morbidity, or hospital length of stay (all p > 0.05). However, hospital readmission within 30 days was 41% greater for BIMA patients compared with SIMA patients (p = 0.01). CONCLUSIONS Bilateral IMA graft use appears to remain underutilized in the modern surgical era, even in low surgical risk patients. The BIMA use does not appear to increase the risk of postoperative morbidity, although requires longer operative times and a higher risk for readmission. Efforts to more clearly understand surgeon motivators for the use of BIMA grafting are needed.
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Affiliation(s)
| | | | | | | | - Alan M Speir
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - John A Kern
- University of Virginia, Charlottesville, Virginia
| | - Curt Tribble
- University of Virginia, Charlottesville, Virginia
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161
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Parasca CA, Head SJ, Mohr FW, Mack MJ, Morice MC, Holmes DR, Feldman TE, Colombo A, Dawkins KD, Serruys PW, Kappetein AP. The impact of a second arterial graft on 5-year outcomes after coronary artery bypass grafting in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery Trial and Registry. J Thorac Cardiovasc Surg 2015; 150:597-606.e2. [PMID: 26055439 DOI: 10.1016/j.jtcvs.2015.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 04/09/2015] [Accepted: 05/02/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Despite various evidence supporting the advantages of multiple arterial grafting, inconsistencies in use of the procedure have resulted in high variability in the acceptance and practice of arterial grafting. The purpose of this study was to assess the effects of an arterial versus venous second grafts on outcomes at 5-year follow-up in the coronary artery bypass grafting population from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial. METHODS Patients (n = 1419) with an arterial graft to the left anterior descending artery and ≥1 other graft were included and divided according to the second graft's type: 2nd-graft-arterial group (n = 456) and 2nd-graft-venous group (n = 963). Five-year outcomes were compared between subgroups. Event rates were estimated with Kaplan-Meier analyses. Propensity-score matching was used, to control for selection bias due to nonrandom group assignment in a 1:1 manner, resulting in 432 pairs with balanced baseline characteristics. RESULTS In unmatched groups, the 2nd-graft-arterial group had significantly lower rates of death (8.9% vs 13.1%; P = .02), and composite safety endpoint of death/stroke/myocardial infarction (13.3% vs 18.7%; P = .02), compared with the 2nd-graft-venous group. The rate of major adverse cardiac or cerebrovascular events was similar between groups (22.9% vs 25.5%; P = .30), because it includes the rate of repeat revascularization (12.6% in the 2nd-graft-arterial group vs 9.6% in the 2nd-graft-venous group; P = .10). After propensity-score matching, no statistically significant differences were found between groups. CONCLUSIONS This study reveals comparable 5-year outcomes with arterial and venous conduits as second grafts after an arterial graft anastomosed to the left anterior descending artery. This study demonstrates the multi-institutional variation in patient selection and operator technique with regard to arterial revascularization, although extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes. CLINICAL TRIAL NUMBER NCT00114972.
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Affiliation(s)
- Catalina A Parasca
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Friedrich W Mohr
- Department of Cardiac Surgery, Herzzentrum Universität Leipzig, Leipzig, Germany
| | - Michael J Mack
- The Heart Hospital, Baylor Health Care Systems, Plano, Tex
| | - Marie-Claude Morice
- Department of Cardiology, Institut Cardiovasculaire Paris Sud, Massy, France
| | - David R Holmes
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minn
| | - Ted E Feldman
- Department of Cardiology, North Shore University Health System, Evanston, Ill
| | - Antonio Colombo
- Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy
| | | | - Patrick W Serruys
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
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162
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Carranza CL, Møller CH, Lindschou J, Olsen PS, Gluud C. Mammario-arterial anastomosis versus aorto-arterial anastomosis as proximal anastomotic sites in coronary artery bypass surgery for patients with multivessel disease. Hippokratia 2015. [DOI: 10.1002/14651858.cd011610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Christian L Carranza
- Rigshospitalet, Copenhagen University Hospital; Department of Cardiothoracic Surgery; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Christian H Møller
- Rigshospitalet, Copenhagen University Hospital; Department of Cardiothoracic Surgery; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Peter Skov Olsen
- Rigshospitalet, Copenhagen University Hospital; Department of Cardiothoracic Surgery; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; The Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
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163
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Khargi K. Stable and moderate glycaemic control in diabetic patients with bilateral internal mammary grafting: a simple and important recommendation. Eur J Cardiothorac Surg 2015; 49:427. [PMID: 25890938 DOI: 10.1093/ejcts/ezv161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Krishna Khargi
- Cardiothoracic and Vascular Center, University Hospital Maastricht, HX Maastricht, Netherlands
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164
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The second best arterial graft to the left coronary system in off-pump bypass surgery: a propensity analysis of the radial artery with a proximal anastomosis to the ascending aorta versus the right internal thoracic artery. Gen Thorac Cardiovasc Surg 2015; 63:335-42. [DOI: 10.1007/s11748-015-0534-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 02/24/2015] [Indexed: 10/23/2022]
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165
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Impact of pump status and conduit choice in coronary artery bypass: A 15-year follow-up study in 1412 propensity-matched patients. J Thorac Cardiovasc Surg 2015; 149:1027-33.e2. [DOI: 10.1016/j.jtcvs.2014.12.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/21/2014] [Accepted: 12/15/2014] [Indexed: 11/24/2022]
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Deo SV, Altarabsheh SE, Shah IK, Cho YH, McGraw M, Sarayyepoglu B, Medalion B, Markowitz AH, Park SJ. Are two really always better than one? Results, concerns and controversies in the use of bilateral internal thoracic arteries for coronary artery bypass grafting in the elderly: a systematic review and meta-analysis. Int J Surg 2015; 16:163-70. [PMID: 25598216 DOI: 10.1016/j.ijsu.2015.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/05/2015] [Accepted: 01/11/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Bilateral internal thoracic artery grafting appears to be the preferred method to achieve durable long-term coronary artery revascularization. However, data reporting the benefit of this technique in the elderly is very conflicting. METHOD We performed a systematic review of available literature (till November 2014) using multiple databases to identify studies comparing clinical events in patients undergoing coronary artery bypass grafting using either a single or double internal thoracic artery in the elderly. While early mortality was the primary end-point of inclusion, other adverse events compared were sternal wound infection (deep and superficial), stroke and peri-operative myocardial infarction. Individual and pooled odd's ratios were calculated using the Mantel-Haenzel method (random effect model); sensitivity analysis was performed. Results are presented using 95% confidence intervals. RESULT Nine retrospective studies (4479 BITA, 7733 LITA patients) fulfilled search criteria. Deep sternal wound infection was significantly higher after BITA harvest [OR 1.86 (1.3-2.5); I(2) = 0%; p < 0.01]. Early mortality (BITA 3.6% vs SITA 3.1%; p = 0.86), stroke [OR 0.7(0.4-1.1); p = 0.1], and peri-operative myocardial infarction (BITA 4.3% vs SITA 2.3%; p = 0.1) were comparable in both cohorts. Long-term survival favored the BITA cohort in two propensity matched studies. CONCLUSION The incidence of deep sternal wound infection may be significantly higher after the harvest of both internal thoracic arteries in the elderly. While other post-operative adverse events are comparable, data regarding the long-term survival advantage in this cohort is conflicting. Hence, the use of both internal thoracic arteries in this age group needs to be invidualized.
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Affiliation(s)
- Salil V Deo
- Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA.
| | - Salah E Altarabsheh
- Department of Cardiovascular Surgery, Queen Alia Heart Institute, Amman, Jordan
| | - Ishan K Shah
- Department of Surgery, University of Minnesota, Minneapolis-St.Paul, MN, USA
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan School of Medicine, Samsung Hospital, Seoul, South Korea
| | - Michael McGraw
- Health Sciences Library, Case Western Reserve University, Cleveland, OH, USA
| | - Basar Sarayyepoglu
- Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA
| | - Benjamin Medalion
- Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA
| | - Alan H Markowitz
- Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA
| | - Soon J Park
- Division of Cardiac Surgery, Harrington Heart and Vascular Institute, Case Medical Center, University Hospitals, Cleveland, OH, USA
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Schwann TA, Hashim SW, Badour S, Obeid M, Engoren M, Tranbaugh RF, Bonnell MR, Habib RH. Equipoise between radial artery and right internal thoracic artery as the second arterial conduit in left internal thoracic artery-based coronary artery bypass graft surgery: a multi-institutional study†. Eur J Cardiothorac Surg 2015; 49:188-95. [PMID: 25762396 DOI: 10.1093/ejcts/ezv093] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 02/03/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Multiple arterial coronary artery grafting (MABG) improves long-term survival compared with single arterial CABG (SABG), yet the best second arterial conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second arterial graft were compared with SABG. METHODS Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts. RESULTS Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively. CONCLUSIONS RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery.
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Affiliation(s)
- Thomas A Schwann
- University of Toledo Medical Center, Toledo, OH, USA Mercy St. Vincent Medical Center, Toledo, OH, USA
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Kajimoto K, Yamamoto T, Amano A. Coronary Artery Bypass Revascularization Using Bilateral Internal Thoracic Arteries in Diabetic Patients: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2015; 99:1097-104. [DOI: 10.1016/j.athoracsur.2014.09.045] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 09/09/2014] [Accepted: 09/12/2014] [Indexed: 11/27/2022]
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169
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The data and use of bilateral internal thoracic artery grafting: A paradox indeed. J Thorac Cardiovasc Surg 2015; 149:848-9. [DOI: 10.1016/j.jtcvs.2014.11.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 11/28/2014] [Indexed: 11/24/2022]
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Takazawa A, Nakajima H, Iguchi A, Tabata M, Morita K, Koike H, Uwabe K, Asakura T, Niinami H. Impacts of Intraoperative Flow on Graft Patency of Sequential and Individual Saphenous Vein Grafts. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Atsushi Iguchi
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Mimiko Tabata
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Kozo Morita
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Hiroyuki Koike
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Kazuhiko Uwabe
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Saitama International Medical Center, Saitama Medical University, Saitama Japan
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171
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Suzuki T, Asai T, Nota H, Kinoshita T, Fujino S, Takashima N. Similar outcome in insulin-dependent and noninsulin-dependent diabetic patients after off-pump coronary artery bypass grafting with multiple skeletonized arterial conduits. Ann Thorac Surg 2015; 99:1562-7. [PMID: 25707586 DOI: 10.1016/j.athoracsur.2014.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 11/26/2014] [Accepted: 12/05/2014] [Indexed: 01/04/2023]
Abstract
BACKGROUND We were interested in whether current multiarterial off-pump coronary artery bypass graft surgery can improve the clinical outcome for insulin-dependent diabetes mellitus patients. METHODS Between January 2002 and December 2013, 1,064 consecutive patients underwent isolated off-pump coronary artery bypass surgery at our hospital; 551 of these patients had diabetes. Of these 551 patients, 166 had insulin-dependent diabetes (IDM) and the remaining 385 had noninsulin-dependent diabetes (NIDM). The propensity score was calculated to achieve one-to-two matching sets (IDM 143 versus NIDM 286). RESULTS Ten patients (3.5%) in the NIDM group and 2 patients (1.4%) in the IDM group died in hospital (p = 0.18). Insulin dependency was not an independent risk factor for any early death or major complications. Follow-up was complete for 96.5% of the patients, with a mean follow-up of 4.6 ± 3.8 years. Overall survival rate at 10 years was 76.3% for the NIDM group and 73.1% for the IDM group (p = 0.79). The rate of 10-year actuarial freedom from major adverse cardiac events was 89.6% in the NIDM group and 86.3% in the IDM group (p = 0.72). Multivariate Cox proportional hazard regression analysis revealed that female sex, congestive heart failure, previous myocardial infarction, lower ejection fraction, and at least one major complication were independent risk factors for combined cardiac events. Insulin dependency did not affect any outcome in the long term. CONCLUSIONS Early and long-term outcomes after off-pump skeletonized multiarterial coronary artery bypass graft surgery were similar among the IDM and NIDM patients.
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Affiliation(s)
- Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan.
| | - Tohru Asai
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Hiromitsu Nota
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takeshi Kinoshita
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Susumu Fujino
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Noriyuki Takashima
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Otsu, Shiga, Japan
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172
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Davierwala PM, Mohr FW. Bilateral internal mammary artery grafting: rationale and evidence. Int J Surg 2015; 16:133-9. [PMID: 25612853 DOI: 10.1016/j.ijsu.2015.01.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/13/2015] [Accepted: 01/15/2015] [Indexed: 11/19/2022]
Abstract
Coronary artery bypass graft (CABG) surgery remains the preferred mode of revascularization in patients with complex multi-vessel coronary artery disease. The left internal mammary artery (IMA) and saphenous vein are the most commonly utilized conduits in CABG surgery and are still considered to be the gold standard by most surgeons. However, there is emerging evidence that use of bilateral IMAs is associated with significantly better long-term outcomes and the benefit increases with time from surgery. In spite of this incremental beneficiary effect, most surgeons are reluctant to use both IMAs, because it is technically more demanding, time-consuming and is associated with marginally higher sternal wound infection rates. This review highlights the histological features, physiological characteristics and genomics of IMAs that provide the basis for the use of these vessels during CABG surgery. Additionally, the superiority of the bilateral IMAs with regard to patency and long-term outcomes is also discussed in detail. Furthermore, the safety of using bilateral IMAs with regard to early postoperative outcomes with special reference to deep sternal wound infections has been addressed. The present review provides enough evidence to convince more surgeons about the advantages of bilateral IMA grafting.
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Affiliation(s)
- Piroze M Davierwala
- Department of Cardiac Surgery, Heart Center, University Leipzig, Leipzig, Germany; Herzzentrum Leipzig, Universitätsklinik, Helios Kliniken, Struempellstraße 39, 04289 Leipzig, Germany.
| | - Friedrich W Mohr
- Department of Cardiac Surgery, Heart Center, University Leipzig, Leipzig, Germany; Herzzentrum Leipzig, Universitätsklinik, Helios Kliniken, Struempellstraße 39, 04289 Leipzig, Germany.
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173
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Vitulli P, Frati G, Benedetto U. Bilateral internal mammary artery grafting in obese: outcomes, concerns and controversies. Int J Surg 2015; 16:158-62. [PMID: 25598215 DOI: 10.1016/j.ijsu.2015.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/06/2015] [Accepted: 01/13/2015] [Indexed: 01/22/2023]
Abstract
Obese patients are generally considered unsuitable to receive bilateral internal mammary arteries (BIMA) during coronary artery bypass grafting (CABG) due to the perceived vulnerability to sternal wound infection and lack of evidence supporting long-term survival benefit. However, no consistent evidence currently discourages the use of BIMA in obese patients. The present review questions the common perception that obesity unacceptably increases the risk of sternal wound complications in patients receiving BIMA grafting. Moreover, the use of skeletonization harvesting technique is expected to further minimize such a risk. Our institutional experience confirmed that BIMA grafting is a safe strategy which does not increase operative mortality and does not significantly affect the incidence of sternal wound complications. On the other hand, a long term benefit in terms of overall survival and freedom from repeat revascularization from the use of BIMA was found.
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Affiliation(s)
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
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Le J, Baskett RJF, Buth KJ, Hirsch GM, Brydie A, Gayner R, Legare JF. A pilot randomized controlled trial comparing CABG surgery performed with total arterial grafts or without. J Cardiothorac Surg 2015; 10:1. [PMID: 25567131 PMCID: PMC4299408 DOI: 10.1186/s13019-014-0203-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 12/26/2014] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To date only a few randomized controlled studies have compared grafting strategies in patients with multi-vessel coronary disease. This study represents a pilot RCT designed to test the feasibility of a trial comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) and CABG performed with total arterial grafting (TAG). METHODS Consenting patients undergoing non-redo isolated CABG surgery at a single institution were randomized to TAG or LIMA+SVG groups. Exclusion criteria included prior CABG, emergent procedure, concomitant procedure, varicose veins and renal dysfunction. The primary endpoints were: enrolment >20% and completion of CT coronary angiography at 6 months >80%. Statistical investigation was performed on an intention to treat analysis. RESULTS Of 421 eligible patients, 60 were enrolled and 2 withdrew (n = 30 in TAG, n = 28 LIMA+SVG) for 14% enrolment rate. Patient characteristics were similar in each group. No patients died in hospital and adverse events such as MI, stroke and deep sternal wound infection were not significantly different between groups. Clinical follow-up was complete in 100% of patients, with 44/58 (76%) undergoing CT coronary angio at 6 months. Graft occlusion occurred in 2 patients in each group for patency rates of 89% (TAG) and 91% (LIMA+SVG). CONCLUSIONS We provide evidence that an RCT comparing grafting strategy is possible but also show that achieving recruitment or follow-up CT may be difficult. Given the excellent patency results and little difference between groups, our findings suggest that the sample size required may make it infeasible to compare graft patency at 6 months as a study end-point. TRIAL REGISTRATION Randomized Controlled Trial number: ISRCTN80270323 . Few RCT's exist comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) compared to CABG performed with total arterial grafting (TAG). This study is a pilot RCT designed to test the feasibility of such a trial and identify pitfalls.
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Affiliation(s)
- Jeffrey Le
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Roger J F Baskett
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Karen J Buth
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Gregory M Hirsch
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Allan Brydie
- Department of Radiology, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Ryan Gayner
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Jean-Francois Legare
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada. .,Division of Cardiovascular Surgery, The Maritime Heart Center, 2269-1796 Summer Street, Halifax, NS, B3H 3A7, Canada.
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175
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Bakaeen FG. Harvesting Arterial Grafts: Barebones or More. Semin Thorac Cardiovasc Surg 2015; 27:121-2. [DOI: 10.1053/j.semtcvs.2015.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2015] [Indexed: 11/11/2022]
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176
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Jatene FB, Kolh P. Bilateral internal thoracic artery grafts for myocardial revascularization in insulin-dependent diabetic patients: time for wide clinical practice? Eur J Cardiothorac Surg 2014; 48:121-2. [PMID: 25501320 DOI: 10.1093/ejcts/ezu459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Fabio Biscegli Jatene
- Cirurgia Cardiovascular, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Philippe Kolh
- Department of Cardiovascular Surgery, University Hospital (CHU, ULg) of Liège, Liège, Belgium
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177
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Benedetto U, Amrani M, Raja SG. Guidance for the use of bilateral internal thoracic arteries according to survival benefit across age groups. J Thorac Cardiovasc Surg 2014; 148:2706-11. [DOI: 10.1016/j.jtcvs.2014.07.088] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 06/27/2014] [Accepted: 07/13/2014] [Indexed: 10/24/2022]
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178
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Benedetto U, Amrani M, Gaer J, Bahrami T, de Robertis F, Simon AR, Raja SG. The influence of bilateral internal mammary arteries on short- and long-term outcomes: A propensity score matching in accordance with current recommendations. J Thorac Cardiovasc Surg 2014; 148:2699-705. [DOI: 10.1016/j.jtcvs.2014.08.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/09/2014] [Accepted: 08/11/2014] [Indexed: 11/25/2022]
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179
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Taggart DP. Contemporary coronary artery bypass grafting. Front Med 2014; 8:395-8. [PMID: 25363396 DOI: 10.1007/s11684-014-0374-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 09/12/2014] [Indexed: 11/25/2022]
Abstract
Current evidence clearly demonstrates that coronary artery bypass grafting (CABG) remains the "gold standard" treatment for most patients with multivessel and left main stem disease. This article summarizes the relevant evidence basis demonstrating that CABG, in comparison to stenting, reduces mortality and subsequent myocardial infarction and the need for repeat revascularization. The article also describes the evidence basis to support the use of more arterial grafts during CABG and the current role of off-pump CABG.
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Affiliation(s)
- David P Taggart
- Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK,
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180
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181
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182
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Surgical versus percutaneous revascularization in patients with multivessel coronary artery disease. Curr Atheroscler Rep 2014; 16:461. [PMID: 25344743 DOI: 10.1007/s11883-014-0461-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
New-generation stents have been continually developed in order to improve the safety and efficacy of percutaneous coronary intervention (PCI). Several randomized clinical trials have been conducted over the last two decades to compare the outcomes of PCI with coronary artery bypass grafting (CABG), which has been the time-tested treatment of multivessel coronary artery disease. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial is one of the most recent and largest randomized controlled trials comparing PCI using the paclitaxel-eluting first-generation stent with CABG and was uniquely formulated to represent "real world" daily practice. The final 5-year main results of this trial and its various prespecified subgroups have been published in the past year. These results will form the basis of the new guidelines that will be published in the near future. This review is a compilation of the results of the SYNTAX trial and comparisons with other contemporary trials, meta-analyses, and retrospective studies of large registries and how these results help cardiac surgeons and cardiologists in judicious decision-making for their patients with multivessel coronary artery disease requiring revascularization.
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183
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Head SJ, Kappetein AP, Kolh P. Bilateral internal thoracic artery use: will another retrospective study ever strengthen the prospect? Eur J Cardiothorac Surg 2014; 47:709-11. [PMID: 25312528 DOI: 10.1093/ejcts/ezu332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Philippe Kolh
- Department of Cardiothoracic Surgery, University Hospital of Liège, Liège, Belgium
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184
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Nicolini F, Agostinelli A, Vezzani A, Benassi F, Gherli T. CABG versus PCI in the treatment of diabetic patients affected by coronary artery disease. Int Heart J 2014; 55:469-73. [PMID: 25297505 DOI: 10.1536/ihj.14-061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical coronary revascularization and percutaneous coronary intervention were demonstrated to be effective treatments for coronary artery disease. However, the optimal revascularization strategy remains unclear in certain patient subsets. The recently published Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial is a randomized study evaluating the use of CABG versus PCI in diabetic patients with multivessel coronary disease. The purpose of this study was to review the available literature based on randomized trials and observational studies in order to allow clinicians to make evidence-based decisions when treating diabetic patients with multivessel coronary disease. The current evidence suggests that CABG should remain the standard of care for this patient population.
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Affiliation(s)
- Francesco Nicolini
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
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185
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Halkos ME, Guyton RA. Coronary bypass: Is it time to take the next step—the routine use of the second arterial graft? J Thorac Cardiovasc Surg 2014; 148:1149-51. [DOI: 10.1016/j.jtcvs.2014.08.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 08/18/2014] [Indexed: 12/16/2022]
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186
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A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting. J Thorac Cardiovasc Surg 2014; 148:1282-90. [DOI: 10.1016/j.jtcvs.2014.01.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/23/2013] [Accepted: 01/10/2014] [Indexed: 11/17/2022]
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187
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3327] [Impact Index Per Article: 332.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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188
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Lessons learned from the use of 1,977 in-situ bilateral internal mammary arteries: a retrospective study. J Cardiothorac Surg 2014; 9:158. [PMID: 25238877 PMCID: PMC4177259 DOI: 10.1186/s13019-014-0158-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/02/2014] [Indexed: 11/18/2022] Open
Abstract
Background We sought to determine the early and long-term results of in-situ bilateral internal mammary artery (BIMA) grafting in patients undergoing coronary artery bypass graft surgery (CABG). Methods Between 1992 and 2011, 16,364 patients underwent primary isolated CABG involving at least one in-situ IMA at our institution. Among these, 1,977 patients underwent in-situ BIMA grafting: the right IMA was used to revascularize the right coronary artery system in 1,279, the circumflex system in 454 patients, and the left anterior descending (LAD) in 244. Logistic and Cox regression analyses were used to predict in-hospital mortality and cumulative late death. Results Late survival among BIMA patients was negatively and independently influenced by chronic obstructive pulmonary disease (hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.6-3.4, p = 0.0005), age (HR 1.2, 95% CI 1.1-1.3, p < 0.001), and mediastinitis (HR 2.1, 95% CI 1.1-4.2, p < 0.03). Gender, body mass index, diabetes, choice of target for the second (non-LAD) IMA, and conduit grafted to the LAD (RIMA vs. LIMA) did not influence late survival among BIMA patients. A BIMA grafting strategy was significantly beneficial for younger patients. However, it was not associated with superior late survival for patients aged 66 years and above at the time of CABG, and showed a trend to harm among octogenarians (HR 1.05, 95% CI 0.70-1.56, p = 0.80). Conclusions Female gender, non-insulin dependent diabetes, and the site of second IMA anastomosis did not influence early and long-term outcomes in patients undergoing CABG with in-situ BIMA grafting. The right and left IMAs are equally effective conduits for the LAD. However, advanced age, chronic obstructive pulmonary disease, and insulin-treated diabetes mellitus have a negative impact on late survival among patients with BIMA grafts. Electronic supplementary material The online version of this article (doi:10.1186/s13019-014-0158-9) contains supplementary material, which is available to authorized users.
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189
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Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM, Flather M. Effects of on-pump and off-pump surgery in the Arterial Revascularization Trial. Eur J Cardiothorac Surg 2014; 47:1059-65. [PMID: 25217501 DOI: 10.1093/ejcts/ezu349] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/01/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The Arterial Revascularization Trial (ART) is a randomized comparison of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting in coronary artery bypass graft (CABG) surgery and is one of the largest randomized trials of surgery ever conducted. ART is also one of the largest studies of contemporary CABG with a high proportion of off-pump surgeries (41%). The objective of this post hoc analysis was to evaluate the surgical process and 1-year outcomes for surgery performed on-pump compared with off-pump. METHODS ART randomized 3102 patients with multivessel coronary artery disease (CAD) to SIMA or BIMA grafts to determine if BIMA grafts have an additional survival advantage at 10 years. The 1-year interim analysis showed an overall very low mortality and major morbidity rate irrespective of whether the procedure was with an SIMA or BIMA. The surgical process and 1-year outcomes were analysed according to whether surgery was performed on-pump or off-pump. RESULTS Baseline variables were not statistically significantly different between on- and off-pump surgery within each treatment group after taking account of the effects of clustering by individual surgeons. At both 30 days and 1 year, there was a low incidence of death (1.2%, 2.3%), stroke (1.1%, 1.7%), myocardial infarction (MI) (1.4%, 1.9%), repeat revascularization (0.5%, 1.5%) and wound reconstruction (1.2%). A similar average number of grafts were performed with on- and off-pump surgery (median = 3), but the duration of surgery was 20-30 min and ventilation time ∼ 2 h shorter with off-pump surgery. Blood loss and platelet transfusions were lower in the off-pump group, with no difference in the need for balloon pump or renal support. Sternal wound reconstruction was similar with off-pump surgery in the SIMA group (0.5 vs 0.6%) and lower with off-pump surgery in the BIMA group (1.4 vs 2.2%). Repeat revascularization was marginally higher in off-pump patients at 30 days (0.8 vs 0.3%) and at 1 year (1.7 vs 1.3%). CONCLUSIONS The outcomes of contemporary CABG are excellent with low mortality, stroke, myocardial infarction and need for wound reconstruction and repeat revascularization whether performed on-pump or off-pump. CLINICAL TRIAL REGISTRATION Controlled-trials.com (ISRCTN46552265).
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Affiliation(s)
- David P Taggart
- Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Oxford, UK
| | - Alastair M Gray
- Department of Public Health, Health Economics Research Centre, University of Oxford, Headington, Oxford, UK
| | - Belinda Lees
- Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, London, UK National Heart and Lung Institute, Imperial College London, London, UK
| | - Fiona Nugara
- Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, London, UK
| | - Ly-Mee Yu
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Oxford, UK
| | - Marcus Flather
- Clinical Trials and Evaluation Unit, Royal Brompton and Harefield NHS Trust, London, UK National Heart and Lung Institute, Imperial College London, London, UK
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190
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Yi G, Shine B, Rehman SM, Altman DG, Taggart DP. Effect of Bilateral Internal Mammary Artery Grafts on Long-Term Survival. Circulation 2014; 130:539-45. [DOI: 10.1161/circulationaha.113.004255] [Citation(s) in RCA: 220] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background—
Although the potential survival benefit of bilateral internal mammary artery (BIMA) grafting in comparison with single internal mammary artery (SIMA) grafting has been emphasized by many investigators, the use of BIMA is still low in clinical practice in the absence of randomized trials and long-term results. In the current study, we aimed to assess if there is a long-term survival benefit of BIMA up to 10 years after coronary bypass surgery.
Methods and Results—
We selected published articles comparing survival between SIMA and BIMA patients with follow-up duration of more than a mean of 9 years. We evaluated the log hazard ratio with 95% confidence interval for included studies by using a random-effects meta-analysis. Nine eligible observational studies provided 15 583 patients (8270 SIMA and 7313 BIMA) for meta-analysis. Five studies used propensity score methods for statistical adjustment, 2 with a propensity score–based patient-matching method and 3 with quintile-based stratification. A significant reduction in mortality by using BIMA was observed (hazard ratio, 0.79; 95% confidence interval, 0.75–0.84); no study showed any significantly harmful effect of BIMA on survival. Subgroups of studies using different statistical approaches—unmatched, quintile-based propensity score analysis, and propensity score–based exact patient matching—all showed the survival benefit of BIMA grafting.
Conclusions—
BIMA grafting appears to have better survival with up to 10 years follow-up in comparison with SIMA grafting. Long-term survival benefit of BIMA seems to continue in the second decade after surgery. An ongoing randomized trial comparing SIMA and BIMA groups will add evidence on this issue.
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Affiliation(s)
- Gijong Yi
- From the Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom (G.Y., S.M.R., D.P.T.); Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea (G.Y.); Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom (B.S.); and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom (D.G.A.)
| | - Brian Shine
- From the Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom (G.Y., S.M.R., D.P.T.); Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea (G.Y.); Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom (B.S.); and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom (D.G.A.)
| | - Syed M. Rehman
- From the Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom (G.Y., S.M.R., D.P.T.); Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea (G.Y.); Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom (B.S.); and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom (D.G.A.)
| | - Douglas G. Altman
- From the Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom (G.Y., S.M.R., D.P.T.); Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea (G.Y.); Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom (B.S.); and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom (D.G.A.)
| | - David P. Taggart
- From the Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom (G.Y., S.M.R., D.P.T.); Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea (G.Y.); Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom (B.S.); and Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom (D.G.A.)
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191
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Rehman SM, Elzain O, Mitchell J, Shine B, Bowler ICJW, Sayeed R, Westaby S, Ratnatunga C. Risk factors for mediastinitis following cardiac surgery: the importance of managing obesity. J Hosp Infect 2014; 88:96-102. [PMID: 25123634 DOI: 10.1016/j.jhin.2014.06.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 06/17/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mediastinitis is a devastating complication of cardiac surgery. Previous studies have often observed small populations, been retrospective in design, and used a variety of definitions for mediastinitis. AIM To identify risk factors for mediastinitis, and strategies to minimize its incidence. METHODS A prospective cohort study of 4883 adult patients who underwent cardiac surgery between October 2003 and February 2009, comparing pre- and peri-operative risk factors, microbial aetiology, requirement for re-admission, length of stay and mortality between patients with and without mediastinitis. FINDINGS Ninety (1.8%) patients were diagnosed with mediastinitis. Microbial aetiology was defined for 75 patients. Staphlyocococcus aureus was the most common isolate (30 episodes; 15 due to meticillin-resistant S. aureus). Univariate analysis revealed the following pre-operative factors associated with mediastinitis: age; body mass index; diabetes; modified logistic European System for Cardiac Operative Risk Evaluation score; urgent admission; and longer pre-operative stay (P < 0.05). Associated peri-operative factors were: combined coronary artery bypass grafting plus aortic valve replacement; longer aortic cross-clamp time; and longer cardiopulmonary bypass time (P < 0.005). Multi-variate analysis revealed that higher body mass index, combined coronary artery bypass grafting plus aortic valve replacement, and older age were associated with mediastinitis (P < 0.05). Mediastinitis was associated with re-admission to hospital, longer inpatient stay and reduced long-term survival (P < 0.05). CONCLUSION Mediastinitis is associated with worse short-term outcomes (re-admission, length of stay) and reduced long-term survival. Obesity is the only modifiable pre-operative risk factor for mediastinitis. It may be possible to reduce risk through pre-operative weight loss programmes before elective surgery.
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Affiliation(s)
- S M Rehman
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Headington, Oxford, UK.
| | - O Elzain
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Headington, Oxford, UK
| | - J Mitchell
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Headington, Oxford, UK
| | - B Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Headington, Oxford, UK
| | - I C J W Bowler
- Department of Microbiology, John Radcliffe Hospital, Headington, Oxford, UK
| | - R Sayeed
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Headington, Oxford, UK
| | - S Westaby
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Headington, Oxford, UK
| | - C Ratnatunga
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Headington, Oxford, UK
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192
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Buxton BF, Shi WY, Tatoulis J, Fuller JA, Rosalion A, Hayward PA. Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival. J Thorac Cardiovasc Surg 2014; 148:1238-43; discussion 1243-4. [PMID: 25131165 DOI: 10.1016/j.jtcvs.2014.06.056] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/20/2014] [Accepted: 06/27/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVES We sought to evaluate our experience with total arterial revascularization and compare it with the traditional approach of a single internal thoracic artery supplemented by saphenous veins. METHODS From 1995 to 2010, 6059 patients with triple-vessel coronary artery disease underwent primary isolated coronary artery bypass grafting at 8 centers. A study cohort of 3774 patients was formed, with 2988 (79%) undergoing total arterial revascularization and 786 (21%) receiving only saphenous veins to supplement a single in situ internal thoracic artery. In the total arterial revascularization group, bilateral internal thoracic arteries were used in 1079 patients (36%) and at least 1 radial artery was used in 2916 patients (97%). Propensity score matching was used for risk adjustment. RESULTS Patients undergoing total arterial revascularization were younger (65.0±10.4 years vs 71.3±7.9 years, P<.001) and less likely to have diabetes, cerebrovascular disease, recent myocardial infarction, and severe left ventricular impairment. At 15 years, patients who underwent total arterial revascularization experienced superior unadjusted survival (62%±1.1% vs 35%±1.9%, P<.001). Multivariable Cox regression in the entire study cohort showed the total arterial group had improved survival with a hazard ratio of 0.79 (95% confidence interval, 0.70-0.90; P<.001). After propensity score matching yielded 384 patient pairs, patients who underwent total arterial revascularization showed improved survival at 15 years than patients who underwent single arterial revascularization (54%±3.3% vs 41%±3.0%, P=.0004). CONCLUSIONS This large multicenter study suggests that a strategy of total arterial revascularization is associated with improved long-term survival compared with the use of only a single arterial and saphenous vein grafts. Total arterial revascularization should be encouraged in patients with a reasonable life expectancy.
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Affiliation(s)
- Brian F Buxton
- Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia.
| | - William Y Shi
- Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - James Tatoulis
- Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - John A Fuller
- Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia
| | - Alexander Rosalion
- Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia
| | - Philip A Hayward
- Victorian Heart Centre, Epworth Hospital, University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, Austin Hospital, University of Melbourne, Melbourne, Australia
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193
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Optimal Conduit for Diabetic Patients: Propensity Analysis of Radial and Right Internal Thoracic Arteries. Ann Thorac Surg 2014; 98:30-6; discussion 36-7. [DOI: 10.1016/j.athoracsur.2014.03.044] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/18/2014] [Accepted: 03/26/2014] [Indexed: 11/23/2022]
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194
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Gagné K, Deschamps A, Cartier R. Sequential Internal Thoracic Artery Bypass Is Safe but Does Not Improve Survival. Ann Thorac Surg 2014; 98:23-9. [DOI: 10.1016/j.athoracsur.2014.03.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 03/07/2014] [Accepted: 03/20/2014] [Indexed: 10/25/2022]
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195
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Taggart DP. Percutaneous or surgical revascularization in multivessel coronary artery disease: synthesis from SYNTAX. Eur Heart J 2014; 35:2789-91. [DOI: 10.1093/eurheartj/ehu253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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196
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Pettinari M, Sergeant P, Meuris B. Bilateral internal thoracic artery grafting increases long-term survival in elderly patients†. Eur J Cardiothorac Surg 2014; 47:703-9. [DOI: 10.1093/ejcts/ezu206] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Head SJ, Kieser TM, Falk V, Huysmans HA, Kappetein AP. Coronary artery bypass grafting: Part 1--the evolution over the first 50 years. Eur Heart J 2014; 34:2862-72. [PMID: 24086085 DOI: 10.1093/eurheartj/eht330] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Surgical treatment for angina pectoris was first proposed in 1899. Decades of experimental surgery for coronary artery disease finally led to the introduction of coronary artery bypass grafting (CABG) in 1964. Now that we are approaching 50 years of CABG experience, it is appropriate to summarize the advancement of CABG into a procedure that is safe and efficient. This review provides a historical recapitulation of experimental surgery, the evolution of the surgical techniques and the utilization of CABG. Furthermore, data on contemporary clinical outcomes are discussed.
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Affiliation(s)
- Stuart J Head
- Department of cardiothoracic surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Head SJ, Börgermann J, Osnabrugge RLJ, Kieser TM, Falk V, Taggart DP, Puskas JD, Gummert JF, Kappetein AP. Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects. Eur Heart J 2014; 34:2873-86. [PMID: 24086086 DOI: 10.1093/eurheartj/eht284] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.
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Affiliation(s)
- Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Stem cells accumulate on a decellularized arterial xenograft in vivo. Ann Thorac Surg 2014; 97:2104-10. [PMID: 24725834 DOI: 10.1016/j.athoracsur.2014.02.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/05/2014] [Accepted: 02/11/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Surgical interest in complete arterial revascularization is expanding, but some patients lack suitable conduits for this goal. The field of stem cell biology is rapidly expanding and, together with the concepts of tissue engineering, offers the promise of growing autologous grafts in the laboratory. We aim to develop a model using human arteries as vascular grafts in a murine model and to assess the cellular accumulation on these grafts. METHODS Human arterial samples were collected and decellularized using an ionic detergent. These vessel scaffolds were then used as grafts in an in vivo mouse model, and the cellular accumulation on them was examined histologically and by cell culture with assessment of their physiologic properties. RESULTS Left internal mammary artery branches were fully decellularized and successfully implanted into a murine model. Grafts were repopulated by cells expressing stem cell markers cluster of differentiation 34 and stage-specific embryonic antigen, and subsequently expressed markers of mature endothelial and smooth muscle cells (cluster of differentiation 31, calponin, and myosin heavy chain). The migratory capacity of the cultured cells was significantly higher than that of mouse smooth muscle cells (p < 0.001). CONCLUSIONS We describe the successful use of human arteries in a murine graft model, allowing the study of repopulation. Decellularized grafts are repopulated by cells expressing stem cell markers and subsequently express smooth muscle and endothelial cell markers. This model has the potential to be used for further development of laboratory-grown vascular grafts.
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Time-Varying Survival Benefit of Radial Artery Versus Vein Grafting: A Multiinstitutional Analysis. Ann Thorac Surg 2014; 97:1328-34; discussion 1334. [DOI: 10.1016/j.athoracsur.2013.09.096] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 09/17/2013] [Accepted: 09/27/2013] [Indexed: 11/20/2022]
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