Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: a propensity-matched study with 30-year follow-up

Current indications and surgical strategies for myocardial revascularization in patients with left ventricular dysfunction: a scoping review

BACKGROUND

Ischemic cardiomyopathy (ICM) accounts for more than 60% of congestive heart failure cases and is associated with high morbidity and mortality rates. Myocardial revascularization in patients with left ventricular dysfunction (LVD) and a left ventricular ejection fraction (LVEF) ≤35% aims to improve survival and quality of life and reduce complications associated with heart failure and coronary artery disease. The majority of randomized clinical trials have consistently excluded those patients, resulting in evidence primarily derived from observational studies.

MAIN BODY

We performed a scoping review using the Arksey and O'Malley methodology in five stages: 1) formulating the research question; 2) locating relevant studies; 3) choosing studies; 4) organizing and extracting data; and 5) compiling, summarizing, and presenting the findings. This literature review covers primary studies and systematic reviews focusing on surgical revascularization strategies in adult patients with ischemic left ventricular dysfunction (LVD) and a left ventricular ejection fraction (LVEF) of 35% or lower. Through an extensive search of Medline and the Cochrane Library, a systematic review was conducted to address three questions regarding myocardial revascularization in these patients. These questions outline the current knowledge on this topic, current surgical strategies (off-pump vs. on-pump), and graft options (including hybrid techniques) utilized for revascularization. Three independent reviewers (MAE, DP, and AM) applied the inclusion criteria to all the included studies, obtaining the full texts of the most relevant studies. The reviewers subsequently assessed these articles to make the final decision on their inclusion in the review. Out of the initial 385 references, 156 were chosen for a detailed review. After examining the full articles were examined, 134 were found suitable for scoping review.

CONCLUSION

The literature notes the scarcity of surgical revascularization in LVD patients in randomized studies, with observational data supporting coronary revascularization's benefits. ONCABG is recommended for multivessel disease in LVD with LVEF < 35%, while OPCAB is proposed for older, high-risk patients. Strategies like internal thoracic artery skeletonization harvesting and postoperative glycemic control mitigate risks with BITA in uncontrolled diabetes. Total arterial revascularization maximizes long-term survival, and hybrid revascularization offers advantages like shorter hospital stays and reduced costs for significant LAD lesions.

Long-term results following off-pump coronary-artery bypass grafting in left ventricular dysfunction

Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women's Medical University).

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients

BACKGROUND

Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG.

METHODS

All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit.

RESULTS

A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG.

CONCLUSIONS

Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Association of HbA1c and utilization of internal mammary arteries with wound infections in CABG

Background

Deep sternal wound infection (DSWI) remains a serious complication after coronary artery bypass grafting (CABG). We herein aimed to stratify diabetic patients who underwent CABG using bilateral internal mammary artery (BIMA) for levels of glycated hemoglobin A1C (HbA1c) and compare postoperative outcomes.

Methods

Between January 2010 and August 2020, 4,186 consecutive patients underwent isolated CABG at our center. In 3,229 patients, preoperative HbA1c levels were available. Primary endpoints were wound healing disorder (WHD), DSWI, and 30-day mortality. Patients were stratified according to preoperative HbA1c levels. Patients were further divided into subgroups according to utilization of BIMA.

Results

After adjustment, no differences in mortality and stroke rates were seen between group 1 (HbA1c < 6.5%) vs. group 2 (HbA1c ≥ 6.5%). WHD was more frequent in group 2 [2.8 vs. 5.6%; adjusted p = 0.002; adjusted odds ratio (OR), 1.853 (1.243-2.711)] but not DSWI [1.0 vs. 1.5%; adjusted p = 0.543; adjusted OR, 1.247 (0.612-2.5409)]. BIMA use showed a higher rate of WHD [no BIMA: 3.0%; BIMA: 7.7%; adjusted p = 0.002; adjusted OR, 4.766 (1.747-13.002)] but not DSWI [no BIMA: 1.1%; BIMA: 1.8%; adjusted p = 0.615; adjusted OR, 1.591 (0.260-9.749)] in patients with HbA1c ≥ 6.5%.

Conclusions

Intraoperative utilization of BIMA is not connected with an increase of DSWI but higher rates of WHD in patients with poor diabetic status and HbA1c ≥ 6.5%. Therefore, application of BIMA should be taken into consideration even in patients with poor diabetic status, while identification of special subsets of patients who are at particular high risk for DSWI is of paramount importance to prevent this serious complication.

Off-pump bilateral internal thoracic artery grafting in patients with left main coronary artery disease

BACKGROUND

To compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).

METHODS

Among 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting.

RESULTS

After adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504-0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499-0.902; p = 0.008).

CONCLUSIONS

Bilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.

Sternal wound infections following internal mammary artery grafts for a coronary bypass: A meta-analysis

The meta-analysis aims to evaluate and compare the sternal wound infections following internal mammary artery grafts for a coronary bypass. Examinations comparing bilateral internal mammary artery to single internal mammary artery for coronary artery bypass grafting were among the meta-analyses from various languages that met the inclusion criteria. Using dichotomous random- or fixed-effect models, the results of these investigations were examined, and the Odd Ratio (OR) with 95% confidence intervals (CIs) was computed. A total of 31 examinations from 2001 to 2023 were recruited for the current analysis including 181 503 personals with coronary artery bypass grafting. Bilateral internal mammary artery had significantly higher sternal wound infection (OR, 1.51; 95% CI, 1.37-1.68, p < 0.001), superficial sternal wound infection (OR, 1.72; 95% CI, 1.16-2.56, p = 0.007), deep sternal wound infection (OR, 1.62; 95% CI, 1.41-1.86, p < 0.001), sternal wound infection in diabetics (OR, 1.48; 95% CI, 1.16-1.90, p = 0.002), sternal wound infection in elderly (OR, 1.38; 95% CI, 1.22-1.57, p < 0.001), sternal wound infection in pedicled preparation (OR, 1.70; 95% CI, 1.30-2.23, p < 0.001) and sternal wound infection in skeletonized preparation (OR, 1.40; 95% CI, 1.09-1.81, p = 0.009) compared to single internal mammary artery in personals with coronary artery bypass grafting. Bilateral internal mammary artery grafting is linked to a higher risk of impaired wound healing, particularly in diabetic individuals, elderly, pedicled preparation, and skeletonized preparation. Nevertheless, caution should be exercised while interacting with its values since examinations were performed by different surgeons with different skills on different types of personals.

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)

PREAMBLE

The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).

Off-Pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Octogenarians

BACKGROUND

We compared postoperative outcomes in octogenarians who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).Methods and Results: Among 1,532 patients who underwent isolated coronary artery bypass grafting between 2002 and 2021, 173 octogenarians were analyzed retrospectively. After inverse probability of treatment weighting, we found no statistically significant difference regarding patients' preoperative characteristics. No patient experienced deep sternal wound infection. More patients in the single than bilateral ITA group died within 30 days after surgery (5.0% vs. 0%, respectively; P=0.003). The mean follow-up duration was 4.2 years. At 5 years, the freedom from overall death following bilateral versus single ITA grafting was 78.2% and 53.7%, respectively (log-rank test, P=0.003), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 67.9% and 44.8% respectively (log-rank test, P=0.002). In multivariable Cox models, bilateral ITA grafting was significantly associated with a lower risk of overall death (hazard ratio [HR] 0.555; 95% confidence interval [CI] 0.342-0.903; P=0.018) and MACCE (HR 0.586; 95% CI 0.376-0.913; P=0.018).

CONCLUSIONS

Compared with single ITA grafting, off-pump skeletonized bilateral ITA grafting is associated with lower rates of overall death and MACCE in octogenarians undergoing CABG and does not increase the risk of deep sternal wound infection.

Single versus multiple arterial grafting in diabetic patients at 10 years: the Arterial Revascularization Trial

AIMS

To evaluate the impact of multiple arterial grafting (MAG) vs. single arterial grafting (SAG) in a post hoc analysis of 10-year outcomes in patients with diabetes mellitus (DM) from the Arterial Revascularization Trial (ART).

METHODS AND RESULTS

The primary endpoint was all-cause mortality and the secondary endpoint was a composite of major adverse cardiac events (MACE) at 10-year follow-up. Patients were stratified by diabetes status (non-DM and DM) and grafting strategy (MAG vs. SAG). A total of 3020 patients were included in the analysis; 716 (23.7%) had DM. Overall, 55.8% non-DM patients received MAG and 44.2% received SAG, while 56.6% DM patients received MAG and 43.4% received SAG. The use of MAG compared with SAG was associated with lower 10-year mortality for both non-DM [17.7 vs. 21.0%, adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.72-1.06] and DM patients (21.5 vs. 29.9%, adjusted HR 0.65, 95% CI 0.48-0.89; P for interaction = 0.12). For both groups, the rate of 10-year MACE was also lower for MAG vs. SAG. Overall, deep sternal wound infections (DSWIs) were uncommon but more frequent in the MAG vs. SAG group in both non-DM (3.3 vs. 2.1%) and DM patients (7.9 vs. 4.8%). The highest rates of DSWI were in insulin-treated patients receiving MAG (9.6 vs. 6.3%, when compared with SAG).

CONCLUSION

In this post hoc analysis of the ART, MAG was associated with substantially lower mortality rates at 10 years after coronary artery bypass grafting in patients with DM. Patients with DM receiving MAG had a higher incidence of DSWI, especially if insulin dependent.

Ultrasound Evaluation of Subclavian Artery and Internal Thoracic Artery Before Coronary Artery Bypass Grafting as Part of Preoperative Vascular Assessment

RATIONALE AND OBJECTIVES

Noninvasive diagnostic imaging of subclavian artery (SCA) and internal thoracic artery (ITA) is crucial to the patients planning to use ITA for coronary artery bypass grafting (CABG). The guidelines have not yet provided guidance on screening high-risk groups. The present study aimed to evaluate the contribution of ultrasonography in the assessment of SCA and ITA, especially for the patients referred for CABG who planned to use ITA graft.

MATERIALS AND METHODS

Patients diagnosed with multivessel coronary heart disease were enrolled and some of them planned CABG. Bilateral SCAs and ITAs were routinely evaluated by color Doppler ultrasound (CDUS) before operation. The luminal diameter and the peak systolic velocity of the proximal and distal parts of SCA and ITA were measured. Depending on the Doppler waveform, the lumen narrowing rate was calculated.

RESULTS

The final analysis was carried out in 572 patients. Thirty-five patients had moderate (50%-69%), severe (70%-99%) stenosis or occlusion in the SCA (left-sided in 21 and right-sided in 14). One patient had severe proximal stenosis in left ITA and one patient had no flow in left ITA due to the occlusion in left SCA. One patient had anatomic variation of isolated right aortic arch with aberrant left SCA. All of those cases were confirmed with multidetector computed tomography angiography.

CONCLUSION

CDUS could be used for the evaluation of SCA and ITA before CABG as part of presurgical vascular assessment and provide an import basis for the imaging diagnosis and surgical plan.

Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting

Background

Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG).

Methods

A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival.

Results

Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with <500 mL blood loss, 86.8% for 500–1,000 mL and 83.8% for >1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival.

Conclusions

Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.

Bilateral Internal Thoracic Artery Grafting in Hemodialysis Patients

BACKGROUND

We compared postoperative outcomes in hemodialysis (HD) patients who underwent isolated coronary artery bypass grafting (CABG) for multivessel disease using either bilateral or single skeletonized internal thoracic artery.Methods and Results:Among 1,486 patients who underwent isolated CABG between 2002 and 2020, 145 HD patients were retrospectively analyzed. After inverse probability of treatment weighting, there were no significant differences in the preoperative characteristics. No significant differences in 30-day mortality (P=0.551) or postoperative deep sternal wound infection (P=0.778) were observed. However, the bilateral internal thoracic artery grafting group had a lower postoperative stroke rate (0% vs. 4.0%, P=0.019). No significant differences in freedom from all-cause death (P=0.760) and cardiac death (P=0.863) were found. In the multivariate Cox proportional hazards models, bilateral internal thoracic artery grafting was not associated with all-cause death (P=0.246) or cardiac death (P=0.435).

CONCLUSIONS

Bilateral internal thoracic artery grafting in HD patients did not improve mid-term outcomes, but it was also not associated with worse postoperative outcomes. Use of the bilateral internal thoracic artery may be an important option in patients with limited conduits to prevent postoperative complications.

Effect of bilateral internal thoracic artery harvesting on deep sternal wound infection in diabetic patients: Review of literature

Instead of its documented superiority of patency and long-term outcomes, the bilateral internal thoracic artery grafts are underused in the general population, and its use is controversial and debatable in diabetic patients due to long surgery duration, post-surgical bleeding, and sternal wound complications such as sternal wound infection, mediastinitis, and sternal wound dehiscence. This review article is particularly focused on deep sternal wound infection (DSWI) of bilateral internal thoracic artery (BITA) grafts in diabetic patients with comparison to single internal thoracic artery (SITA) graft.

•

Bilateral internal thoracic artery grafting is superior to single internal thoracic artery grafting in terms of outcomes.

•

Bilateral internal thoracic artery grafting is underused, especially in diabetic patients.

•

The risk of DSWI in skeletonized BITA grafting in diabetic patients is almost similar to SITA grafting.

•

Skeletonized BITA grafting should be encouraged in selected diabetic patients.

Multiple arterial conduits for multi-vessel coronary artery bypass grafting in patients with mild to moderate left ventricular systolic dysfunction: a multicenter retrospective study

Background

Advantages of multiple arterial conduits for coronary artery bypass grafting (CABG) have been reported previously. We aimed to evaluate the mid-term outcomes of multiple arterial CABG (MABG) among patients with mild to moderate left ventricular systolic dysfunction (LVSD).

Methods

This multicenter study using propensity score matching took place from January 2013 to June 2019 in Jiangsu Province and Shanghai, China, with a mean and maximum follow-up of 3.3 and 6.8 years, respectively. We included patients with mild to moderate LVSD, undergoing primary, isolated multi-vessel CABG with left internal thoracic artery. The in-hospital and mid-term outcomes of MABG versus conventional left internal thoracic artery supplemented by saphenous vein grafts (single arterial CABG) were compared. The primary end points were death from all causes and death from cardiovascular causes. The secondary end points were stroke, myocardial infarction, repeat revascularization, and a composite of all mentioned outcomes, including death from all causes (major adverse events). Sternal wound infection was included with 6 months of follow-up after surgery.

Results

243 and 676 patients were formed in MABG and single arterial CABG cohorts after matching in a 1:3 ratio. In-hospital death was not significantly different (MABG 1.6% versus single arterial CABG 2.2%, p = 0.78). After a mean (±SD) follow-up time of 3.3 ± 1.8 years, MABG was associated with lower rates of major adverse events (HR, 0.64; 95% CI, 0.44–0.94; p = 0.019), myocardial infarction (HR, 0.39; 95% CI, 0.16–0.99; p = 0.045) and repeat revascularization (HR, 0.42; 95% CI, 0.18–0.97; p = 0.034). There was no difference in the rates of death, stroke, and sternal wound infection.

Conclusions

MABG was associated with reduced mid-term rates of major adverse events and cardiovascular events and may be the procedure of choice for patients with mild to moderate LVSD requiring CABG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01463-5.

Bilateral Internal Thoracic Artery Grafting Improves Survival for Severe Left Ventricular Dysfunction and Diabetes

BACKGROUND

In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.Methods and Results:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024).

CONCLUSIONS

NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.

Glycemic control and risk factors for in-hospital mortality and vascular complications after coronary artery bypass grafting in patients with and without preexisting diabetes

BACKGROUND

The purpose of this study was to investigate risk factors of in-hospital mortality and vascular complications after coronary artery bypass grafting (CABG), particularly the effect of different glycemic control levels on outcomes in patients with and without previous evidence of diabetes.

METHODS

A total of 8682 patients with and without previous diabetes undergoing CABG were categorized into strict, moderate, and liberal glucose control groups according to their mean blood glucose control level <7.8 mmol/L, 7.8 to 10.0 mmol/L, and ≥10.0 mmoL/L after in-hospital CABG.

RESULTS

The patients with previous diabetes had higher rates of in-hospital mortality (1.3% vs 0.4%, P < .001) and major complications (7.0% vs 4.8%, P < .001) than those without diabetes. Current diabetes was significantly associated with a higher risk of in-hospital mortality (odds ratio [OR] = 3.14, 95% confidence interval [CI] 1.87-5.27) and major complications (OR = 1.49, 95% CI 1.24-1.80), and smoking and higher low-density lipoprotein cholesterol (LDL-C) levels showed similar results. Among patients with previous diabetes, strict glucose control was significantly associated with an increased risk of in-hospital mortality (OR = 8.32, 95% CI 3.95-17.51) compared with moderate glucose control. Nevertheless, among non-previous diabetic patients with stress hyperglycemia, strict glucose control led to a lower risk of major complications (OR = 0.71, 95% CI 0.52-0.98).

CONCLUSIONS

Diabetes status, smoking, and LDL-C levels were modifiable risk factors of both in-hospital mortality and major complications after CABG. Strict glucose control was associated with an increased risk of in-hospital mortality among patients with diabetes, whereas it reduced the risk of major complications among non-previous diabetic patients.

Application of bilateral internal mammary artery with different configurations in coronary artery bypass grafting

Background

A large number of studies have shown that BIMA grafting is superior to single internal mammary artery grafting in cardiac function protection and long-term survival after surgery. While, there is still no consensus on how is the best configuration to use BIMA. This study aims to compare intraoperative blood flow, early clinical results and early postoperative patency of different configurations of BIMA.

Methods

There were 74 patients who underwent CABGs with bilateral internal mammary artery with different configurations we included. According to the different target territories that RIMA grafted to, the patients were divided into bilateral group (group I) with 20 cases and left group (group II) with 54 cases. Intraoperative blood flow, early clinical results and early postoperative patency of different configurations of BIMA were compared.

Results

There was no difference in the early postoperative death and major complications between group I and Group II(P>0.05). Compared with the LIMA in group II, the LIMA in group I had a slightly higher DF value (76.7 ± 6.2 vs 73.1 ± 6.8, P = 0.040). Compared with the RIMA in group II, the RIMA in group I had a slightly higher MGF (51.7 ± 34.4 ml/min vs 31.4 ± 21.4 ml/min, P = 0.024). There was no difference in the other TTFM parameters of LIMA and RIMA between group I and Group II(P>0.05). Further subgroup analysis revealed that compared with free RIMA in group II, in situ RIMA had a higher DF value (71.4 ± 7.8 vs 61.8 ± 18.1,P = 0.025). The PI of LIMA in free RIMA subgroup was higher than the PI of LIMA in in-situ RIMA subgroup (3.0 ± 1.6 vs 2.1 ± 1.0,P = 0.018). The results of early postoperative CTA examination showed that all IMAs grafts were completely patent.

Conclusions

The use of BIMA for CABG is safe and efficacious, RIMA used in right coronary artery received more satisfactory graft flow. BIMA with no stenosis and occlusion in the early stage, therefore is the ideal and stable coronary bypass graft.

Bilateral internal thoracic artery grafting in haemodialysis patients with diabetic nephropathy

OBJECTIVES

To compare postoperative outcomes in patients with diabetic nephropathy receiving haemodialysis and undergoing isolated coronary artery bypass grafting (CABG) using bilateral or single skeletonized internal thoracic artery (ITA).

METHODS

Among 1441 consecutive patients undergoing isolated CABG between 2002 and 2019 at our university hospital, we retrospectively analysed data for 107 patients with diabetic nephropathy receiving haemodialysis. After inverse probability of treatment weighting, we found no statistically significant differences regarding patients' preoperative characteristics.

RESULTS

All patients underwent myocardial revascularization using the off-pump technique. There was no statistical significance in postoperative deep sternal wound infection (P = 0.902) and 30-day mortality (P = 0.755). However, the bilateral ITA group had a lower rate of postoperative stroke versus the single group (0% vs 5.5%, respectively; P = 0.021). Follow-up was completed in 95.3% (102/107) of the patients, and the mean follow-up duration was 3.3 years. Thirty-eight deaths occurred in the bilateral ITA group and 18 in the single ITA group. There was no significant difference in all-cause death (P = 0.558) and cardiac death rates (P = 0.727). Multivariable Cox regression models showed that the independent predictors of all-cause death were age [hazard ratio (HR) 1.031; P = 0.010], previous percutaneous intervention (HR 1.757; P = 0.009) and gastroepiploic artery grafting (HR 0.582; P = 0.026).

CONCLUSIONS

Bilateral ITA grafting in patients with diabetic nephropathy receiving haemodialysis did not improve mid-term outcomes.

EFFECT OF PREOPERATIVE RESPIRATORY REHABILITATION IN PATIENTS UNDERGOING CARDIAC SURGERY

The aim of the study was to evaluate the effects of preoperative respiratory rehabilitation on functional capacity, length of stay in intensive care unit (ICU), duration of mechanical ventilation (MV) and total hospitalization, as well as to estimate arterial blood gas (ABG) values in patients undergoing cardiac surgery. Nineteen patients were included in the randomized observational study, divided into two groups: group A (intervention) and B (control). Preoperative and postoperative rehabilitation was performed in group A, and only postoperative rehabilitation in group B. Rehabilitation was carried out according to a predefined protocol. We used ABG to evaluate respiratory function, two-minute walk test (2MWT) and sit-to-stand test to assess functional capacity. The following data were obtained from medical documentation: duration of MV, length of stay at ICU, occurrence of postoperative pulmonary complications, and length of total hospitalization in both groups. Significant between-group difference was found for the length of total hospitalization and duration of MV (p<0.05 both). Analysis of the mean values of 2MWT on the last day of hospitalization (p=0.005), sit-to-stand test before surgery (p=0.022) and on the last day of hospitalization (p=0.008) showed statistically significant differences. The length of hospital stay significantly correlated with preoperative rehabilitation in group A (r=0.885; p<0.0001). There was no difference in ABG parameters between the groups. The study showed that preoperative respiratory rehabilitation had an effect on reducing duration of MV and length of total hospitalization, and improved functional capacity.

Single versus bilateral internal thoracic artery grafting in patients with low ejection fraction

Coronary artery bypass grafting (CABG) is the standard of care for the treatment of complex coronary artery disease. However, the optimal surgical treatment for patients with reduced left ventricular function with low ejection fraction (EF) is inconclusive. In our center, left-sided coronary grafting with bilateral internal thoracic artery (BITA) is generally the preferred method for surgical revascularization, also for patients with low EF. We compared early and long-term outcomes between BITA grafting and single internal thoracic artery (SITA) grafting in patients with low EF.We evaluated short- and long-term outcomes of all patients who underwent surgical revascularization in our center during 1996 to 2011, according to EF ≥30% and <30%. Univariate and multivariate analyses were performed. In addition, patients who underwent BITA and SITA grafting were matched using propensity score matching.In total, 5337 patients with multivessel disease underwent surgical revascularization during the study period. Of them, 394 had low EF. Among these, 188 underwent SITA revascularization and 206 BITA grafting. Those who underwent SITA were more likely to have comorbidities such as chronic obstructive pulmonary disease, diabetes, congestive heart failure, chronic renal failure, and a critical preoperative condition including preoperative intra-aortic balloon pump insertion.Statistically significant differences were not observed between the SITA and BITA groups in 30-day mortality (8.5% vs 6.8%, P = .55), sternal wound infection (2.7% vs 1.0%, P = .27), stroke (3.7% vs 6.3%, P = .24), and perioperative myocardial infarction (5.9% vs 2.9%, P = .15). Long-term survival (median follow up of 14 years, interquartile range, 11.2-18.9) was also similar between the groups. Propensity score matching (129 matched pairs) yielded similar early and long-term outcomes for the groups.This study did not demonstrate any clinical benefit for BITA compared with SITA revascularization in individuals with low EF.

Wound Infection after CABG Using Internal Mammary Artery Grafts: A Meta-Analysis

BACKGROUND

 Internal mammary arteries show better long-term patency rates than venous grafts. The use of both mammary arteries is associated with a higher risk of sternal wound infections. This meta-analysis was designed to assess the incidence of a wound healing disorder after bilateral compared with single mammary artery bypass grafting. Compared with existing meta-analysis this paper includes more current literature and one randomized controlled trial.

METHODS

 A literature search was performed using PubMed and the Cochrane Library. The quality of the articles was assessed by the Newcastle Ottawa Scale. The odds ratio was used as a measure of the chance of developing a wound healing disorder after bilateral internal mammary artery (BIMA) surgery. Meta-analyses were performed for different subgroups.

RESULTS

 Twenty studies met the quality criteria, including one randomized controlled trial. The use of both mammary arteries significantly increased the risk of superficial (odds ratio [OR] 1.72) and deep (OR 1.75) wound healing disorder in the total population (OR 1.80) as well as in the diabetic subgroup (OR 1.38) and with both preparation techniques. The increased risk with BIMA grafting was present independently of the preparation technique (pedicled: OR 1.89, skeletonized: OR 1.37).

CONCLUSION

 Bilateral internal mammary artery grafting, especially in high-risk and diabetic patients, is associated with an increased risk of wound healing impairment. Skeletonized preparation does not eliminate the elevated wound healing disorder risk after BIMA use.

Impacts of Skeletonized Bilateral Internal Mammary Artery Bypass Grafting on the Risk of Deep Sternal Wound Infection

This single-center study aimed to evaluate the incidence of deep sternal wound infection (DSWI) following skeletonized bilateral internal mammary artery (BIMA) harvest in a Chinese cohort. Using propensity score matching, this study also provided a present-day assessment of the impacts of skeletonized BIMA grafting versus skeletonized single internal mammary artery (SIMA) grafting on early outcomes.From January 2014 to December 2017, 2403 eligible patients were entered into either a BIMA group (n = 368) or a SIMA group (n = 2035). The incidence of DSWI was recorded. Analysis of early outcomes was further performed for propensity score-matched (1:1) cohorts.The BIMA group received a similar incidence of DSWI as did the SIMA group (1.6% versus 0.9%, P = 0.247). No significant differences between subgroup diabetic-BIMA, subgroup nondiabetic-BIMA, subgroup diabetic-SIMA, and subgroup nondiabetic-SIMA were found regarding the incidence of DSWI (2.0%, 1.4%, 1.0%, and 0.7%, respectively; P > 0.05 between groups). After matching, treatment type (skeletonized BIMA grafting versus skeletonized SIMA grafting) was not an independent risk factor for postoperative DSWI (OR = 1.309, 95% CI 0.897-2.714, P = 0.704) or predictors of other early outcomes. Additionally, the two matched groups shared similar early outcomes (including postoperative DSWI), regardless of whether or not the merger with diabetes (all P > 0.05).Skeletonized BIMA harvest as compared with skeletonized SIMA harvest was not associated with an increased risk of DSWI, regardless of whether or not the merger with diabetes. Patients with skeletonized BIMA grafting received similar surgical mortality and major postoperative morbidity as did matched patients with skeletonized SIMA grafting.

[Effect of the degree of stenosis of the right coronary artery on remote results of bypass grafting]

AIM

The purpose of this study was to assess the long-term results of right coronary artery bypass grafting and identify predictors of coronary artery bypass graft occlusion.

PATIENTS AND METHODS

Our retrospective single-centre study included a total of 245 patients subjected to isolated coronary artery bypass graft operations during the follow up period from 2010 to 2015. All patients endured bypass grafting of the right coronary artery (RCA) with either autovenous or autoarterial conduits. Control coronary bypass angiography was performed in all patients in connection with a relapse of angina pectoris. The duration of the follow up period amounted to 43.7±20.2 months. The patients were divided into two groups depending on the type of the conduit used to bypass the RCA. Group One patients (n=106) endured bypass grafting of the RCA and its branches using the internal thoracic artery. Group Two patients (n=139) underwent autovenous coronary artery bypass grafting of the RCA basin. By the main clinical, demographic and intraoperative parameters the groups were statistically homogeneous (p>0.05). The effect of the degree of proximal stenosis, the diameter of the grafted artery on the viability of bypass grafts was assessed.

RESULTS

During the follow-up period up to 84 months, 19 (17.9%) occluded arterial and 29 (20.9%) venous conduits were revealed. The Kaplan-Meier analysis showed that the probability of the absence of venous graft occlusion during the follow-up period up to 84 months was significantly lower than that of arterial grafts (log rank=0.012). The Cox regression analysis results revealed that shunt occlusion was influenced by the degree of proximal stenosis and the diameter of the shunted artery.

CONCLUSION

When shunting a moderate stenosis of the RCA (up to 70%), an advantage of autovenous conduits was revealed. When shunting the RCA with a critical stenosis and occlusion, advantages were revealed for the internal thoracic artery.

Left anterior descending artery revascularization with the right internal thoracic artery T-graft: the 'reverse composite' configuration

OBJECTIVES

The use of bilateral internal thoracic artery graft for myocardial revascularization has improved the long-term survival and decreased the rate of repeat interventions in patients. A key technical factor for complete arterial revascularization is sufficient length of the internal thoracic artery (ITA) graft. The purpose of this study was to compare early and long-term outcomes of 'standard composite' grafting and 'reverse composite' grafting. In the former, the left ITA (LITA) is connected to the left anterior descending artery, and the right ITA is connected end-to-side to the LITA for revascularization of the left circumflex artery. In 'reverse composite' grafting, the LITA is connected to the left circumflex artery, and the right ITA is connected end-to-side to the LITA, for revascularization of the left anterior descending artery.

METHODS

We compared the outcomes of 1365 patients who underwent coronary artery bypass grafting in Tel-Aviv Sourasky Medical Centre, using bilateral ITA as standard composite versus 'reverse composite' grafts, between January 1996 and December 2011. A propensity score matching analysis compared 132 pairs of patients who underwent bilateral ITA by the 2 modes.

RESULTS

Twelve hundred and thirty patients underwent standard 'composite' grafts and 135 underwent 'reverse composite' grafts. Early mortality and early adverse effects did not differ significantly between the groups. After matching, the difference in late mortality between the groups was not statistically significant.

CONCLUSIONS

This study suggests that revascularization of the left anterior descending with the right ITA, arising from an in situ LITA, is safe and provides early outcomes and long-term survival that are not significantly different from those of the standard composite grafting technique. However, there was evidence of better survival in the standard composite group.

Revascularization in left ventricular dysfunction: an update

PURPOSE OF REVIEW

The purpose of this article is to provide an overview of revascularization in patients with coronary artery disease (CAD) and left ventricular dysfunction (LVD).

RECENT FINDINGS

Patients with significant CAD and LVD are a high-risk patient population. They make up a minority of the cases from the largest, prospective coronary revascularization trials. The Surgical Treatment for Ischemic Heart Failure (STICH) Trial and its substudies are the most important and well cited in this field. The 10-year data from STICH showed that surgical revascularization was associated with lower all-cause mortality compared with medical therapy. Several smaller studies have confirmed that surgical revascularization carries a significant risk of short-term mortality but overall improved long-term outcomes in patients with LVD. Data from multiple observational studies further confirm that coronary artery bypass graft (CABG) is superior to percutaneous coronary revascularization for long-term survival and freedom from repeat revascularization in patients with LVD. We suggest that patients with LVD undergoing CABG should be considered for multiarterial grafting and that some patients may benefit from an off-pump procedure.

SUMMARY

Surgical revascularization confers a long-term survival benefit in patients with significant CAD and LVD. Further studies will be needed to precisely determine the ideal candidate for surgical versus percutaneous revascularization.

Bilateral internal thoracic artery versus single internal thoracic artery: a meta-analysis of propensity score-matched observational studies

The lack of benefit in terms of mid-term survival and the increase in the risk of sternal wound complications published in a recent randomized controlled trial have raised concerns about the use of bilateral internal thoracic artery (BITA) in myocardial revascularization surgery. For this reason, we decided to explore the current evidence available on the subject by carrying out a meta-analysis of propensity score-matched studies comparing BITA versus single internal thoracic artery (SITA). PubMed, EMBASE and Google Scholar were searched for propensity score-matched studies comparing BITA versus SITA. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The DerSimonian and Laird method was used to compute the combined risk ratio of 30-day mortality, deep sternal wound infection and reoperation for bleeding. Forty-five BITA versus SITA matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival in favour of the BITA group [HR 0.78; 95% confidence interval (CI) 0.71-0.86]. These results were consistent with those obtained by a pooled analysis of the matched populations comprising patients with diabetes (HR 0.65; 95% CI 0.43-0.99). When compared with the use of SITA plus radial artery, BITA did not show any significant benefit in terms of long-term survival (HR 0.86; 95% CI 0.69-1.07). No differences between BITA and SITA groups were detected in terms of 30-day mortality or in terms of reoperation for bleeding. Compared with the SITA group, patients in the BITA group had a significantly higher risk of deep sternal wound infection (risk ratio 1.66; 95% CI 1.41-1.95) even when the pooled analysis was limited to matched populations in which BITA was harvested according to the skeletonization technique (risk ratio 1.37; 95% CI 1.04-1.79). The use of BITA provided a long-term survival benefit compared with the use of SITA at the expense of a higher risk of sternal deep wound infection. The long-term survival advantage of BITA is undetectable when compared with SITA plus radial artery.

Right internal thoracic or radial artery as the second arterial conduit for coronary artery bypass surgery

PURPOSE OF REVIEW

To summarize the available evidence on the use of the right internal thoracic artery (RITA) and the radial artery as the second arterial graft in coronary artery bypass surgery.

RECENT FINDINGS

The current data support the equipoise of the two conduits in terms of clinical and angiographic outcomes. Both RITA and radial artery have better patency than saphenous vein grafts. The use of the RITA carries an increased risk of deep sternal wound infection (DSWI) if the artery is harvested as pedicle. Bilateral internal thoracic artery grafting is more technically demanding than radial artery use and there is a volume-outcome relationship in terms of mortality and incidence of DSWI. The radial artery is preferable over RITA in right-sided or distal circumflex artery targets with high-degree stenosis and in patients at higher risk for DSWI, whereas it is not recommended to graft vessels with moderate stenosis and in cases of insufficient collateralization from the ulnar artery or previous transradial procedures.

SUMMARY

The patency rate and clinical outcomes of radial artery and RITA are similar. The use of one or the other should be based on a careful evaluation of the patient's coronary anatomy and comorbidities, the conduit availability and the surgeon's and center's experience.

Long-term Outcomes of Multiple Arterial Coronary Artery Bypass Grafting: A Population-Based Study of Patients in British Columbia, Canada

Importance

Although the long-term survival advantage of multiple arterial grafting (MAG) vs the standard use of left internal thoracic artery (LITA) supplemented by saphenous vein grafts (LITA+SVG) has been demonstrated in several observational studies, to our knowledge its safety and other long-term clinical benefits in a large, population-based cohort are unknown.

Objective

To compare the safety and long-term outcomes of MAG vs LITA+SVG among overall and selected subgroups of patients.

Design, Setting, and Participants

In this population-based observational study, we included 20 076 adult patients with triple-vessel or left-main disease who underwent primary isolated coronary artery bypass grafting (MAG, n = 5580; LITA+SVG, n = 14 496) in the province of British Columbia, Canada, from January 2000 to December 2014, with follow-up to December 2015. We performed propensity-score analyses by weighting and matching and multivariable Cox regression to minimize treatment selection bias.

Exposures

Multiple arterial grafting or LITA+SVG.

Main Outcomes and Measures

Mortality, repeated revascularization, myocardial infarction, heart failure, and stroke.

Results

Of 5580 participants who underwent MAG, 586 (11%) were women and the mean (SD) age was 60 (8.7) years. Of 14 496 participants who underwent LITA+SVG, 2803 (19%) were women and the mean (SD) age was 68 (8.9) years. The median (interquartile range) follow-up time was 9.1 (5.1-12.6) years and 8.1 (4.5-11.7) years for the groups receiving MAG and LITA+SVG, respectively. Compared with LITA+SVG, MAG was associated with reduced mortality rates (hazard ratio [HR], 0.79; 95% CI, 0.72-0.87) and repeated revascularization rates (HR, 0.74; 95% CI, 0.66-0.84) in 15-year follow-up and reduced incidences of myocardial infarction (HR, 0.63; 95% CI, 0.47-0.85) and heart failure (HR, 0.79; 95% CI, 0.64-0.98) in 7-year follow-up. The long-term benefits were coherent by all 3 statistical methods and persisted among patient subgroups with diabetes, obesity, moderately impaired ejection fraction, chronic obstructive pulmonary disease, peripheral vascular disease, or renal disease. Multiple arterial grafting was not associated with increased morbidity or mortality rates at 30 days overall or within patient subgroups.

Conclusions and Relevance

Compared with LITA+SVG, MAG is associated with reduced mortality, repeated revascularization, myocardial infarction, and heart failure among patients with multivessel disease who are undergoing coronary artery bypass grafting without increased mortality or other adverse events at 30 days. The long-term benefits consistently observed across multiple outcomes and subgroups support the consideration of MAG for a broader spectrum of patients who are undergoing coronary artery bypass grafting in routine practice.

Outcome of Robot-Assisted Bilateral Internal Mammary Artery Grafting via Left Pleura in Coronary Bypass Surgery

Studies are extremely limited for the investigation of the clinical outcome of da Vinci robot-assisted bilateral internal mammary artery (BIMA) grafting in coronary artery bypass grafting (CABG) surgery. This study aimed to explore the short-term outcome of da Vinci robot-assisted BIMA grafting through the left pleural space. Relevant data were collected from patients with multi-vessel coronary artery disease receiving two kinds of CABG: a group of patients receiving da Vinci robot-assisted CABG with BIMA grafting, and another group of patients receiving sternotomy CABG with BIMA grafting. Primary endpoints, which included cardiovascular and renal endpoints, were analyzed between the groups using the chi-square test, analysis of variance test, and Kaplan-Meier analysis. Compared with the conventional group (n = 22), the robotic group (n = 22) had a significantly longer operation time (12.7 ± 1.7 vs. 8.5 ± 1.5 hours; p < 0.01) and a marginally lower mean of serum creatinine at baseline (1.2 ± 0.3 vs. 2.0 ± 1.7 mg/dL; p = 0.04). Primary endpoints (5, 22.7% vs. 12, 54.5%; p = 0.03) and renal endpoints (1, 4.5% vs. 7, 31.8%; p = 0.02) at six months were significantly reduced in the robotic group compared with the conventional group. There were no differences in cardiovascular endpoints at six months between the groups (1, 4.5% vs. 0; p = 1.00). The data showed that da Vinci robot-assisted BIMA grafting was safe, with equal cardiovascular events and lowered renal events at six months, as compared to conventional sternotomy BIMA grafting, despite the longer procedure time. The short-term study suggests that da Vinci robot-assisted BIMA grafting may be considered a favorable surgical option for patients with severe coronary artery disease.

State-of-the-Art Coronary Artery Bypass Grafting: Patient Selection, Graft Selection, and Optimizing Outcomes

Despite the progressive expansion of clinical indications for percutaneous coronary intervention and the increasingly high risk profile of referred patients, coronary artery bypass grafting (CABG) remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates. Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes. A surgical approach individualized to the patients' clinical and anatomic characteristics, and surgeon and team experience, are key to excellent outcomes. Current evidence regarding patient selection, indications, graft selection, and potential strategies to optimize outcomes in patients treated with CABG is summarized.

CABG in patients with left ventricular dysfunction: indications, techniques and outcomes

Ischemic chronic heart failure (CHF) represents one of the cardiovascular diseases with the worst degree of morbidity and mortality in the western world, and with the highest health care costs. Despite several studies demonstrated that surgical revascularization (CABG), especially in the presence of viable myocardium, improve heart function, and therefore, survival, the matter remains unclear and controversial. In the late 1970s, the Coronary Artery Surgery Study showed that a subgroup of patients with coronary artery disease, angina, and reduce LV function had a significant survival benefit after CABG compared to those treated medically. The key concept behind this observation was the presence of viable myocardium, which can resume function following revascularization. In contrary, the surgical treatment for ischemic heart failure (STICH) trial, which randomized patients with CAD and LV dysfunction to evidence-based medical therapy or CABG plus medical therapy, failed to demonstrate at a median follow-up of 56 months a significant difference between the CABG group and the medical therapy group in the rate of death from any cause. However, the results of the STICH extension study (STICHES) at 10 years follow-up demonstrated that CABG is associated with a significant reduction in all-cause mortality, cardiovascular mortality, and readmission for heart compared to optimal medical therapy (OMT) in patients with severe ischemic LV dysfunction. Therefore, this review discusses the available evidences in literature, from observational studies to randomized trials, including operative techniques and controversial issues, in order to better clarify the role of CABG in the current management of ischemic patients with LVD.

The risk of mediastinitis and deep sternal wound infections with single and bilateral, pedicled and skeletonized internal thoracic arteries

Bilateral internal thoracic artery (BITA) grafting may prolong survival in coronary artery bypass graft (CABG) patients, but its use has been curtailed due to concerns of deep sternal wound infections (DSWI) resulting in mediastinitis. This article examines the association of single internal thoracic artery (SITA) and BITA grafting and the role of harvesting techniques with the development of DSWI in CABG patients. The development of DSWI following BITA grafting is multifactorial and is independent of the harvesting technique.

Scoring system to guide decision making for the use of bilateral internal mammary arteries: The BIMA score

OBJECTIVE

Currently, surgeons are unable to estimate whether the survival benefit from bilateral internal mammary artery (BIMA) grafting outweighs the increased deep sternal infection (DSWI) risk in the individual cases. As a consequence BIMA grafting is still largely underutilized. We aimed to develop and validate a scoring system to predict the individual risk for DSWI and 10 year survival probability to guide surgeons in decision making process for the use of BIMA over single internal mammary artery (SIMA).

METHODS

Fast backward elimination on predictors was performed using Lawless and Singhal method. BIMA score was reported as a partial nomogram that can be used to manually obtain predicted individual risk of DSWI and 10 year survival probability from the regression models. Bootstrapping validation of the regression models was performed.

RESULTS

The study population consisted of 5234 patients of which a total of 960 (18%) received BIMA and the remaining 4274 (82%) underwent conventional strategy using SIMA. A total of 119 patients experienced DSWI (2.3%). A total of 489 deaths were recorded after a median follow-up time of 5.68 years (interquartile range 2.7-8.8, range 0-12.1). BIMA grafting was found to have effect on both risk of DSWI and 10 year survival probability and was included into partial nomograms. Bootstrapping validation confirmed a good discriminative power of the models.

CONCLUSION

The BIMA score provides an impartial assessment of the decision making process for clinicians to establish the optimum revascularization strategy for individual patients.

Rerouting the internal thoracic pedicle: a novel solution for maxillofacial reconstruction in vessel-depleted situations? A preliminary anatomic study

PURPOSE

Microsurgical reconstruction in a vessel-depleted neck is a challenge due to the lack of reliable vessels in or nearby the host site. The use of the internal thoracic pedicle (ITP) by rib section or sparring is a limited option due to the small length of the pedicle of some flaps. However, in cardiac surgery, the internal thoracic artery (ITA) is widely used for myocardial revascularization, providing a long and versatile pedicle. We aimed at determining precise anatomical bases for the use of the ITP, approached by sternotomy and rerouted in the neck, as recipient vessels for free-flap facial reconstructions.

METHODS

We performed a descriptive single centre anatomical study on 20 formalin-embalmed cadavers. The ITP was harvested on both sides from the emergence of the artery under the brachiocephalic vein to its terminal division. The level reached by the ITP in the cervicofacial area was described. Distal arterial and venous diameters, pedicle length and other parameters were measured.

RESULTS

In at least 85% of the cases, the ITP reached the mandibular angle. The mean diameter at the distal extremity for the ITA was 2.36 ± 0.15, and 2.48 ± 0.19 mm for the committing vein. The mean length of the ITP was 177.3 mm.

CONCLUSION

Rerouting the ITP towards the cervicofacial area could provide a reliable pedicle for free-flap reconstructions in patients with a vessel-depleted neck but it should be limited to selected patients. This novel solution for situations where current techniques are unfeasible warrants further clinical research.

The Surgical Treatment of Coronary Artery Occlusive Disease: Modern Treatment Strategies for an Age Old Problem

Coronary artery disease remains a formidable challenge to clinicians. Percutaneous interventions and surgical techniques for myocardial revascularization continue to improve. Concurrently, in light of emerging data, multiple practice guidelines have been published guiding clinicians in their therapeutic decisions. The multidisciplinary Heart Team concept needs to be embraced by all cardiovascular providers to optimize patient outcomes.

Bilateral vs unilateral internal mammary revascularization in patients with left ventricular dysfunction

AIM

To investigate the survival benefit of bilateral internal mammary artery (BIMA) grafts in patients with left ventricular dysfunction.

METHODS

Between 1996 and 2009, we performed elective, isolated, primary, multiple cardiac arterial bypass grafting in 430 consecutive patients with left ventricular ejection fraction ≤ 40%. The early and long-term results were compared between 167 patients undergoing BIMA grafting and 263 patients using left internal mammary artery (LIMA)-saphenous venous grafting (SVG).

RESULTS

The mean age of the overall population was 60.1 ± 15 years. In-hospital mortality was not different between the two groups (7.8% vs 10.3%, P = 0.49). Early postoperative morbidity included myocardial infarction (4.2% vs 3.8%, P = 0.80), stroke (1.2% vs 3.8%, P = 0.14), and mediastinitis (5.3% vs 2.3%, P = 0.11). At 8-year follow-up, Kaplan-Meier-estimated survival (74.2% vs 58.9%, P = 0.02) and Kaplan-Meier-estimated event-free survival (all cause deaths, myocardial infarction, stroke, target vessel revascularization, heart failure) (61.7% and 41.1%, P < 0.01) were significantly higher in the BIMA group compared with the LIMA-SVG group in univariate analysis. The propensity score matching analysis confirmed that BIMA grafting is a safe revascularization procedure but there was no long term survival (P = 0.40) and event-free survival (P = 0.13) in comparison with LIMA-SVG use.

CONCLUSION

Our longitudinal analysis suggests that BIMA grafting can be performed with acceptable perioperative mortality in patients with left ventricular dysfunction.

Bilateral internal thoracic artery grafting in India-Time to raise the bar

Objectives

Bilateral internal thoracic artery (BITA) grafting strategy is the current trend in coronary artery bypass grafting for multivessel coronary artery disease. Although better long-term outcomes have been shown, BITA grafting is underutilized as a main strategy for revascularization by most of the surgeons. The survey was conducted to ascertain the current usage and concerns of BITA grafting in India.

Methods

Database of 856 Indian cardiac surgeons currently with predominantly adult practice was prepared and a questionnaire was sent about use of single and bilateral ITA grafts and BITA grafting strategy in different clinical scenarios.

Results

A total of 112 surgeons (13.08%) from 75 institutions responded and 92 surgeons (10.7%) completed the survey. Single ITA is used by 79% of surgeons in more than 90% of their patients. 31% and 29% of surgeons use BITA grafting in 5–10% and 11–98% of their patients respectively. 53% of surgeons avoided the usage of BITA grafting in patients with smoking, 35% of surgeons in chronic obstructive pulmonary disease, 58% of surgeons in obesity and 62% of surgeons in acute coronary syndrome, 36% of surgeons in patients with left ventricular dysfunction and 61% of surgeons in patients with poor coronary anatomy. The concerns for BITA usage are risk of deep sternal wound infection (DSWI) (40%), increased operative time (27%), unknown superiority (12%) and limited length of right ITA (5%).

Conclusions

The usage of BITA grafting is restricted to 10% in India and main concerns are DSWI and increased operative time.

Total arterial anaortic off-pump coronary artery bypass grafting in a patient with heart failure - Case report

A 69-year-old male diabetic patient of heart failure underwent successful off-pump coronary artery bypass grafting (CABG) using both internal thoracic arteries and left radial artery. There was improvement of left ventricular ejection fraction within 4 days. This is the first ever case report of off-pump CABG in a heart failure patient.

Prevention of surgical site sternal infections in cardiac surgery: a two-centre prospective randomized controlled study

OBJECTIVES

Surgical site infection (SSI) of the sternum is a devastating complication in cardiac surgery. The aim of this prospective randomized controlled two-centre clinical study was to compare the use of a gentamicin-collagen sponge (Genta-Coll® resorb) and of a cyanoacrylate-based microbial skin sealant (InteguSeal®) on the SSI rate of the sternum.

METHODS

We analysed data from 996 consecutive patients following isolated coronary artery bypass grafting between 2012 and 2014. The patients were randomized into three groups: standard group (S-group), Genta-Coll group (G-group) and InteguSeal group (I-group). The primary study end-point was to analyse the incidence of superficial and deep sternal SSI. The secondary study end-point was to determine independent risk factors for an increased SSI rate.

RESULTS

Of the 996 patients investigated, 332 patients were in S-group, 336 patients in G-group and 328 patients in I-group. The mean age was 67.7 ± 9.4 years, 18.6% were women and the overall SSI rate was 6.2% with 2.2% deep sternal wound infections. SSI rates were 8.3% (S-group), 5.4% (G-group) and 4.9% (I-group) (P 0.16). Multiple regression analysis demonstrated a preoperative body mass index (BMI) of >30 kg/m² (P 0.047), re-thoracotomy for postoperative bleeding (P < 0.001) and sternum instability (P < 0.001) as independent predictors for an increased SSI rate.

CONCLUSIONS

The application of InteguSeal® or Genta-Coll® resorb had no significant influence on the incidence of the sternal SSI rate in 996 consecutive cardiac surgery patients but demonstrated a trend towards a benefit from using these prophylactic approaches. Multiple regression analysis demonstrated a preoperative BMI of >30 kg/m², re-thoracotomy for bleeding and sternum instability as independent predictors for an increased sternal SSI rate.

Is Bilateral Internal Mammary Arterial Grafting Beneficial for Patients Aged 75 Years or Older?

BACKGROUND

Although bilateral internal mammary artery (BIMA) grafting is performed with increasing regularity in elderly patients, whether it is truly beneficial, and therefore indicated, in these patients remains uncertain. We retrospectively investigated early and late outcomes of BIMA grafting in patients aged ≥75 years.

METHODS AND RESULTS

We identified 460 patients aged ≥75 years from among 2,618 patients who underwent either single internal mammary artery (SIMA) grafting (n=293) or BIMA grafting (n=107). Early outcomes did not differ between the SIMA and BIMA patients (30-day mortality: 1.7% vs. 0%, P=0.39; sternal wound infection: 1.0% vs. 4.7%; P=0.057). Late outcomes, 10-year survival in particular, were improved in the BIMA group (36.6% vs. 48.1%, P=0.033). In the analysis of the results in propensity score-matched groups (196 patients in the SIMA group, 98 patients in the BIMA group), improved 10-year survival was documented in the BIMA group (34.8% vs. 47.6%, P=0.030). Cox proportional regression analysis showed SIMA usage (non-use of BIMA) to be a predictor for late mortality (hazard ratio: 0.65, 95% confidence interval: 0.43-0.98, P=0.042). We further compared outcomes between the total non-elderly patients (n=2,158) and total elderly patients (n=460). BIMA usage was similar, as was 30-day mortality (1.0% vs. 1.3%, respectively).

CONCLUSIONS

A survival advantage, with no increase in early mortality, can be expected from BIMA grafting in patients aged ≥75 years. (Circ J 2016; 80: 1756-1763).