Bilateral internal thoracic artery grafting is superior to other forms of multiple arterial grafting in providing survival benefit after coronary bypass surgery

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.

Assessing the benefits of anaortic off-pump coronary artery bypass grafting

Introduction

The procedure called the "aorta no-touch" (NT) or anaortic technique in off-pump coronary artery bypass grafting (OPCAB) is designed to reduce the perioperative risk of stroke. We have observed an increased frequency of anaortic OPCAB procedures at our institution. The main purpose of the present study is to investigate the effectiveness of anaortic OPCAB in reducing the perioperative risk of stroke.

Methods

From April 2011 to July 2023, a total of 2,236 patients underwent isolated OPCAB at our single center. The patients were divided into the anaortic group (NT, n = 762) and the aortic group (A, n = 1,474). The NT group was propensity score-matched (PSM) with the A group at a 1:1 ratio (NT n = 640; A n = 640), and matching was performed based on 26 covariates with preoperative clinical characteristics.

Results

In both the unmatched and matched cohorts of the NT and A groups, there were no significant differences observed in new stroke rates (NT vs. A; unmatched, 1.0% vs. 1.2%, p = 0.624; matched, 0.9% vs. 1.3%, p = 0.789). The univariable logistic analysis did not identify the anaortic technique as an independent factor negatively associated with new stroke events (OR = 0.81, 95% CI = 0.35-1.86, p = 0.624).

Conclusion

The present study did not find the anaortic technique to reduce the perioperative risk of stroke in OPCAB. Hence, further large studies are needed to identify patient cohorts in which anaortic OPCAB is significantly beneficial.

Bilateral internal thoracic artery versus single internal thoracic artery plus radial artery: A double meta-analytic approach

OBJECTIVES

We explored the current evidence on the best second conduit in coronary surgery carrying out a double meta-analysis of propensity score matched or adjusted studies comparing bilateral internal thoracic artery (BITA) versus single internal thoracic artery plus radial artery.

METHODS

PubMed, Embase, and Google Scholar were searched for propensity score matched or adjusted studies comparing BITA versus single internal thoracic artery plus radial artery. The end point was long-term mortality. Two statistical approaches were used: the generic inverse variance method and the pooled meta-analysis of Kaplan-Meier-derived individual patient data.

RESULTS

Twelve matched populations comparing 6450 patients with BITA versus 9428 patients with single internal thoracic artery plus radial artery were included in our meta-analysis. The generic inverse variance method showed a statistically significant survival benefit of the BITA group (hazard ratio, 0.84; 95% CI, 0.74-0.95; P = .04). The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the BITA group were 97.0%, 91.3%, 80.0%, and 68.0%, respectively. The Kaplan-Meier estimates of survival at 1, 5, 10, and 15 years of the single internal thoracic artery plus radial artery group were 97.3%, 91.5%, 79.9%, and 63.9%, respectively. The Kaplan-Meier-derived individual patient data meta-analysis applied to very long follow-up time data, showed that BITA provided a survival benefit after 10 years from surgery (hazard ratio, 0.77; 95% CI, 0.63-0.94; P = .01). No differences in terms of survival between the 2 groups were detected when the analysis was focused on the first 10 years of follow-up (hazard ratio, 0.99; 95% CI, 0.91-1.09; P = .93).

CONCLUSIONS

The present meta-analysis suggests that double internal thoracic artery may provide, compared with single internal thoracic artery plus radial artery, a statistically significant survival advantage after 10 years of follow-up, but not before. VIDEO ABSTRACT.

Is gender a risk factor for bilateral internal thoracic artery grafting? A twenty-year follow-up

BACKGROUND

Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique, especially in female patients, due to its greater complexity and potential increased risk of sternal infection. The aim of this study was to compare the outcomes of male and female patients who underwent BITA grafting.

METHODS

We evaluated at the early outcome and late mortality, 551 female versus 2525 male patients who underwent isolated BITA grafting between January 1996 and December 2011. To adjust for differences in demographic and clinical characteristics, a multivariate risk analysis and propensity score matching were performed. Kaplan-Meier analysis was performed for the entire cohort and for the matched cohort.

RESULTS

Female patients were older and were more likely than males to have congestive heart failure, unstable angina pectoris, and diabetes. Sternal infection was more frequent in females than males (3.3% vs. 1.8%; p = .04). Differences were not observed in operative mortality (2.9% vs. 1.9%; p = .15) and stroke incidence (3.4% vs. 2.6; p = .30). After multivariate risk analysis and propensity score matching, the female gender was not found to be a predictor of worse outcomes. There was no difference in median survival among female and male patients (14.3 and 14.2 years, respectively; p = .68).

CONCLUSION

Our results support the routine use of BITA grafting in proper selected female patients who undergo myocardial revascularization.

Robustness of the Comparative Observational Evidence Supporting Class I and II Cardiac Surgery Procedures

Background

Current cardiac surgery guidelines give Class I and II recommendations to valve‐sparing root replacement over the Bentall procedure, mitral valve (MV) repair over replacement, and multiple arterial grafting with bilateral internal thoracic artery based on observational evidence. We evaluated the robustness of the observational studies supporting these recommendations using the E value, an index of unmeasured confounding.

Methods and Results

Observational studies cited in the guidelines and in the 3 largest meta‐analyses comparing the procedures were evaluated for statistically significant effect measures. Two E values were calculated: 1 for the effect‐size estimate and 1 for the lower limit of the 95% CI. Thirty‐one observational studies were identified, and E values were computed for 75 effect estimates. The observed effect estimates for improved clinical outcomes with valve‐sparing root replacement versus the Bentall procedure, MV repair versus replacement, and grafting with bilateral internal thoracic artery versus single internal thoracic artery could be explained by an unmeasured confounder that was associated with both the treatment and outcome by a risk ratio of more than 16.77, 4.32, and 3.14, respectively. For MV repair versus replacement and grafting with bilateral internal thoracic artery versus single internal thoracic artery, the average E values were lower than the effect sizes of the other measured confounders in 33.3% and 60.9% of the studies, respectively. For valve‐sparing root replacement versus the Bentall procedure, no study reported effect sizes for associations of other covariates with outcomes.

Conclusions

The E values for observational evidence supporting the use of valve‐sparing root replacement, MV repair, and grafting with bilateral internal thoracic artery over the Bentall procedure, MV replacement, and grafting with single internal thoracic artery are relatively low. This suggests that small‐to‐moderate unmeasured confounding could explain most of the observed associations for these procedures.

Coronary artery bypass surgery plus medical therapy versus medical therapy alone for ischaemic heart disease: a protocol for a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Despite increasing survival, cardiovascular disease remains the primary cause of death worldwide with an estimated 7.4 million annual deaths. The main symptom of ischaemic heart disease is chest pain (angina pectoris) most often caused by blockage of a coronary artery. The aim of coronary artery bypass surgery is revascularisation achieved by surgically grafting harvested arteries or veins distal to the coronary lesion restoring blood flow to the heart muscle. Older evidence suggested a clear survival benefit of coronary artery bypass graft surgery, but more recent trials yield less clear evidence. We want to assess the benefits and harms of coronary artery bypass surgery combined with different medical therapies versus medical therapy alone in patients with ischaemic heart disease.

METHODS

This protocol for a systematic review follows the recommendations of Cochrane and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all randomised clinical trials assessing coronary artery bypass surgery combined with different medical therapies versus medical therapy alone in patients with ischaemic heart disease. We plan to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, Science Citation Index Expanded on Web of Science, and BIOSIS to identify relevant trials. Any eligible trial will be assessed as high risk or low risk of bias, and our conclusions will primarily be based on trials at low risk of bias. The analyses of the extracted data will be performed using Review Manager 5, STATA 16 and trial sequential analysis. For both our primary and secondary outcomes, we will create a 'Summary of Findings' table and use GRADE to assess the certainty of the evidence.

DISCUSSION

Coronary artery bypass surgery is invasive and can cause death, which is why its use must be thoroughly studied to determine if it yields a large enough long-term benefit for the thousands of patients receiving it every year.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 131924.

Short-term results of bilateral internal mammary arterial grafting for patients aged 60-75 years - a retrospective study

BACKGROUND

Bilateral internal mammary artery (BIMA) grafting has a good long-term survival rate and graft patency rate, but it is only recommended in young patients due to its high technical requirements and high incidence of sternal complications. Previous studies indicated that BIMA grafting has a significant benefit in patients aged 50-59 years, but this benefit does not extend to patients aged > 60 years. Thus, this study was designed to analyse the immediate artery graft function, short-term (3 months) results, and experience in preventing sternal complications for BIMA grafting in elderly patients (60-75 years old).

METHODS

Clinical records and echocardiographic and coronary artery computed tomography angiography data of 155 patients who underwent BIMA grafting for coronary artery disease between 2015 and 2017 in our hospital were analysed retrospectively to summarise the operative experience and short-term (3 months) results. Patients were divided into two groups: Group A (n = 95), aged < 60 years and Group B (n = 60), aged 60-75 years. The operation time, aortic clamp time, and cardiopulmonary bypass time of these two groups were compared to analyse the operation difficulty and the flow and pulsatility index were compared to analyse the immediate artery graft function. The left ventricular end-diastolic dimension (LVEDD) and left ventricular ejection fraction (LVEF) of these two groups were compared to analyse heart function.

RESULTS

There were no significant differences in the operation time, aortic clamp time, and cardiopulmonary bypass time as well as the flow and pulsatility index between these two groups (P > 0.05). There was no significant difference in the incidence of sternal wound complications, graft occlusion, and other common complications 3 months post-BIMA grafting between these two groups (P > 0.05). Furthermore, there was no significant difference in LVEDD and LVEF between the groups 3 months post-operation (P > 0.05).

CONCLUSIONS

BIMA grafting was safe and effective for older patients (60-75 years). Similar to younger patients (< 60 years), BIMA grafting in elderly patients (60-75 years) can also achieve a satisfactory short-term (3 months) result. Thus, advanced age (60-75 years) should not be a contraindication for BIMA grafting.

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.

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.

Graft Strategy for Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction

Background

Optimal graft selection for coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) dysfunction remains debatable. We report an analysis of our experiences of isolated CABG in patients with severe LV dysfunction and the impact of graft strategy on long-term outcomes.

Methods

We analyzed 209 patients with severe LV dysfunction (ejection fraction [EF] <30%) who underwent primary isolated CABG. Of these, 169 were revascularized with a bilateral internal thoracic arterial (ITA) graft (BITA group) and 40 were revascularized with a single ITA graft (SITA group). The mean follow-up duration was 22±32 months.

Results

There were 18 early deaths (8.6%). Overall survival at 5 years was 66.7%. The rate of freedom from cardiac-related death at 5 years was 74.1%, and was significantly higher in patients who underwent off-pump CABG (p=0.005) and in the BITA group (p=0.023). Multivariate analysis demonstrated that old age (hazard ratio [HR], 2.548; 95% confidence interval [CI], 1.134–5.762; p=0.024), off-pump CABG (HR, 0.245; 95% CI, 0.090–0.661; p=0.006), and BITA grafts (HR, 0.333; 95% CI, 0.146–0.757; p=0.009) were correlated with cardiac mortality.

Conclusion

CABG in patients with severe LV dysfunction (EF <30%) showed reasonable long-term outcomes. The rate of freedom from cardiac-related death was significantly higher in patients who underwent off-pump CABG and in the BITA group. Off-pump BITA grafting strategies can be accepted as a viable primary option in patients with severe LV dysfunction if performed by an experienced surgeon.

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.

Use Rate and Outcome in Bilateral Internal Thoracic Artery Grafting: Insights From a Systematic Review and Meta-Analysis

Background

This meta‐analysis was designed to assess whether center experience affects the short‐ and long‐term results and the relative benefits of bilateral internal thoracic artery grafting (BITA) for coronary artery bypass grafting.

Methods and Results

MEDLINE and EMBASE were searched to identify all articles reporting the outcome of BITA in patients undergoing coronary artery bypass grafting. The BITA center experience was gauged according to the percentage use of BITA in the institutional overall coronary artery bypass grafting population (%BITA). The primary outcome was long‐term all‐cause mortality. Secondary outcomes were operative mortality, perioperative myocardial infarction, perioperative stroke, deep sternal wound infections (DSWIs), and major postoperative adverse event. The rates of the primary and secondary outcomes were calculated after adjusting for %BITA. Primary and secondary outcomes were also compared between the BITA and the single internal thoracic artery arms in the adjusted studies. Meta‐regression was used to evaluate the effect of %BITA on the primary and secondary outcomes. Thirty‐four studies (27 894 patients undergoing BITA) were included. In the pooled analysis, the incidence rate for long‐term mortality was 2.83% (95% confidence interval, 2.21%–3.61%). %BITA was significantly and inversely associated with long‐term mortality and the rate of DSWI. In the pairwise comparison, %BITA was significantly and inversely associated with the risk of long‐term mortality and DSWI in the group undergoing BITA.

Conclusions

BITA series with higher %BITA report significantly lower long‐term mortality and DSWI rate as well as higher long‐term survival advantage and lower relative risk of DSWI in their BITA cohort. These findings suggest that a specific volume‐outcome relationship exists for BITA grafting.

Optimal management of radial artery grafts in CABG: Patient and target vessel selection and anti-spasm therapy

The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting.

Unmeasured Confounders in Observational Studies Comparing Bilateral Versus Single Internal Thoracic Artery for Coronary Artery Bypass Grafting: A Meta-Analysis

Background

Observational studies suggest a survival advantage with bilateral single internal thoracic artery (BITA) versus single internal thoracic artery grafting for coronary surgery, whereas this conclusion is not supported by randomized trials. We hypothesized that this inconsistency is attributed to unmeasured confounders intrinsic to observational studies. To test our hypothesis, we performed a meta‐analysis of the observational literature comparing BITA and single internal thoracic artery, deriving incident rate ratio for mortality at end of follow‐up and at 1 year. We postulated that BITA would not affect 1‐year survival based on the natural history of coronary artery bypass occlusion, so that a difference between groups at 1 year could not be attributed to the intervention.

Methods and Results

We searched MEDLINE and Pubmed to identify all observational studies comparing the outcome of BITA versus single internal thoracic artery. One‐year and long‐term mortality for BITA and single internal thoracic artery were compared in the propensity‐score–matched (PSM) series, that is, the form of observational evidence less prone to confounders. Thirty‐eight observational studies (174 205 total patients) were selected for final comparison. In the 12 propensity‐score–matched series (34 019 patients), the mortality reduction for BITA was similar at 1 year and at the end of follow‐up (incident rate ratio, 0.70; 95% confidence interval, 0.60–0.82 versus 0.77; 95% confidence interval, 0.70–0.85; P for subgroup difference=0.43).

Conclusions

Unmeasured confounders, rather than biological superiority, may explain the survival advantage of BITA in observational series.

Coronary Artery Bypass Grafting with Arterial Conduits in the Elderly

Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.

Recovery free of heart failure after acute coronary syndrome and coronary revascularization

Aims

Previous studies have examined risk factors for the development of heart failure (HF) subsequent to acute coronary syndrome (ACS). Our study seeks to clarify the clinical variables that best characterize patients who remain free from HF after coronary artery bypass grafting (CABG) surgery for ACS to determine novel biological factors favouring freedom from HF in prospective translational studies.

Methods and results

Nova Scotia residents (1995–2012) undergoing CABG within 3 weeks of ACS were included. The primary outcome was freedom from readmission to hospital due to HF. Descriptive statistics were generated, and a Cox proportional hazards model assessed outcome with adjustment for clinical characteristics. Of 11 936 Nova Scotians who underwent isolated CABG, 3264 (27%) had a recent ACS and were included. Deaths occurred in 210 (6%) of subjects prior to discharge. A total of 3054 patients were included in the long‐term analysis. During follow‐up, HF necessitating readmission occurred in 688 (21%) subjects with a hazard ratio of 12% at 2 years. The adjusted Cox model demonstrated significantly better freedom from HF for younger, male subjects without metabolic syndrome and no history of chronic obstructive pulmonary disease, renal insufficiency, atrial fibrillation, or HF.

Conclusions

Our findings have outlined important clinical variables that predict freedom from HF. Furthermore, we have shown that 12% of patients undergoing CABG after ACS develop HF (2 years). Our findings support our next phase in which we plan to prospectively collect blood and tissue specimens from ACS patients undergoing CABG in order to determine novel biological mechanism(s) that favour resolution of post‐ACS inflammation.

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 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.

Conduits Used in Coronary Artery Bypass Grafting: A Review of Morphological Studies

There is a significant variety of vascular conduits options for coronary bypass surgery. Adequate graft selection is the most important factor for the success of the intervention. To ensure durability, permeability, and bypass function, there must be a morphological similarity between the graft and the coronary artery. The objective of this review was to analyze the morphological characteristics of the grafts that are most commonly used in coronary bypass surgery and the coronary arteries that are most frequently occluded. We included clinical information regarding the characteristics that determine the behavior of the grafts and its permeability over time. Currently, the internal thoracic artery is the standard choice for bypass surgery because of the morphological characteristics of the wall that makes less prone to developing atherosclerosis and hyperplasia. The radial and right gastroepiploic arteries are the following second and third best options, respectively. The ulnar artery is the preferred choice when other conduits are not feasible.

Is the Risk of Wound Infection Related to Bilateral Internal Thoracic Artery Graft Potentiated by Age?

BACKGROUND

Older age and the use of bilateral internal thoracic artery (ITA) grafting are both considered risk factors for surgical wound infection (SWI) after coronary artery bypass grafting (CABG). The 2014 European Guidelines recommend that bilateral ITA grafting should be considered in patients aged younger than 70 years. Our aim was to investigate interaction between age and the number of ITA grafts.

METHODS

All patients aged 18 years and older who had undergone CABG with at least 1 ITA at Rouen University Hospital between 2001 and 2012 were selected. Data regarding surgical procedure (single/bilateral ITA grafting) were extracted from the medical information system. SWI was identified from prospective surveillance of patients according to Centers for Disease Control and Prevention criteria. Independent factors associated with SWI were assessed by logistic regression, and an interaction test between age (≤69 or ≥70 years) and the number of ITA grafts was performed.

RESULTS

SWI occurred in 71 of 2,726 patients (2.6%). Bilateral ITA grafting was associated with SWI (adjusted odds ratio [aOR], 2.55; 95% confidence interval, 1.51 to 4.30). After fitting an interaction term between age and number of ITA grafts, the aORs for SWI after bilateral ITA grafting substantially differed between patients aged 69 years and younger (aOR, 1.88; 95% confidence interval, 0.94 to 3.75) and 70 years and older (aOR, 3.52; 95% confidence interval, 1.69 to 7.33). However, this interaction failed to reach statistical significance (p = 0.2213), possibly because of insufficient statistical power (23.5%) despite the large sample size.

CONCLUSIONS

Age 70 years and older compared with age 69 years and younger was associated with higher occurrence of SWI after bilateral ITA grafting, but this interaction was not statistically significant. Larger studies are needed to test this interaction.

Incidence of Deep Sternal Wound Infection in Diabetic Patients Undergoing Off-Pump Skeletonized Internal Thoracic Artery Grafting

OBJECTIVES

To evaluate the impact of skeletonized bilateral or single internal thoracic artery (ITA) grafting on the risk of deep sternal wound infection (DSWI) in diabetic patients undergoing off-pump coronary artery bypass grafting (OPCAB).

MATERIALS AND METHODS

A total of 803 diabetic patients undergoing OPCAB surgery from January 2010 to December 2014 were enrolled into this study and assigned to the pSITA group (patients undergoing pedicled single ITA grafting, n = 362), the sSITA group (skeletonized single ITA grafting, n = 295), or the sBITA group (skeletonized bilateral ITA grafting, n = 146). The primary end point was the diagnosis of a DSWI.

RESULTS

Eighteen patients developed postoperative DSWI, with an incidence of 2.2%. Patients in the sSITA group had a significantly lower incidence of DSWI than those in the pSITA group (1.0 vs. 3.6%, p = 0.0408). In multivariate logistic regression analysis, the risk of DSWI in the sSITA group was 0.41 times that in the pSITA group.

CONCLUSIONS

sSITA grafting lowered the risk of DSWI in diabetic patients undergoing OPCAB surgery compared to pSITA grafting. Multicenter clinical trials involving larger sample sizes are needed to determine the merit of pSITA grafting in reducing the risk of DSWI following OPCAB surgery.

Bilateral Internal Thoracic Artery Grafting: Is It Reasonable in Octogenarians?

PURPOSE

The feasibility of using bilateral internal thoracic artery (BITA) grafts for coronary artery bypass grafting (CABG) in octogenarians is not clear. This study aimed to compare outcomes between use of BITA and single internal thoracic artery (SITA) grafts in octogenarians undergoing isolated CABG.

METHODS

Isolated CABG was performed in 1,566 patients at the Sakakibara Heart Institute between September 2004 and December 2012. Of these, 125 consecutive octogenarians were included and divided into two groups, according to the use of BITA grafts (101 subjects) or SITA grafts (24 subjects). Early and late outcomes were compared between groups.

RESULTS

The preoperative patient characteristics were similar between the two groups. Early outcomes were similar, including hospital death or deep sternal infection. The estimated 5-year survival rate was similar in the BITA and SITA groups (78% vs 62%, p = 0.269). Freedom from major adverse cardiac or cerebrovascular events was significantly higher in the BITA group than in the SITA group after 5 years (90% vs 75%, p = 0.032).

CONCLUSIONS

Our results suggest that use of BITA grafts for CABG is feasible and beneficial in octogenarians, resulting in improved late outcomes without increased operative risk.

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†

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.

Retroaortic right internal thoracic artery grafting of circumflex artery targets

BACKGROUND

Retroaortic right internal thoracic artery grafting has failed to gain popularity. We aimed to delineate patient correlates of eligibility, distribution of targets, and effects of target remoteness on outcome and risk of retroaortic bleeding.

METHODS

Data of 861 patients undergoing skeletonized bilateral internal thoracic artery grafting (2007-2012) were analyzed according to retroaortic (n = 300) or T-graft configuration. Retroaortic graft subgroups were categorized according to proximal (first obtuse marginal, ramus) or distal (2nd, 3rd, or sequential 1st-2nd obtuse marginal) circumflex artery targets.

RESULTS

LOESS curve analyses revealed that taller patients had a higher likelihood of retroaortic grafting. The distribution of 337 retroaortic graft targets (300 patients) was first obtuse marginal in 74.5%, 2nd marginal in 12.4%, ramus in 11.2%, 3rd marginal in 1.9% and sequential 1st-2nd marginal in 12.3%. The success rate in reaching proximal and distal circumflex artery targets was 97% and 30%, respectively, 5-year survival (92.2%) and freedom from major adverse cardiac and cerebrovascular events (85.8%) were comparable between proximal and distal retroaortic graft subgroups. Distal circumflex artery targets had no effect on the occurrence of major adverse cardiac and cerebrovascular events. The incidence of retroaortic bleeding from skeletonized retroaortic grafts was 0.6%.

CONCLUSIONS

Taller patients have a greater likelihood of qualifying for retroaortic grafting. This technique is highly reproducible for proximal but not distal circumflex artery targets. Distal circumflex artery targets are not independent correlates of early or late adverse outcomes. The risk of retroaortic bleeding is low despite retroaortic right internal thoracic artery skeletonization.

Concomitant grafting of both postbifurcation internal thoracic artery branches

OBJECTIVE

We aimed to assess the clinical outcome and graft patency after concomitant grafting of both postbifurcation internal thoracic artery (ITA) branches.

METHODS

Between 2007 and 2013, 17 patients (14 men; mean [SD] age, 60 [9.3] years) underwent skeletonized bifurcated ITA grafting. Respective targets were restricted to non-left anterior descending (LAD) area. In all patients, a complementary standard ITA was used to graft the LAD artery. Graft patency was assessed by standard coronary angiography or serial multidetector computed tomography.

RESULTS

Of the bifurcated conduits, 94% were right ITA. Respective right ITA target sets were first and second obtuse marginal arteries (M1-M2) (n = 12), ramus-M1 (n = 2), and distal right coronary artery-posterior descending artery (n = 2). Right ITAs were mobilized retroaortic (via the transverse sinus) in 14 patients (82%) (to circumflex artery targets). Circumflex artery targets comprised 88.2% of all anastomoses (30/34). There were no early mortalities, myocardial infarctions, or hypoperfusion syndromes. During median follow-up of 44 months (range, 3-63), there was no late mortality. Overall reintervention rate was 11.7%, and bifurcated ITA-related reintervention rate was 5.8%. At 5 years, freedom from major adverse cardiac or cerebrovascular event related to bifurcated ITA respective territory was 87% (Kaplan-Meier). Coronary imaging was achieved in 76% of the patients (elective multidetector computed tomography, n = 9; symptoms-directed coronary catheterization, n = 4). Bifurcation branch patency rate was 88.4% (23/26) at a median of 3.5 years.

CONCLUSIONS

Grafting both postbifurcation ITA branches is technically feasible and may be selectively considered. Current observations are valid for skeletonized conduits and limited to non-LAD targets. These preliminary findings should be corroborated by larger data sets.

Bilateral internal mammary artery grafting in obese: outcomes, concerns and controversies

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.

A pilot randomized controlled trial comparing CABG surgery performed with total arterial grafts or without

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.

Obesity and coronary artery disease: evaluation and treatment

With the increasing prevalence of obesity, clinicians are now facing a growing population of patients with specific features of clinical presentation, diagnostic challenges, and interventional, medical, and surgical management. After briefly discussing the effect of obesity on atherosclerotic burden in this review, we will focus on strategies clinicians might use to ensure better outcomes when performing revascularization in obese and severely obese patients. These patients tend to present comorbidities at a younger age, and their anthropometric features might limit the use of traditional cardiovascular risk stratification approaches for ischemic disease. Alternative techniques have emerged, especially in nuclear medicine. Positron emission tomography-computed tomography might be the diagnostic imaging technique of choice. When revascularization is considered, features associated with obesity must be considered to guide therapeutic strategies. In percutaneous coronary intervention, a radial approach should be favoured, and adequate antiplatelet therapy with new and more potent agents should be initiated. Weight-based anticoagulation should be contemplated if needed, with the use of drug-eluting stents. An "off-pump" approach for coronary artery bypass grafting might be preferable to the use of cardiopulmonary bypass. For patients who undergo bilateral internal thoracic artery grafting, harvesting using skeletonization might prevent deep sternal wound infections. In contrast to percutaneous coronary intervention, lower surgical bleeding has been observed when lean body mass is used for perioperative heparin dose determination.

Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: a case-control study of 1526 patients

OBJECTIVE

Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG.

METHODS

A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes.

RESULTS

RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46).

CONCLUSIONS

RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.

Bilateral versus single internal mammary coronary artery bypass grafting in Sweden from 1997-2008

BACKGROUND

Prior observational studies have suggested better outcomes in patients who receive bilateral internal mammary arteries (BIMA) during coronary artery bypass grafting (CABG) compared with patients who receive a single internal mammary artery (SIMA). The aim of this study was to analyze the association between BIMA use and long-term survival in patients who underwent primary isolated CABG.

METHODS AND RESULTS

Patients who underwent primary isolated non-emergent CABG in Sweden between 1997 and 2008 were identified. The SWEDEHEART registry and other national Swedish registers were used to acquire information about patient characteristics and outcomes. Unadjusted and multivariable adjusted regression models were used to estimate the association between BIMA use and early mortality, long-term survival, and a composite of death from any cause or rehospitalization for myocardial infarction, heart failure, or stroke in the overall cohort and in a propensity score-matched cohort. The study population consisted of 49702 patients who underwent CABG with at least one internal mammary artery, and 559 (1%) of those had BIMA grafting. In the adjusted analyses, BIMA use was not associated with better survival compared with SIMA use in the overall cohort (hazard ratio (HR) for death: 1.16, 95% confidence interval (CI): 0.97 to 1.37) or in the matched cohort (HR: 1.04, 95% CI: 0.78 to 1.40). The results were similar for early mortality and the composite endpoint. Reoperation for sternal wound complications was more common among BIMA patients (odds ratio: 1.71, 95% CI: 1.01 to 2.88).

CONCLUSIONS

BIMA grafting was performed infrequently and was not associated with better outcomes compared with SIMA grafting in patients undergoing non-emergent primary isolated CABG in Sweden during 1997-2008.

Determinants of outcome after isolated coronary artery bypass grafting in patients aged ≤50 years (from the Coronary aRtery diseAse in younG adultS study)

This study was planned to identify the determinants of outcome after coronary artery bypass (CABG) in young patients. Data on 592 patients aged ≤50 years who underwent CABG from 9 European institutions were collected retrospectively. Twenty-eight percent of patients received at least 2 arterial grafts. Clopidogrel was used at discharge in 16.2% and statins in 67.2% of patients. Freedom from major adverse cardiac and cerebrovascular events at 1, 3, and 5 years was 93.8%, 90.1%, and 85.0%; survival rate was 98.3%, 96.3%, and 94.9%; freedom from myocardial infarction was 96.3%, 95.1%, and 92.5%; and freedom from repeat revascularization was 96.3%, 95.1%, and 92.5%, respectively. Neither types of grafts nor medication at discharge had any impact on the late outcome. Age <40 years (relative risk [RR] 2.19, 95% confidence interval [CI] 1.17 to 4.11), diabetes (RR 1.71, 95% CI 1.02 to 2.88), estimated glomerular filtration rate <60 ml/min/1.73 m(2) (RR 2.44, 95% CI 1.26 to 4.72), non-ST-elevation myocardial infarction/ST-elevation myocardial infarction (RR 2.12, 95% CI 1.27 to 3.55), emergency procedure (RR 2.34, 95% CI 1.13 to 4.88), and left ventricular ejection fraction <30% (RR 3.18, 95% CI 1.41 to 7.16) were independent predictors of major adverse cardiac and cerebrovascular events. Patients with left ventricular ejection fraction <30% had a particularly poor survival rate (at 5 years 67.7% vs 96.1%; adjusted analysis RR 14.01, 95% CI 5.16 to 38.03). Poor left ventricular function, myocardial infarction, diabetes, renal failure, and age <40 years are major determinants of late outcome after CABG in young patients. In conclusion, data from this real-world registry indicate that multiple arterial grafts and statin treatment are largely underutilized in these patients.

Conduits for coronary bypass: strategies

Strategic planning is integral to any operation but complexity varies immensely and therefore the effort necessary to create the optimal plan. The previous three reports have discussed individual conduits and herein is an attempt to present approaches to common situations which the author favors. Although much has been learned over 45 years about use and subsequent behavior of venous and arterial grafts we continue to learn and, as a result, evolve new strategies or modify those now popular. Thus the reader must recognize that in spite of trying to be balanced and inclusive all surgeons have personal opinions and also prejudices which influence the approach taken and which may not be the optimal one for others or for the patient.

A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting

BACKGROUND

Increasing evidence continues to demonstrate a survival advantage for bilateral internal mammary artery (BIMA) over left internal mammary artery (LIMA) for coronary artery bypass grafting (CABG). We performed an updated meta-analysis of published studies comparing BIMA versus LIMA in CABG operations and assessed differences in long-term survival.

METHODS

Electronic searches for studies comparing BIMA versus LIMA were performed using three databases from 1972 to December 2012. Studies with at least four years of follow-up and at least 100 patients in each group were included for review. We used a random-effect model and pooled hazard ratios from across all included studies.

RESULTS

No randomized controlled trials and 27 observational studies totaling 79,063 patients (19,277 BIMA, 59,786 LIMA) were included for final analysis. The BIMA group demonstrated significantly better long-term survival than the LIMA group [hazard ratio, 0.78; confidence interval, 0.72-0.84; P<0.00001].

CONCLUSIONS

In an updated meta-analysis, we demonstrate an increase in long-term survival in patients receiving BIMA as a primary grafting strategy over those receiving a LIMA. Although no randomized controlled trials were included in this meta-analysis, the survival benefit seen with a BIMA cannot be overlooked when determining which operation to perform in CABG patients. Until the long-term results of the ART trial are published, we offer best available evidence in favor of BIMA over LIMA for CABG surgery.

The art of arterial revascularization-total arterial revascularization in patients with triple vessel coronary artery disease

The use of the left internal thoracic artery to graft the left anterior descending artery has been widely accepted as the gold standard for surgical treatment of coronary disease for over 40 years. However the use of multiple other arterial grafts to support this has not been accepted readily, in spite of evidence of superiority over saphenous vein grafts, probably because of perceptions of technical complexity, time constraints for conduit harvesting and increased peri-operative complications. As a result, even today most patients with multivessel coronary artery disease do not receive the potential benefits of extensive or total arterial revascularization. We discuss here the use of contemporary techniques and grafts configurations to simplify this, and the safety and benefit data underpinning this practice. Current patency data confirm that a left internal thoracic artery graft performs well beyond 20 years, with over 80% freedom from failure, but accumulating data suggest that the right internal thoracic artery behaves in the same way. Radial artery grafts are being studied in several randomized trials, but observational studies already suggest a performance which compares favourably with saphenous vein. Total arterial revascularization is achievable in most patients with a small but acceptable increase in risk of sternal complications when certain defined subgroups are excluded.