Outcomes of off-pump coronary bypass grafting with the bilateral internal thoracic artery for left ventricular dysfunction

Comparison of long-term clinical outcomes between revascularization versus medical treatment in patients with silent myocardial ischemia

BACKGROUND

There have been limited and conflicting results regarding the prognostic impact of revascularization treatment on the long-term clinical outcomes of silent ischemia. The current study aimed to determine whether revascularization treatment compared with medical treatment (MT) alone reduces long-term risk of cardiac death of asymptomatic patients with objective evidence of inducible myocardial ischemia.

METHODS

A total of 1473 consecutive asymptomatic patients with evidence of inducible myocardial ischemia were selected from a prospective institutional registry. All patients showed at least 1 epicardial coronary stenosis with ≥50% diameter stenosis in coronary angiography. Patients were classified according to their treatment strategies. The primary outcome was cardiac death up to 10 years.

RESULTS

Among the total population, 709 patients (48.1%) received revascularization treatment including percutaneous coronary intervention (PCI, n = 558) or coronary artery bypass graft surgery (CABG, n = 151), with the remaining patients (764 patients, 51.9%) receiving MT alone. During the follow-up period, the revascularization treatment group showed a significantly lower risk of cardiac death compared with the MT alone group (25.4% vs. 33.7%, HR 0.624, 95%CI 0.498-0.781, p < 0.001). Among revascularized patients, patients with negative non-invasive stress test results after revascularization showed significantly lower risk of cardiac death compared to those with residual myocardial ischemia (8.9% vs. 18.7%, HR 0.406, 95% CI 0.175-0.942, p = 0.036).

CONCLUSIONS

In patients with silent myocardial ischemia, revascularization treatment was associated with significantly lower long-term risk of cardiac death compared with the MT alone group. The current results support contemporary practice of ischemia-directed revascularization, even in patients with silent myocardial ischemia.

Anaortic off-pump bilateral internal mammary grafting in severe left ventricular dysfunction - Case report

A 64 years old male diabetic patient with ejection fraction of 16% and renal dysfunction underwent off-pump CABG using both in situ internal mammary artery grafts. Left internal mammary artery was used to bypass left anterior descending artery and right internal mammary artery was used as composite graft. Patient had uneventful recovery and left ventricular ejection fraction improved to 34% within 8 months after surgery. In presence of left ventricular dysfunction, both internal thoracic artery grafting should be preferred for better patency rate and flow reserve. This is the first ever case report of anaortic off-pump bilateral internal thoracic artery grafting in a patient with left ventricular ejection fraction less than 20%.