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Balkhy HH, Nisivaco S, Kitahara H, AbuTaleb A, Nathan S, Hamzat I. Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents. JTCVS Tech 2022; 16:76-88. [PMID: 36510526 PMCID: PMC9735326 DOI: 10.1016/j.xjtc.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
Objective Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention. Methods From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8 years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization. Results The mean age of patients was 65 ± 10 years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26 ± 1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311 ± 54 minutes, and the mean hospital length of stay was 2.7 ± 1.1 days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14 ± 0.4, and the mean number of vessels stented was 1.23 ± 0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39 ± 26 months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%. Conclusions In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.
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Key Words
- AHCR, advanced hybrid coronary revascularization
- BITA, bilateral internal thoracic artery
- BMI, body mass index
- CABG, coronary artery bypass grafting
- CAD, coronary artery disease
- DAPT, dual-antiplatelet therapy
- HCR, hybrid coronary revascularization
- LAD, left anterior descending artery
- LITA, left internal thoracic artery
- LOS, length of stay
- MACCE, major adverse cardiac/cerebrovascular events
- MAG, multi-arterial grafting
- MI, myocardial infarction
- MIDCAB, minimally invasive direct coronary artery bypass
- PCI, percutaneous coronary intervention
- RCA, right coronary artery
- RITA, right internal thoracic artery
- SITA, single internal thoracic artery
- TECAB
- TECAB, totally endoscopic coronary artery bypass
- bilateral internal thoracic arteries
- coronary artery bypass
- hybrid revascularization
- off-pump
- percutaneous coronary intervention
- robotic
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Affiliation(s)
- Husam H. Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill,Address for reprints: Husam H. Balkhy, MD, Department Cardiothoracic Surgery, University of Chicago, 5841 S. Maryland Ave, E-500, Chicago, IL 60637.
| | - Sarah Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
| | | | - Sandeep Nathan
- Department of Cardiology, University of Chicago Medicine, Chicago, Ill
| | - Ibraheem Hamzat
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
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Davierwala PM, Leontyev S, Garbade J, Lehmann S, Holzhey D, Misfeld M, Borger MA. Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience. Ann Cardiothorac Surg 2018; 7:483-491. [PMID: 30094212 DOI: 10.21037/acs.2018.06.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Contrasting results of recent randomized controlled trials (RCTs) comparing off-pump and on-pump coronary artery bypass graft (CABG) surgery, as well as the lack of evidence for any survival benefit of bilateral internal thoracic artery (ITA) grafting over single ITA use, has intensified the debate about the role of the off-pump technique and bilateral ITA use in CABG surgery. We therefore investigated our 15-year experience in off-pump CABG with bilateral ITA grafting and evaluated temporal trends in preoperative characteristics and postoperative outcomes. Methods Demographic, intra-operative, and outcome data of 1,199 consecutive patients undergoing off-pump CABG with bilateral ITA grafting was prospectively collected in a computerized database. Patients who underwent on-pump cardiac procedures and other extra-cardiac procedures were excluded from this study. Assessment of changes in perioperative characteristics and parameters with time was performed by dividing the whole cohort into three groups (2003-2007, 2008-2012, and 2013-2017) based on the year of surgery. Results The overall 30-day mortality was 0.6%, with no differences observed between the three time cohorts (0.6%, 0.7%, 0.5%; P=0.8). The perioperative stroke rate for whole cohort was 0.6% and demonstrated a significant reduction in the last two time cohorts (1%, 0.5%, 0.5%; P<0.0001). The overall incidence of deep sternal wound infections was 0.7%, but was marginally higher in the last time-cohort (0.6%, 0.5%, 0.9%; P=0.7). Overall survival for the entire cohort was 92.9%±1% and 78.9%±4% at 5 and 10 years follow-up, respectively. Older age at surgery and presence of peripheral vascular disease were the only predictors of late mortality. Conclusions Off-pump CABG with bilateral skeletonized ITAs is a safe operation and is associated with a low mortality and morbidity, which can be maintained in high volume center unit over a long period of time. The long-term survival of patients undergoing such an operation is excellent.
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Affiliation(s)
- Piroze M Davierwala
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sergey Leontyev
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Jens Garbade
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sven Lehmann
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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Gaudino M, Puskas JD, Di Franco A, Ohmes LB, Iannaccone M, Barbero U, Glineur D, Grau JB, Benedetto U, D'Ascenzo F, Gaita F, Girardi LN, Taggart DP. Three Arterial Grafts Improve Late Survival: A Meta-Analysis of Propensity-Matched Studies. Circulation 2017; 135:1036-1044. [PMID: 28119382 DOI: 10.1161/circulationaha.116.025453] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed. METHODS A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals. RESULTS Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71-1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75-0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33-0.98; P=0.04). CONCLUSIONS The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status.
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Affiliation(s)
- Mario Gaudino
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.).
| | - John D Puskas
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Antonino Di Franco
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Lucas B Ohmes
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Mario Iannaccone
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Umberto Barbero
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - David Glineur
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Juan B Grau
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Umberto Benedetto
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Fabrizio D'Ascenzo
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Fiorenzo Gaita
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - Leonard N Girardi
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
| | - David P Taggart
- From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.)
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Benedetto U, Altman DG, Gerry S, Gray A, Lees B, Pawlaczyk R, Flather M, Taggart DP. Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial. J Thorac Cardiovasc Surg 2016; 152:270-6. [PMID: 27112712 DOI: 10.1016/j.jtcvs.2016.03.056] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/02/2016] [Accepted: 03/11/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The question of whether skeletonized internal thoracic artery harvesting reduces the incidence of sternal wound complications in comparison with the pedicled technique, in the context of single or bilateral internal thoracic arteries, remains controversial. We studied the impact of the internal thoracic artery harvesting strategy on sternal wound complication in the Arterial Revascularization Trial. METHODS Patients enrolled in the Arterial Revascularization Trial (n = 3102) were randomized to coronary artery bypass grafting with single or bilateral internal thoracic arteries. Sternal wound complication rates were examined according to the harvesting technique that was documented in 2056 patients. The internal thoracic artery harvesting technique, based on the surgeon's preference, resulted in 4 groups: pedicled single internal thoracic artery (n = 607), pedicled bilateral internal thoracic artery (n = 459), skeletonized single internal thoracic artery (n = 512), and skeletonized bilateral internal thoracic artery (n = 478). Propensity scores weighting was used to estimate the impact of the harvesting technique on sternal wound complications. RESULTS A total of 219 of 2056 patients (10.6%) experienced a sternal wound complication within 1 year from the index operation. Of those, only 25 patients (1.2%) required sternal wound reconstruction. Pedicled bilateral internal thoracic artery (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.23-2.63) but not skeletonized bilateral internal thoracic artery (OR, 1.00; 95% CI, 0.65-1.53) or skeletonized single internal thoracic artery (OR, 0.89; 95% CI, 0.57-1.38) was associated with a significantly increased risk of any sternal wound complications compared with pedicled single internal thoracic artery. CONCLUSIONS The present Arterial Revascularization Trial substudy suggests that, with a skeletonization technique, the risk of sternal wound complication with bilateral internal thoracic artery grafting is similar to that after standard pedicled single internal thoracic artery harvesting, whereas skeletonized single internal thoracic artery harvesting did not add any further benefit when compared with pedicled single internal thoracic artery harvesting.
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Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom.
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Alastair Gray
- Department of Public Health, Health Economics Research Centre, University of Oxford, Headington, Oxford, United Kingdom
| | - Belinda Lees
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Rafal Pawlaczyk
- Department of Cardiovascular Surgery, Medical University of Gdansk, Poland
| | - Marcus Flather
- Research and Development Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
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