Long-Term Results of the RAPCO Trials.

BACKGROUND: An internal thoracic artery graft to the left anterior descending artery is standard in coronary bypass surgery, but controversy exists on the best second conduit. The RAPCO trials (Radial Artery Patency and Clinical Outcomes) were designed to compare the long-term patency of the radial artery (RA) with that of the right internal thoracic artery (RITA) and the saphenous vein (SV). METHODS: In RAPCO-RITA (the RITA versus RA arm of the RAPCO trial), 394 patients <70 years of age (or <60 years of age if they had diabetes mellitus) were randomized to receive RA or free RITA graft on the second most important coronary target. In RAPCO-SV (the SV versus RA arm of the RAPCO trial), 225 patients ≥70 years of age (or ≥60 years of age if they had diabetes mellitus) were randomized to receive RA or SV graft. The primary outcome was 10-year graft failure. Long-term mortality was a nonpowered coprimary end point. The main analysis was by intention to treat. RESULTS: In the RA versus RITA comparison, the estimated 10-year patency was 89% for RA versus 80% for free RITA (hazard ratio for graft failure, 0.45 [95% CI, 0.23-0.88]). Ten-year patient survival estimate was 90.9% in the RA arm versus 83.7% in the RITA arm (hazard ratio for mortality, 0.53 [95% CI, 0.30-0.95]). In the RA versus SV comparison, the estimated 10-year patency was 85% for the RA versus 71% for the SV (hazard ratio for graft failure, 0.40 [95% CI, 0.15-1.00]), and 10-year patient survival estimate was 72.6% for the RA group versus 65.2% for the SV group (hazard ratio for mortality, 0.76 [95% CI, 0.47-1.22]). CONCLUSIONS: The 10-year patency rate of the RA is significantly higher than that of the free RITA and better than that of the SV. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00475488.

Association of Radial Artery Graft vs Saphenous Vein Graft With Long-term Cardiovascular Outcomes Among Patients Undergoing Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis.

Importance: Observational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials. Objective: To compare clinical outcomes between patients receiving radial artery vs saphenous vein grafts for coronary artery bypass grafting after long-term follow-up. Design, Setting, and Participants: Patient-level pooled analysis comparing radial artery vs saphenous vein graft in adult patients undergoing isolated coronary artery bypass grafting from 5 countries (Australia, Italy, Serbia, South Korea, and the United Kingdom), with enrollment from 1997 to 2009 and follow-up completed in 2019. Interventions: Patients were randomized to undergo either radial artery (n = 534) or saphenous vein (n = 502) grafts for coronary artery bypass grafting. Main Outcomes and Measures: The primary outcome was a composite of death, myocardial infarction, or repeat revascularization and the secondary outcome was a composite of death or myocardial infarction. Results: A total of 1036 patients were randomized (mean age, 66.6 years in the radial artery group vs 67.1 years in the saphenous vein group; 376 [70.4%] men in the radial artery group vs 351 [69.9%] in the saphenous vein group); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 in the radial artery group). At a median (interquartile range) follow-up of 10 (10-11) years, the use of the radial artery, compared with the saphenous vein, in coronary artery bypass grafting was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction, or repeat revascularization (220 vs 237 total events; 41 vs 47 events per 1000 patient-years; hazard ratio, 0.73 [95% CI, 0.61-0.88]; P < .001) and of the composite of death or myocardial infarction (188 vs 193 total events; 35 vs 38 events per 1000 patient-years; hazard ratio, 0.77 [95% CI, 0.63-0.94]; P = .01). Conclusions and Relevance: In this individual participant data meta-analysis with a median follow-up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with the saphenous vein was associated with a lower risk of a composite of cardiovascular outcomes.

Impact of socioeconomic status and rurality on early outcomes and mid-term survival after CABG: insights from a multicentre registry.

BACKGROUND: We examined whether socioeconomic status and rurality influenced outcomes after coronary surgery. METHODS: We identified 14,150 patients undergoing isolated coronary surgery. Socioeconomic and rurality data was obtained from the Australian Bureau of Statistics and linked to patients' postcodes. Outcomes were compared between categories of socioeconomic disadvantage (highest versus lowest quintiles, n= 3150 vs. 2469) and rurality (major cities vs. remote, n=9598 vs. 839). RESULTS: Patients from socioeconomically-disadvantaged areas experienced a greater burden of cardiovascular risk factors including diabetes, obesity and current smoking. Thirty-day mortality (disadvantaged 1.6% vs. advantaged 1.6%, p>0.99) was similar between groups as was late survival (7 years: 83±0.9% vs. 84±1.0%, p=0.79). Those from major cities were less likely to undergo urgent surgery. There was similar 30-day mortality (major cities: 1.6% vs. remote: 1.5%, p=0.89). Patients from major cities experienced improved survival at seven years (84±0.5% vs. 79±2.0%, p=0.010). Propensity-analysis did not show socioeconomic status or rurality to be associated with late outcomes. CONCLUSION: Patients presenting for coronary artery surgery from different socioeconomic and geographic backgrounds exhibit differences in their clinical profile. Patients from more rural and remote areas appear to experience poorer long-term survival, though this may be partially driven by the population's clinical profile.

Lipid management in high risk coronary patients: how effective are we at secondary intervention?

OBJECTIVE: To assess the proportion of patients who achieve and maintain target lipid levels during optimum long term follow up after coronary bypass surgery. METHODS: From a prospectively compiled database, we identified 440 patients followed for up to 13 years after CABG as part of a radial artery randomised controlled trial. All available lipid assays conducted during the follow-up period were collected from pathology databases. These were used to calculate the annualised mean lipid exposure for each patient. Based upon National Heart Foundation guidelines, we determined the proportion of patients whose mean lipid exposure attained target levels (total cholesterol <4.0 mmol/L, LDL-C <2.0 mmol/L, HDL-C >1.0 mmol/L and triglycerides <1.5 mmol/L). This was compared with the proportion who had achieved these targets pre-operatively and on their most recent cholesterol measurement. RESULTS: 6077 lipid studies (total cholesterol, LDL, HDL and triglycerides) in total were obtained. In those who had baseline data available, target levels for total cholesterol, HDL-C, LDL-C and triglycerides were attained pre-operatively by 16%, 64%, 14% and 39% of patients respectively. Annualised mean lipid exposures during up to 13 years of follow up for all patients revealed somewhat improved but still suboptimal target attainment figures of 24%, 83%, 20% and 53%. The most recent review shows the greatest improvement at 47%, 68%, 43% and 62% respectively. Of 141 diabetic patients, target attainment was significantly higher for total cholesterol (31%; p=0.038) and LDL-C (28%; p=0.006) but lower for HDL-C (75%; p=0.002) and triglycerides (40%; p<0.001). CONCLUSION: Despite some improvements seen over careful follow up, only HDL-C targets appear attainable for the majority of CABG patients. Over half still do not achieve non-HDL national lipid targets.

The Radial Artery Patency and Clinical Outcomes trial: design, intermediate term results and future direction.

The Radial Artery Patency and Clinical Outcomes Study (RAPCO) was devised and implemented in Melbourne in order to establish the appropriate place of the radial artery in the hierarchy of conduits available to the modern coronary bypass surgeon. Designed as a biological comparison with minimisation of other confounding variables, it compares this free arterial graft with the right internal thoracic artery and saphenous vein, with all conduits used in an identical fashion in two parallel cohorts of different age ranges. Enrolment was completed in 2004 and 10-year follow-up is in progress, with mean duration of about seven years at present. The midterm clinical and angiographic results to date are reviewed here, but definitive conclusions will not be possible until full completion angiographic data is available. The trial data provides a number of potential substudies of conduits, risk factors for failure and the natural history of treated coronary disease.

Impact of chronic kidney disease on patient outcome following cardiac surgery.

BACKGROUND: Renal impairment is a major risk factor for cardiovascular disease. This study addressed clinical predictors of outcome following cardiac surgery, focusing on pre-operative renal dysfunction. METHODS: All patients undergoing cardiac surgery at Austin Health from June 1, 2001 to June 30, 2006, were included in the analysis. Logistic regression models were used to evaluate clinical factors predicting "operative mortality" and common post-operative complications. RESULTS: The operative mortality was 1.36% for coronary artery bypass grafting (CABG) alone (n=1027), 5.07% for valve surgery alone (n=217), 4.43% for combined CABG and valve surgery (n=158) and 11.11% for other cardiac surgical procedures (n=270). Amongst CABG alone patients, pre-operative renal impairment was a strong predictor of operative mortality, with a 35-43% increased risk of death (p=0.005) for every 10 ml/min/1.73 m(2) that the glomerular filtration rate was lower. Peripheral vascular disease, recent myocardial infarction and congestive cardiac failure also predicted operative mortality. Pre-operative renal impairment also increased the rate of various post-operative complications, as well as duration of admission. CONCLUSION: Renal dysfunction is significantly associated with increased mortality and morbidity following cardiac surgery and necessitates careful consideration in risk benefit analysis when considering cardiac surgery.

The RADial artery International ALliance (RADIAL) extended follow-up study: rationale and study protocol.

It is generally accepted that radial artery (RA) grafts have better mid-term patency rate compared to saphenous vein grafts. However, the clinical correlates of the improved patency rate are still debated. Observational studies have suggested increased survival and event-free survival for patients who receive an RA rather than a saphenous vein, but they are open to bias and confounders. The only evidence based on randomized data is a pooled meta-analysis of 6 randomized controlled trial comparing the RA and the saphenous vein published by the RADial artery International Alliance (RADIAL). In the RADIAL database, improved freedom from follow-up cardiac events (death, myocardial infarction and repeat revascularization) was found at 5-year follow-up in the RA arm. The most important limitation of the RADIAL analysis is that most of the included trials had an angiographic follow-up in the first 5 years and it is unclear whether the rate of repeat revascularization (the main driver of the composite outcome) was clinically indicated due to per-protocol angiographies. Here, we present the protocol for the long-term analysis of the RADIAL database. By extending the follow-up beyond the 5th postoperative year (all trials except 1 did not have angiographic follow-up beyond 5 years), we aim to provide data on the role of RA in coronary artery bypass surgery with respect to long-term outcomes.

Effect of radial artery or saphenous vein conduit for the second graft on 6-year clinical outcome after coronary artery bypass grafting. Results of a randomised trial.

OBJECTIVES: In order to determine the best conduit for coronary targets other than the left anterior descending (LAD) artery, long-term clinical outcomes following revascularisation with a radial artery or saphenous vein graft were evaluated as part of the radial artery patency and clinical outcomes (RAPCO) study. METHODS: As part of the RAPCO protocol for this prospective, randomised, single-centre trial, patients aged over 70 years undergoing primary CABG were randomly assigned to use of a radial artery (n=113) or saphenous vein (n=112) to revascularise the best non-LAD coronary vessel. Follow-up was annual. Primary clinical end-points were death, myocardial infarction or need for revascularisation. Data were analysed by intention to treat. RESULTS: The preoperative demographics (age, gender, presence of hypertension or diabetes mellitus) and urgency of surgery did not differ significantly between the two groups. The allocated arterial or venous conduit was utilised as intended in 104/113 and 110/112 patients, respectively. Mean number of grafts was 3.2+/-0.9 and 3.3+/-0.7 in the two groups. During follow-up of mean duration 6.2 years (maximum 10.8 years) there were 16 deaths in each group and 9 vs 13 other events in the radial artery and saphenous vein groups, respectively. These clinical outcomes did not differ significantly (log rank p=0.98 for survival and p=0.52 for event-free survival). CONCLUSIONS: Use of a radial artery or saphenous vein for the second graft during primary CABG does not significantly influence clinical outcome at 6 years. Mean 5-year angiographic patency data are awaited, but from the patient's perspective the likelihood of a satisfactory long-term result is equivalent, whichever conduit is used.

Is the radial artery associated with improved survival in older patients undergoing coronary artery bypass grafting? An analysis of a multicentre experience†.

OBJECTIVES: Studies suggest that the radial artery (RA) may exhibit superior patency compared with the saphenous vein (SV). It is unclear whether older patients undergoing coronary artery bypass grafting (CABG) derive any survival benefit from the use of RAs. We sought to evaluate this using a multicentre database. METHODS: From 1995 to 2010, 6059 patients with three-vessel coronary artery disease underwent primary isolated CABG at 8 centres. A study cohort of 4006 patients was formed with 3220 (80%) receiving at least 1 RA to supplement a single in situ internal thoracic artery (RA group) while 786 (20%) received only veins to supplement a single ITA (SV group). In the RA group, bilateral RAs were used in 1418 (44%) cases, while total arterial revascularization was achieved in 1859 (58%). RAs were mostly grafted to the left circumflex and right coronary territories. Survival data were obtained using the National Death Index and propensity-score matching was used for risk adjustment. Separate propensity-score analyses were conducted for the 2149 patients (1645 RA, 504 SV) who were 70 years or older. RESULTS: Patients receiving RAs were younger (mean age in years RA: 68 ± 9.7 vs SV: 71 ± 7.9, P < 0.001) and less likely to have cerebrovascular disease, obstructive airways disease, myocardial infarction within 7 days and left-main coronary disease. At 30 days, RA patients experienced reduced unadjusted mortality (49 of 3220, 1.5% vs 25 of 786, 3.2%, P = 0.004). At 15 years, the RA group showed superior unadjusted survival (51 ± 1.1 vs 35 ± 1.9%, P < 0.001). After propensity-score matching of 507 patient pairs, there was comparable 30-day mortality between groups (RA: 9, 1.8 vs SV: 14, 2.8%, P = 0.41). However, at 15 years, the RA group still showed superior survival (42 ± 2.6 vs 35 ± 2.5%, P = 0.008). Among those 70 years and older (327 matched pairs), despite similar 30-day mortality (RA: 6, 1.8% vs SV: 10, 3.1%, P = 0.42), RA patients again exhibited improved survival (35 ± 3.3 vs 22 ± 2.8%, P = 0.004) at 15 years. CONCLUSIONS: This multicentre analysis suggests that the use of an RA is associated with a survival benefit in older patients undergoing CABG.

Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies.

OBJECTIVE: Total arterial revascularization (TAR) with internal thoracic arteries (ITAs) and radial arteries (RA) is associated with greater long-term survival compared with the use of a single internal thoracic artery supplemented by veins. The optimal conduit choice and configuration in achieving TAR remains controversial, with uncertainty regarding the individual prognostic impact of ITAs and RAs. As such, among patients solely undergoing TAR, we compared long-term survival between patients receiving single thoracic arteries and those receiving bilateral ITAs. METHODS: From 1995 to 2010, 2821 patients with 3-vessel coronary artery disease at 8 centers underwent primary isolated coronary artery bypass with TAR using ITAs and RAs. Bilateral ITAs were used in 912 patients. In 380 cases, bilateral in situ ITAs were grafted to the left coronary system. RAs were used in 848 patients (93%) receiving bilateral ITAs and 1906 patients (99.8%) receiving single ITAs. Survival data were obtained using the National Death Index. Separate 1:1 propensity score-matched analyses were performed for (1) bilateral ITA versus single ITA and (2) bilateral ITA incorporating a free right ITA versus single ITA and RAs. Among the 912 patients with bilateral ITAs, those receiving an in situ right ITA to the left coronary system were compared with those receiving a free right ITA. RESULTS: In the propensity score-matched analysis comparing bilateral versus single ITAs (591 matched pairs), there were similar rates of 30-day mortality and deep sternal wound infection. Bilateral ITA use was associated with greater 15-year survival (79% ± 3.9% vs 67% ± 4.7%, P < .001). In the analysis between bilateral ITA incorporating a free right ITA versus single ITA + RAs (380 matched pairs), bilateral ITA use demonstrated comparable survival at 15 years (79% ± 4.7% vs 67% ± 5.7%, P = .09). Among patients receiving bilateral ITAs, comparison between in situ right ITA versus free right ITA recipients (206 matched pairs) revealed comparable 15-year survival (84% ± 6.1% vs 79% ± 6.7%, P = .13). Multivariable Cox regression found bilateral ITA use to be protective from mortality (hazard ratio, 0.73; 95% confidence interval, 0.59-0.90, P = .004). CONCLUSIONS: The use of bilateral ITAs as an in situ or free conduit is associated with greater survival and seems to offer a prognostic advantage over the use of only a single ITA supplemented by RAs. Therefore, all configurations of TAR are not equivalent.

Regression of coronary disease after bypass surgery: Urban myth or common finding?

OBJECTIVES: Coronary artery disease has been viewed as a relentless, progressive disease. We sought to describe the prevalence and distribution of regression of native vessel disease in coronary artery bypass patients and characterize its relationship with bypass grafting. METHODS: Among 619 patients who underwent bypass surgery in a radial artery trial, 405 had follow-up angiography available a mean of 6.2 ± 3.1 years (range, 0-14) after surgery. The percentage of diameter stenosis of each major native coronary vessel was reported by 3 cardiac specialists and classified into grades of nonflow limiting (0%-39%), moderate (40%-69%), flow limiting (70%-80%), severely stenosed (81%-99%), and occluded (100%). Native vessel disease regression was defined as decrease in 1 or more grades of stenosis between the pre- and postoperative angiograms. RESULTS: A total of 1742 native coronary arteries had preoperative stenosis of at least 40% and were included in the present analysis, receiving 753 arterial grafts and 391 saphenous vein grafts. Overall, the prevalence of disease regression was 19.7%, and 45% of patients demonstrated regression in 1 or more vessels. The presence of an arterial graft increased the likelihood of disease regression (21.3% compared with 16% for venous bypassed vessels, P = .012) as did the location in the left circulation (22.6% compared with 13.9% for the right circulation, P < .001) and having a flow-limiting (≥70%) lesion (21.9% compared with 9.8% for moderate lesions, P < .001). CONCLUSIONS: Native coronary artery disease regression after coronary artery bypass grafting is common and affected by conduit type, vessel location, and lesion severity. Surgeons must consider these factors when assessing the requirement for bypass grafts in a borderline lesion.

Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival.

OBJECTIVES: We sought to evaluate our experience with total arterial revascularization and compare it with the traditional approach of a single internal thoracic artery supplemented by saphenous veins. METHODS: From 1995 to 2010, 6059 patients with triple-vessel coronary artery disease underwent primary isolated coronary artery bypass grafting at 8 centers. A study cohort of 3774 patients was formed, with 2988 (79%) undergoing total arterial revascularization and 786 (21%) receiving only saphenous veins to supplement a single in situ internal thoracic artery. In the total arterial revascularization group, bilateral internal thoracic arteries were used in 1079 patients (36%) and at least 1 radial artery was used in 2916 patients (97%). Propensity score matching was used for risk adjustment. RESULTS: Patients undergoing total arterial revascularization were younger (65.0±10.4 years vs 71.3±7.9 years, P<.001) and less likely to have diabetes, cerebrovascular disease, recent myocardial infarction, and severe left ventricular impairment. At 15 years, patients who underwent total arterial revascularization experienced superior unadjusted survival (62%±1.1% vs 35%±1.9%, P<.001). Multivariable Cox regression in the entire study cohort showed the total arterial group had improved survival with a hazard ratio of 0.79 (95% confidence interval, 0.70-0.90; P<.001). After propensity score matching yielded 384 patient pairs, patients who underwent total arterial revascularization showed improved survival at 15 years than patients who underwent single arterial revascularization (54%±3.3% vs 41%±3.0%, P=.0004). CONCLUSIONS: This large multicenter study suggests that a strategy of total arterial revascularization is associated with improved long-term survival compared with the use of only a single arterial and saphenous vein grafts. Total arterial revascularization should be encouraged in patients with a reasonable life expectancy.

Effect of lipid exposure on graft patency and clinical outcomes: arteries and veins are different.

OBJECTIVES: We evaluated the influence of lipid exposure upon conduit patency in long-term follow-up after primary CABG. METHODS: From a prospectively compiled database, we identified 1207 grafts (436 SV and 771 mixed arterial grafts) among 413 CABG patients with 9.4 ± 2.4 years of follow-up (range 3-13). Surveillance angiography was performed as part of a randomized trial. All available lipid assays were collected from pathology laboratories, and from these, mean annualized lipid exposure was calculated for total cholesterol, HDL, LDL and triglycerides. Angiographical and clinical data were analysed against lipid exposure. Graft failure was defined as occlusion, string sign or >80% stenosis. RESULTS: Six thousand and seventy-seven lipid measurements were obtained, and there were 154 failed grafts. Three hundred and eleven patients received at least one vein graft, and all 413 patients received at least one arterial graft. Overall, only HDL levels were inversely correlated with graft failure, with total cholesterol and LDL showing no associations in a mixed pool of arterial and venous grafts. To assess whether total/LDL cholesterol had no effect or were exerting competing effects in arteries and veins, separate multivariate analyses were performed. Venous graft failure was associated with increased total cholesterol/HDL (P=0.006) and LDL/HDL (P=0.032). By contrast, elevated total cholesterol was correlated with a reduced risk of arterial graft failure (OR for graft failure 0.705, P 0.023) with increasing LDL cholesterol following a similar trend (OR for graft failure 0.729, P=0.051). CONCLUSION: Sub-fractions of dyslipidaemia known to be risk factors for native vessel disease appear to similarly influence vein grafts. Arterial conduits are at least more resistant to the effects of high lipid exposure, and appear to be protective. These results favour the use of arterial grafts in patients with poorly controlled dyslipidaemia.

Mid-term results of the Radial Artery Patency and Clinical Outcomes randomized trial.

BACKGROUND: The radial artery (RA), as an alternative to the saphenous vein or the right internal thoracic artery (RITA) for coronary artery bypass grafting, has gained considerable interest over the years. A randomized controlled trial was undertaken to assess the suitability of the radial artery as a conduit. METHOD: The Radial Artery Patency and Clinical Outcomes (RAPCO) trial is a double-armed randomized controlled trial comparing the RA with the free RITA in a younger cohort of patients undergoing elective coronary bypass surgery, and the RA with the saphenous vein in an older group. The trial conduit was grafted to the most important coronary target after the left anterior descending artery, which received the gold standard left internal thoracic artery. Clinical outcomes and angiographic patency up to 10 years was recorded during careful follow up, with annual clinical review and a program of randomly assigned, staggered angiography. The final trial results will be available in 2014. RESULTS: Mid-trial results have shown equivalent survival and event-free survival and graft patency in both arms at median follow up of approximately 6 years. The demographic and clinical data, pre- and postoperative angiographic findings of the trial database have led to a number of substudies focusing on the role of lipid exposure in patency and disease progression, the fate of moderate lesions when grafted or left alone, patterns of disease regression, and patient satisfaction with graft harvest sites. CONCLUSIONS: While the final analysis of the primary trial end points is eagerly awaited, the additional insight into the natural history of grafted coronary artery disease with modern secondary prevention will be of considerable interest.

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.

Should all moderate coronary lesions be grafted during primary coronary bypass surgery? An analysis of progression of native vessel disease during a randomized trial of conduits.

OBJECTIVE: Whether to graft a moderately stenosed coronary vessel remains debatable. We investigated whether grafting such vessels is warranted based on angiographic evidence of disease progression. METHODS: Of 619 patients who underwent on-pump coronary artery bypass grafting in an ongoing, randomized radial artery trial, 405 have at least 1 follow-up angiogram at a mean of 6.2 ± 3.1 years (range, 0-14 years) after surgery. Percent diameter stenosis in each major native vessel was reported by 3 cardiac specialists and classified as either moderate (40%-69%) or severe (≥70%) stenosis. Progression of native vessel disease and graft patency were determined by comparison of pre- and postoperative angiography. RESULTS: A total of 3816 native vessels and 1242 bypass grafts were analyzed, of which 386 moderate preoperative lesions were identified, 323 of which were grafted. In all territories, grafted vessels had greater risk of disease progression than ungrafted equivalents (43.4% vs 10.5%, P < .001). Moderate lesions were more likely than severe lesions to remain unchanged on follow-up angiography (52.6% vs 31.1%, P < .001). Only 1 in 7 moderate lesions in the right coronary artery exhibited significant progression during follow-up if left ungrafted, whereas the likelihood of progression in left-sided counterparts approached 50%. Arterial and vein grafts to left-sided moderately stenosed vessels had excellent patency (83% and 77% at 8 years, respectively), which was not matched by right-sided grafts (P = .051). Placement of a graft for a moderate lesion was associated with significantly greater incidence of disease progression, most marked in the right coronary territory. CONCLUSIONS: The greater risk of progression of left-sided moderate lesions, and high graft patency rates when bypassed, suggests that the balance of clinical judgment lies in favor of grafting moderate left-sided lesions. In the right coronary system, however, a lesion is likely to remain moderate if left ungrafted and, with a low risk of progression, it may be reasonable to leave these vessels undisturbed.

Custodiol versus blood cardioplegia in complex cardiac operations: an Australian experience.

OBJECTIVES: A single or dual-dose strategy for myocardial protection is attractive in long operations, in avoiding the need to interrupt the procedure to re-administer cardioplegia. We hypothesized that a single administration of Bretschneider histidine-tryptophan-ketoglutarate (HTK) crystalloid solution (Custodiol) offers myocardial protection comparable with repeated tepid blood cardioplegia. METHODS: We reviewed a prospectively compiled single-centre database containing all adult cardiac procedures performed from January 2005 to January 2011. Preoperative demographic and investigative data, operative variables and postoperative (30-day) mortality and morbidity were compared between the Custodiol and blood cardioplegia groups. The study primary endpoints were 30-day mortality, return to the operating theatre, myocardial infarction, stroke, postoperative requirement for an intra-aortic balloon pump, new renal failure, prolonged ventilation and re-admission to hospital within 30 days. Propensity score matching was performed to correct for any bias that may have been associated with the usage of Custodiol. RESULTS: A total of 1900 cardiac surgical procedures were identified of which 126 (7%) utilized Custodiol and 1774 (93%) used blood cardioplegia as the primary cardioplegic agent. After propensity-score matching, we were able to match 71 Custodiol cases one-to-one to those receiving blood cardioplegia. There were no statistically significant differences noted for any of the endpoints studied after propensity-score matching. In particular, the proportion of mortality (blood cardioplegia: 1 vs Custodiol 4%, P = 0.63) any mortality/morbidity (blood cardioplegia: 35 vs Custodiol: 39% P = 0.46) was similar between the groups. CONCLUSIONS: The use of Custodiol is convenient, simple and at least as safe as tepid blood cardioplegia for myocardial protection in complex cardiac operations. A randomized prospective comparison of myocardial protection strategies is warranted.

Long-term impact of radial artery harvest on forearm function and symptoms: a comparison with leg vein.

OBJECTIVE: The radial artery (RA) has gained popularity as a conduit for coronary artery bypass surgery despite a paucity of patient-centered analysis of long-term quality of life after its removal. We sought to characterize forearm function and symptoms after RA harvest and compare these with those associated with saphenous vein (SV) removal. METHODS: A total of 408 patients from an RA trial completed a questionnaire up to 14 years after primary coronary artery bypass surgery. The survey included 7 statements concerning hand and forearm symptoms or limitations in daily life and 4 questions on concerns associated with arm or leg scars. A total of 230 patients had received an RA graft (RA group). Responses were graded in order of severity from 0 to 7, with greater than 3 (mild concern) being regarded as a significant symptom. Mean response to each question and total scores were compared with the non-RA harvest group. Comparisons were also made with responses to the same questionnaire completed preoperatively and 3 months postoperatively. In patients who had both RA and SV removal, we compared the impact of a forearm scar on quality of life with that of a leg scar. RESULTS: The mean duration of follow-up was 9.3 years (range, 4-14 years), and the response rate was 83%. In the RA group, 92% to 99% reported no significant symptoms, with the most frequent concerns relating to pain and numbness (8% each), but this was not significantly higher than in those who had not had an RA harvested. In the RA group, the mean scores for scar appearance and discomfort were 0.95 and 0.93, respectively (where 1 = no concern), suggesting satisfactory cosmesis and no impact on function. Symptom severity was significantly worse in 6 of 7 questions when compared with preoperative responses and in 4 of 7 items compared with 3-month follow-up, indicating a general deterioration in function over long-term follow-up. In those who had both the RA and SV harvested, patients reported more scar discomfort associated with SV harvest at 3 months (1.69 vs 1.34, P < .001) and in the present questionnaire (1.21 vs 0.97, P = .002). Concerns with scar appearance were no different between the arm and leg. CONCLUSIONS: RA harvesting is associated with high patient satisfaction and less scar discomfort than SV removal. Overall, functionality declines with time, and a small proportion of patients seem to experience forearm pain and numbness. However, this is not different than in those without artery removal and may therefore be unrelated to the effects of surgery.

Does the addition of a radial artery graft improve survival after higher risk coronary artery bypass grafting? A propensity-score analysis of a multicentre database.

OBJECTIVES: The use of the radial artery as a second arterial graft during coronary surgery has grown in popularity due to high patency and low harvest site complication rates. We sought to assess whether higher risk patients derive prognostic benefit. METHODS: From 2001 to 2009, 11,388 patients underwent isolated primary multivessel coronary surgery. We identified a higher risk subgroup (n = 2581) according to emergent status, coronary instability, low ejection fraction and/or aortic counterpulsation. Among these, 1832 (71%) received at least one radial artery graft in addition to a left internal thoracic artery (LITA). The remaining 749 (29%) received LITA and veins only. RESULTS: Patients not receiving a radial artery were more likely to be elderly, female, have poor left ventricular function or be of emergent status. These patients experienced higher unadjusted 30-day mortality (radial: 2% vs vein: 8%, P < 0.0001) with lower unadjusted 7-year survival (80 ± 1.3 vs 67 ± 2.4%, P < 0.0001). Subsequently, 515 patients in the radial group were propensity-matched to 515 receiving LITA + veins (mean logistic EuroSCORE, radial: 11.6 ± 9.7% vs vein: 11.6 ± 10.3%, P = 0.99). At 30 days, there were comparable rates of mortality (radial: 4% vs vein: 3%, P > 0.99), stroke (1 vs 1%, P > 0.99), myocardial infarction (1 vs 2%, P = 0.79), and any morbidity/mortality (34 vs 35%, P = 0.95). At 7 years, survival rates between the radial and vein groups were similar (radial: 75 ± 2.6% vs vein: 74 ± 2.9%, P = 0.65). CONCLUSIONS: Patients with the greatest coronary instability, urgency of surgery or impairment of ventricular function are not disadvantaged in early outcomes or mid-term survival by the use of only a single arterial graft.

Impact of prosthesis--patient mismatch after mitral valve replacement: a multicentre analysis of early outcomes and mid-term survival.

BACKGROUND: Prosthesis-patient mismatch (PPM) is characterised by the effects of inadequate prosthesis size relative to body surface area (BSA). It is uncertain whether PPM after mitral valve replacement impacts upon clinical outcome. This was examined in an Australian population. METHODS: From 2001 to 2009, 1006 mechanical and bioprosthetic mitral valves were implanted across 10 institutions. Effective orifice areas (EOA) were obtained from a literature review of in vivo echocardiographic data. Absent, moderate and severe PPM was defined as an indexed EOA (EOA/BSA) of >1.20 cm(2)/m(2), >0.90 to ≤1.20 cm(2)/m(2) and ≤0.9 cm(2)/m(2), respectively. Early outcomes and 7-year survival were compared between these three groups. RESULTS: PPM was absent in 34%, moderate in 53% and severe in 13% of patients. Patients with PPM were more likely to be male (42% vs 52% vs 62%, p<0.0001) and obese (14% vs 20% vs 56%, p<0.0001). Postoperatively there was similar 30-day mortality (5% vs 5% vs 6%, p=0.83) and early any mortality/morbidity (24% vs 27% vs 29%, p=0.40). Seven-year survival was similar between groups (72±4.1% vs 76±3.2% vs 69±10.3%, p=0.76). PPM did not predict adverse events after logistic and Cox regressions with and without propensity score adjustment. Subgroup analyses of those with isolated mitral valve surgery, patients with preoperative congestive heart failure and non-obese patients failed to show an association between PPM and mid-term mortality. CONCLUSIONS: Overall, PPM was not associated with poorer early outcomes or mid-term survival. Oversizing valves may be technically hazardous and do not yield superior outcomes. Easier implantation by appropriate sizing appears justified.