Single versus bilateral internal thoracic artery grafting in patients with impaired renal function.

OBJECTIVE: The optimal strategy for surgical revascularization in patients with impaired renal function is inconclusive. We compared early and late outcomes between bilateral internal thoracic artery (BITA) and single ITA (SITA) grafting in patients with renal dysfunction. METHODS: This is a retrospective analysis of all the patients with multivessel disease and impaired renal function (estimated glomerular filtration rate <60mL/min/1.73m2) who underwent isolated coronary artery bypass graft (CABG) in our center during 1996-2011, utilizing either BITA or SITA revascularization. RESULTS: Of the 5301 patients with multivessel disease who underwent surgical revascularization during the study period, 391 were with impaired renal function: 212 (54.2%) underwent BITA, 179 (45.8%) underwent SITA. Patients who underwent BITA were less likely to have comorbidities. Statistically significant differences were not observed between the BITA and SITA groups in 30-day mortality (5.6% vs. 9.0%, p = 0.2) and in rates of early stroke, myocardial infarction, and sternal infection (4.5% vs. 6.1%, p = 0.467; 1.7% vs. 2.8%, p = 0.517; and 2.2% vs. 5.7%, p = 0.088, respectively). Long-term survival of the BITA group was better: median 8.36 vs. 4.14 years, p<0.001. In multivariable analysis, BITA revascularization was associated with decreased late mortality (HR = 0.704, 95% CI: 0.556-0.89, p = 0.003). In analysis of a matched cohort (134 pairs), early outcomes did not differ between the groups; however, in multivariable analysis, BITA revascularization was associated with decreased late mortality (HR = 0.35 (95%CI 0.18-0.68), p = 0.002) . CONCLUSIONS: BITA revascularization did not impact early outcome in patients with CRF, but demonstrated a significant protective effect on long-term survival in the unmatched and matched cohorts.

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

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

Long-term outcomes of coronary artery bypass grafting patients supported preoperatively with an intra-aortic balloon pump.

OBJECTIVE: Most studies describing the outcome of coronary artery bypass grafting patients supported preoperatively with an intra-aortic balloon pump (IABP) have reported early results. The purpose of our study was to evaluate the early and long-term results. METHODS: Of 2658 isolated coronary artery bypass grafting procedures performed from 1996 to 2001, 215 were supported preoperatively with an IABP. The indications for IABP insertion were cardiogenic shock in 18 (8.4%), acute evolving myocardial infarction in 38 (17.7%), clinical instability in 84 (39.1%), and critical coronary lesions in 75 (34.9%). RESULTS: Operative mortality was 12.6%. The mortality of the cardiogenic shock patients was greater (22.2%; P=.174). Logistic regression analysis showed patient age (odds ratio, 1.057; 95% confidence interval, 1.010-1.108) and cardiopulmonary bypass (CPB) time (odds ratio, 1.020; 95% confidence interval, 1.008-1.031) were associated with increased operative mortality. An increased number of bypass grafts had a protective effect (odds ratio, 0.241; 95% confidence interval, 0.113-0.515). The actual early mortality was lower than the logistic EuroSCORE calculated mortality (12.6% vs 32.8%, P<.0001). The mean follow-up was 8±4 years. The Kaplan-Meier 10-year survival was 49%. The Cox adjusted overall (early and late) survival and major adverse cardiac events-free survival of the different IABP subgroups was similar. Cox analyses showed peripheral vascular disease, off-pump coronary artery bypass surgery, age, CPB time, female gender, and fewer bypass grafts were associated with decreased survival. CONCLUSIONS: In patients supported preoperatively with an IABP, better early and long-term results were strongly related to younger age, a shorter CPB time, and a greater number of bypass grafts. Avoiding the use of CPB (off pump) in these emergency cases is not recommended.

Off-pump coronary artery bypass grafting: single center experience with 1,000 consecutive patients.

BACKGROUND: Advances in surgical techniques and retractor-stabilizer devices allowing access to all coronary segments have resulted in increased interest in off-pump coronary artery bypass. The residual motion in the anastomotic site and potential hemodynamic derangements, however, render this operation technically more demanding. OBJECTIVES: To evaluate the OPCAB experience in a single Israeli center. METHODS: Between 2000 and 2003 in our institution, 1,000 patients underwent off-pump operations. Patients were grouped by the type of procedure, i.e., minimally invasive direct coronary artery bypass or mid-sternotomy OPCAB. RESULTS: One hundred MIDCAB operations were performed. Of the 900 OPCAB, 767 patients received multiple grafts with an average of 2.6 +/- 0.6 grafts per patient (range 2-4) and the remaining patients underwent single grafting during hybrid or emergency procedures. In the multiple-graft OPCAB group, complete revascularization was achieved in 96%. Multiple arterial conduits were used in 76% of the patients, and total arterial revascularization without aortic manipulation, using T-graft (35%) or in situ configurations, was performed in 61%. The respective rates for early mortality, myocardial infarction and stroke in the MIDCAB were 1%, 0% and 2%, and 2%, 1.3% and 0.9% in the multiple-vessel OPCAB groups. Multivariate analysis identified renal dysfunction (odds ratio 11.5, confidence interval 3.02-43.8; P < 0.0001) and emergency operation (OR 8.74, CL 1.99-38.3; P = 0.004) as predictors of mortality. The proportion of off-pump procedures increased from 9% prior to the study period to 59%. CONCLUSIONS: The use of OPCAB does not compromise the ability to achieve complete myocardial revascularization. Our procedure of choice is OPCAB using arterial conduits, preferably the 'no-touch' aorta technique.

Bilateral internal thoracic artery grafting in diabetic patients: short-term and long-term results of a 515-patient series.

BACKGROUND: Despite potential long-term benefits, bilateral internal thoracic artery grafting in diabetics remains controversial because of the risk of sternal infection. We sought to assess the short- and long-term outcome after left-sided bilateral internal thoracic artery grafting and to determine the configuration of choice in diabetic subsets. METHODS: Between 1996 and 2001, 515 diabetics underwent isolated left-sided skeletonized bilateral internal thoracic artery grafting. The outcome of 468 consecutive oral-treated diabetics and 47 selective insulin-treated patients was analyzed. Patients undergoing T-grafting were compared with those undergoing in situ bilateral internal thoracic artery arrangements. RESULTS: The respective rates for early mortality and sternal infections were 2.4% and 1.9% in oral-treated diabetics and 6.3% and 4.3% in insulin-treated diabetics. Multivariate correlates of sternal infection were chronic lung disease (odds ratio, 10), obesity (odds ratio, 7), reoperation (odds ratio, 22), and a creatinine level of 2 mg/dL or more (odds ratio, 8). Five-year survival was 82%. The T-graft (n = 437) and in situ (n = 162) subgroups had comparable baseline profiles. Freedom from cardiac mortality at 6.5 years was 95.6% and 87.6% (P =.277), and freedom from repeat revascularization was 91.5% and 92.7% (P =.860), respectively. The choice of bilateral internal thoracic artery configuration did not appear as a correlate of mortality, cardiac mortality, or major adverse cardiac events. Complementary right-sided gastroepiploic artery (hazard ratio, 0.36) and sequential (hazard ratio, 0.55) grafting were identified as protective factors against the occurrence of major adverse cardiac events. CONCLUSIONS: Routine skeletonized bilateral internal thoracic artery grafting can be implemented safely in oral-treated diabetics. This strategy is associated with a favorable late cardiac outcome and is thus recommended. Both left-sided bilateral internal thoracic artery configurations provide comparable short- and long-term outcomes.

Reduced strokes in the elderly: the benefits of untouched aorta off-pump coronary surgery.

BACKGROUND: Avoiding aortic manipulation during off-pump coronary artery bypass (OPCAB) reduces the risk for atheroembolic complications and may, thus, benefit elderly patients who are prone to atherosclerotic aortic involvement. METHODS: During a period of 18 months (2000-2002), 160 consecutive OPCAB patients older than 75 years were evaluated. One hundred and three patients undergoing clampless OPCAB were compared to 57 patients in whom side clamps were applied. Clampless revascularization was achieved by in situ or T-graft arterial configurations. RESULTS: Mean age was older (79.3 years vs 78.2, p = 0.049) and the prevalence (43% vs 7%, p < 0.0001) and severity of aortic disease was higher in the clampless group. The main conduits used were bilateral skeletonized internal thoracic artery (47%) and radial arteries (42%). More grafts were performed in the side-clamp group (2.5 +/- 0.5 vs 2.3 +/- 0.6, p = 0.023), however, revascularization of the postero-lateral territory was comparable. While early mortality (2.9% vs 7%, p = >or=0.05), perioperative myocardial infarction (3% vs 5%, p = >or=0.05), and sternal infections (none) were similar, the incidence of major neurological complications (0% vs 5.3%, p = 0.044) and the combined outcome of stroke or mortality (3% vs 12%, p = 0.035) were lower in the clampless group. Multivariate analysis identified side clamping as a predictor for the occurrence of stroke or mortality (OR, 6.28, CL 1.39-28.4, p = 0.017), increasing this risk by sixfold. CONCLUSIONS: Clampless OPCAB is associated with reproducible neurological benefit. Improved neurological outcome may be conferred irrespective of the method of aortic screening in patients 75 years or older. The use of arterial conduits for this purpose is feasible despite the patients' advanced years.

Myocardial revascularization for acute myocardial infarction: benefits and drawbacks of avoiding cardiopulmonary bypass.

BACKGROUND: Coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) is associated with increased mortality compared with CABG in non-AMI patients. Operating without cardiopulmonary bypass (CPB) might reduce this mortality. METHODS: Between January 1992 and December 1998, 225 patients underwent CABG within 7 days of AMI, 119 with CPB and 106 without. The two groups were similar regarding age, gender, left ventricular dysfunction, and incidence of cardiogenic shock. Mean number of grafts per patient was 3.1 in the CPB group, and 1.7 in the no-CPB group (p < 0.0001). RESULTS: Operative mortality in the CPB group was 12% compared with 3.8% without CPB (p = 0.027). Independent predictors of operative mortality were preoperative use of intraaortic balloon counterpulsation (IABP), nonuse of internal thoracic artery (ITA) to the left anerior descending artery, and the use of less than three grafts. Mortality of patients operated on with CPB within 48 hours of AMI was significantly higher (16.5% vs 4.3%, respectively; p = 0.044). However, patients operated on after 48 hours had similar mortality (5.8% vs 3.4%, respectively). Follow-up ranged from 6 to 84 months. Five-year survival (Kaplan-Meier) of both groups was similar (81%). Patients operated on with CPB had similar rates of recurrent angina; however, they had lower prevalence of reinterventions (0.8% vs 6.3%; p = 0.03). CONCLUSIONS: Our study suggests that CPB can be used safely for most patients referred for CABG within the first week of AMI. However, for emergency patients operated on within the first 48 hours of symptom onset, we advocate avoiding CPB because it is associated with lower operative mortality.

Bilateral internal thoracic artery grafting: midterm results of composite versus in situ crossover graft.

BACKGROUND: Two common techniques of bilateral internal thoracic artery grafting are the composite T graft and in situ crossover graft. The superiority of one method over the other has not yet been established. METHODS: From April 1996 to July 1999, bilateral skeletonized internal thoracic arteries were used as T grafts (composite group, n = 649) and in situ grafts (cross group, n = 351) in 1,000 consecutive patients. In the cross group, in situ right internal thoracic artery was routed anterior to the aorta across the midline for grafting to the left anterior descending artery, and the left internal thoracic artery was used for the circumflex branches. RESULTS: The two groups had comparable preoperative risk profiles. Bypass time and aortic cross-clamping time were longer in the composite group (80 +/- 38 and 67 +/- 29 minutes versus 66 +/- 43 and 55 +/- 34 minutes, respectively). Number of anastomoses per patient was similar (3.1 versus 3.2). However, more sequential anastomoses were performed in the composite group (62% versus 53%), and the gastroepiploic artery was used more often in the cross group (30% versus 19%). Thirty-day mortality was 3.9% in the composite and 2.3% in the cross group (not significant). Occurrence of postoperative complications (sternal infection, myocardial infarction, cerebrovascular accident, and bleeding) was similar. Late follow-up (2 to 56 months) showed increased return of angina (6% versus 3.1%; p = 0.046) and decreased 4-year survival (Kaplan-Meier; 86% +/- 2.7% versus 92.4% +/- 1.5%; p = 0.07) in composite patients. CONCLUSIONS: Early results of bilateral internal thoracic artery grafting with composite T graft are comparable with those of in situ grafts. However, increased angina return and decreased midterm survival led us to recommend in situ grafting whenever technically possible.