Complete myocardial revascularization using only bilateral internal thoracic arteries provides a low-risk and durable 10-year clinical outcome.

OBJECTIVES: Bilateral internal thoracic artery (BITA) bypass provides long-term survival benefits over strategies that use single internal mammary arteries during coronary artery bypass grafting (CABG). However, the rate of adoption of this strategy remains very low. Moreover, optimal BITA configuration and the use of cardiopulmonary bypass still remain a matter of debate. We investigated the long-term results of a coronary revascularization strategy, utilising exclusively BITA-Y composite grafts using off-pump platform and sequential anastomoses. METHODS: From March 2000 to November 2010, all isolated CABGs (n = 2057 patients) were performed using an off-pump platform. Of these, 1240 patients had three-vessel coronary disease (60.3%), with severe coronary disease defined as >70% stenosis and three-vessel disease defined as the presence of 3 vessels with >70% stenosis, of which 784 (63.2%) were treated with two internal thoracic artery grafts in a composite fashion with a no-touch technique avoiding any manipulation of the ascending aorta. The primary end-point was the long-term survival and freedom from major adverse cerebral and cardiovascular events (MACCEs). The follow-up was completed using the annual anniversary method. RESULTS: The mean number of anastomoses per patient was 4.0. Hospital mortality occurred in 8 patients (1%). Ninety-day stroke, myocardial infarction and repeat revascularization rates were respectively 0.7, 0.6 and 0.3%. The mean follow-up was 6.6 ± 3.2 years and was obtained for 99% of the patients. The 5- and 10-year survival rates were 93.1 ± 1.6 and 83.8 ± 3.2%, respectively. Freedom from major adverse cardiac and cardiovascular event (MACCE) at 5 and 10 years was: cardiovascular event: 98.7 ± 1.6 and 96.1 ± 1.7%, documented ischaemia: 90.5 ± 2 and 80.2 ± 3.8%, revascularization: 94.0 ± 1.5 and 89.7 ± 2.5%, infarction: 98.1 ± 0.8 and 96.0 ± 1.6%. The patency of left and right internal thoracic artery in a BITA-Y configuration was 91.1 and 88.8% at 5 ± 3 years, respectively. CONCLUSION: Performance of an exclusive composite BITA off-pump revascularization strategy optimal and sustained long-term protection from MACCE.

Five-year follow-up of drug-eluting stents implantation vs minimally invasive direct coronary artery bypass for left anterior descending artery disease: a propensity score analysis.

OBJECTIVES: The spread of drug-eluting stents (DES) has reduced the incidence of early restenosis following percutaneous coronary interventions (PCI). Meanwhile, development of minimally invasive coronary artery bypass surgery (MIDCAB) has offered a valuable alternative to conventional sternotomy with preservation of the benefit of the internal mammary artery use. Therefore, the revascularization of the left anterior descending (LAD) artery is suitable for both techniques. However, few data with long-term comparison of these two techniques exist. METHODS: Prospective data were collected for 456 patients undergoing isolated LAD revascularization between 1997 and 2011. Two hundred and sixty patients were treated with MIDCAB and 196 with first-generation DES implantation. A propensity score model was created to adjust for 19 relevant confounding variables. Primary and secondary end-points were, respectively, 5-year survival and freedom from major adverse cerebro-cardiovascular events (MACCE). RESULTS: Both groups were similar in age, EuroSCORE and mean duration of follow-up. Five-year survival was similar after MIDCAB or DES (hazard ratio (HR): 0.95; P = 0.89). Freedom from MACCE was significantly in favour of the MIDCAB group (HR: 0.32, P < 0.0001), mainly triggered by high subsequent need for revascularization of the targeted vessel in the DES group (HR: 0.17, P < 0.0001). CONCLUSIONS: MIDCAB and DES implantation showed similar rates of survival but despite an expected lower rate of reintervention on the targeted vessel with DES use, a highly significant higher MACCE rate was observed in the PCI group at 5-year follow-up.

Comparison of minimally invasive direct coronary artery bypass surgery with implantation of drug-eluting stentsin patients with left anterior descending coronary artery disease.

OBJECTIVE: : Bypass surgery and percutaneous coronary interventions improve the clinical status of patients with left anterior descending coronary artery disease. However, these techniques differ in invasiveness and in the need for subsequent reinterventions. The development of minimally invasive direct coronary artery bypass (MIDCAB) surgery and of drug-eluting stents (DES) offers perspectives to close this gap. METHODS: : We compared the long-term clinical outcome of 308 patients after revascularization for isolated left anterior descending coronary artery disease. One hundred fifty-four patients were treated with MIDCAB and 154 with percutaneous coronary interventions and DES implantation. RESULTS: : Both groups were similar in age (63 ± 13 and 62 ± 10 years), Euroscore (3.3 ± 2.8 and 3.4 ± 2.6), and mean duration of follow-up (30 ± 17 and 24 ± 10 months). Two-year survival was similar after MIDCAB and after DES (97.4% and 94.8%). During follow-up, four patients (2.6%) of the MIDCAB group and 21 patients (13.6%) of the DES group needed subsequent revascularization of the target vessel (P = 0.001). Revascularization of a nontarget vessel was needed in 11 patients (7%) of the MIDCAB group and in 17 patients (11%) of the DES group (NS). Neurologic complications included two transient ischemic accidents and two strokes in the MIDCAB group but three fatal cerebral hemorrhages and one stroke in the DES group. Major adverse coronary and cerebrovascular events rates were 14% in the MIDCAB and 31% in the DES group. CONCLUSIONS: : MIDCAB and DES implantation showed similar rates of mortality but a higher reintervention rate after DES. Anticoagulation implications remain critical for the future of DES.

Reduced mortality in high-risk coronary patients operated off pump with preoperative intraaortic balloon counterpulsation.

BACKGROUND: Preoperative intraaortic balloon pump (IABP) counterpulsation has better outcomes compared with perioperative or postoperative insertion in critical patients, and off-pump surgical procedures have been advocated to reduce mortality in high-risk patients. However, some surgeons are reluctant to perform beating heart operations in specific patient subgroups, including those with unstable angina or patients with low ejection fraction, because of their possible perioperative hemodynamic instability. METHODS: We evaluated combined beating heart procedures and preoperative IABP in selected high-risk patients and compared our results with the predictive European System for Cardiac Operative Risk Evaluation (EuroSCORE) model. Fifty-five high-risk patients with a mean logistic EuroSCORE of 24 were prospectively enrolled and then divided into emergency (group 1, n = 25) and nonemergency (group 2, n = 30) groups. IABP was inserted immediately before operation in group 1 and the day before the procedure in group 2. RESULTS: Compared with the EuroSCORE predictive model, a dramatic decrease in mortality occurred in both groups. Group I predicted mortality was 36.8%, and observed was 20%; and group 2 predicted mortality was 15.2% and observed was 0%. No specific complications from the use of IABP were encountered. During mid-term (2 years) follow-up, no patient died from a cardiac cause or required percutaneous coronary intervention or subsequent reoperation due to incomplete revascularization. CONCLUSIONS: The combined use of preoperative intraaortic counterpulsation and beating heart intervention allows complete revascularization in high-risk patients with a important reduction in operative mortality and excellent mid-term results.