[Fifteen-year results of bilateral and unilateral internal mammary artery grafting]. / Pyatnadtsatiletnie rezul'taty revaskulyarizatsii miokarda s ispol'zovaniem dvukh i odnoi vnutrennei grudnoi arterii.

OBJECTIVE: To evaluate the clinical effectiveness of bilateral internal mammary artery grafting over long-term (15 years) postoperative period. MATERIAL AND METHODS: There were 276 patients divided into two groups: 135 patients (group A) underwent bilateral internal mammary artery grafting and 141 patients (group B) underwent unilateral internal mammary artery grafting together with venous bypass grafts. On-pump surgeries and cardioplegia, parallel CPB and on-pump procedures were performed in equal proportions. Mean age of patients was 57.3±7.6 years. Diabetes mellitus was detected in 21 (15.5%) and 24 (19.1%) patients, respectively (p>0.05). Mean LV ejection fraction was 55.4±9.9%, revascularization index - 3.1±0.8 and 3.0±0.7, respectively. In the 1st group, 43 patients underwent bilateral internal mammary artery grafting alone. Autovenous grafts were additionally used in other 84 patients. RESULTS: Ten-year survival exceeded 90% in both groups. Freedom from adverse cardiac events after 15 years was significantly higher in group A (77.3% vs. 59.3%, p=0.018). In group A, 16 patients died throughout this period due to cancer (50%), myocardial infarction (12.5%), stroke (18.8%) and complications of diabetes mellitus (6.3%). In group B, 22 patients died mainly from cardiac causes (myocardial infarction - 40.9%, cancer - 27.3%). CONCLUSION: Bilateral internal mammary artery grafting has obvious advantages over traditional coronary artery bypass grafting. If we take into account higher proportion of cardiac causes in structure of mortality in group B, we can talk about positive impact of bilateral internal mammary artery grafting not only on the quality of life, but also on life expectancy in long-term postoperative period.

Long-term outcomes of percutaneous revascularization for internal mammary artery-left anterior descending artery bypass failure.

Despite the excellent long-term results of internal mammary artery (IMA)-left anterior descending (LAD) bypass, percutaneous revascularization of IMA is sometimes required for IMA-LAD bypass failure. However, its clinical outcomes have not been fully elucidated. The aim of this study was to investigate the long-term clinical outcomes, including target lesion revascularization (TLR) following contemporary percutaneous revascularization of failed IMA bypass graft. We examined data of 59 patients who had undergone percutaneous revascularization of IMA due to IMA-LAD bypass failure at nine hospitals. Patients with IMA graft used for Y-composite graft or sequential bypass graft were excluded. The incidence of TLR was primarily examined, whereas other clinical outcomes including cardiac death, myocardial infarction, and target vessel revascularization were also evaluated. Mean age of the enrolled patients was 67.4 ± 11.3 years, and 74.6% were men. Forty patients (67.8%) had anastomotic lesions, and 17 (28.8%) underwent revascularization within three months after bypass surgery. Procedural success was achieved in 55 (93.2%) patients. Stent implantation was performed in 13 patients (22.0%). During a median follow-up of 1401 days (interquartile range, 282-2521 days), TLR was required in six patients (8.5% at 1, 3, and 5 years). Patients who underwent percutaneous revascularization within 3 months after surgery tended to have a higher incidence of TLR. Clinical outcomes of IMA revascularization for IMA-LAD bypass failure were acceptable.

Multiple Grafting with Single Left Internal Mammary Artery as T-Graft with Itself.

BACKGROUND: Revascularization strategies might be limited in patients with lack of sufficient bypass graft material and increased risk of wound healing disturbances. In this regard, we present first results of patients treated with left internal mammary artery (LIMA) as T-graft with itself due to left-sided double-vessel disease, elevated risk of wound healing infection, and lack of graft material. METHODS: Eighteen patients were retrospectively analyzed in this study. All patients received LIMA grafting, and additional T-graft with itself during off-pump coronary artery bypass surgery. The investigation was focused on intraoperative and postoperative outcomes. RESULTS: LIMA-LIMA T-graft was performed in a total of 18 patients. Mean Fowler score accounted for 18.2 ± 2.9. Severe vein varicosis was present in 9 patients, and 38.9% of patients had lacking venous graft material due to prior vein stripping. A total of 2.5 ± 0.5 distal anastomoses were performed. Mean flow of LIMA-left anterior descending anastomosis was 41.72 ± 12.11 mL/min with a mean pulsatility index (PI) of 1.01 ± 0.21. Mean flow of subsequent T-graft accounted for 26.31 ± 4.22 mL/min with a mean PI of 1.59 ± 0.47. Median hospital stay was 7(6.75;8) days. No incidence of postoperative wound healing disorders was observed and all patients were discharged off hospital. CONCLUSIONS: LIMA as T-graft with itself to treat left-sided double-vessel disease is feasible and safe in patients with missing bypass graft material and increased risk of deep sternal wound infection. Further prospective studies are necessary to confirm our results.

Left internal mammary artery side branch intervention in the management of coronary steal syndrome following coronary artery bypass grafting.

OBJECTIVE: The objective of this qualitative review is to summarize the pathophysiological and clinical data behind the clinical entity of left internal mammary artery (LIMA) side branch coronary steal as well as the potential diagnostic and therapeutic modalities available. BACKGROUND: The presence of persistent unligated LIMA side branches following coronary artery bypass grafting has previously been associated with stable angina and acute coronary syndromes. However, despite numerous attempts to objectively demonstrate a coronary steal phenomenon, the pathophysiology of LIMA side branch flow diversion remains elusive and the clinical utility of intervention is not well elucidated. METHODS: A review of literature and available data including case reports, case series, and investigational studies was performed. RESULTS: Therapeutic closure of LIMA side branches has been reported in at least 44 patients and in at least 31 publications since 1990 and is associated with an 87.5% rate of freedom from angina amongst technically successful initial interventions. In all patients with pre- and post- stress testing, intervention was associated with an improvement and/or resolution of previously observed reversible ischemia. CONCLUSIONS: LIMA side branch coronary steal should remain an ongoing consideration in symptomatic patients with large unligated side branches on angiography, particularly when there is clear evidence of reversible ischemic on perfusion imaging.

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature.

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

Wound Infection after CABG Using Internal Mammary Artery Grafts: A Meta-Analysis.

BACKGROUND: Internal mammary arteries show better long-term patency rates than venous grafts. The use of both mammary arteries is associated with a higher risk of sternal wound infections. This meta-analysis was designed to assess the incidence of a wound healing disorder after bilateral compared with single mammary artery bypass grafting. Compared with existing meta-analysis this paper includes more current literature and one randomized controlled trial. METHODS: A literature search was performed using PubMed and the Cochrane Library. The quality of the articles was assessed by the Newcastle Ottawa Scale. The odds ratio was used as a measure of the chance of developing a wound healing disorder after bilateral internal mammary artery (BIMA) surgery. Meta-analyses were performed for different subgroups. RESULTS: Twenty studies met the quality criteria, including one randomized controlled trial. The use of both mammary arteries significantly increased the risk of superficial (odds ratio [OR] 1.72) and deep (OR 1.75) wound healing disorder in the total population (OR 1.80) as well as in the diabetic subgroup (OR 1.38) and with both preparation techniques. The increased risk with BIMA grafting was present independently of the preparation technique (pedicled: OR 1.89, skeletonized: OR 1.37). CONCLUSION: Bilateral internal mammary artery grafting, especially in high-risk and diabetic patients, is associated with an increased risk of wound healing impairment. Skeletonized preparation does not eliminate the elevated wound healing disorder risk after BIMA use.

Challenges associated with treatment of left internal mammary artery graft thrombosis.

Acute occlusion of the left internal mammary artery (LIMA) graft late after coronary artery bypass grafting surgery is a rare and potentially life-threatening complication. We describe a case of acute myocardial infarction 19 years after coronary artery bypass graft surgery due to acute occlusion of the distal anastomosis of a LIMA graft to the left anterior descending artery. Aspiration thrombectomy failed to remove the thrombus. Laser thrombectomy caused perforation. After drug-eluting and covered stent implantation, antegrade TIMI 3 flow was restored with an uneventful postprocedural course.

Does Bilateral Internal Mammary Artery Grafting Better Suit Patients With Diabetes?　- Two Different Ways to Explore Outcomes.

BACKGROUND: This analysis compared short-term mortality, sternal wound infection (SWI), and long-term survival outcomes in diabetic patients who underwent coronary artery bypass grafting (CABG) with bilateral (BIMA) vs. single (SIMA) internal mammary artery, as well as in diabetic vs. non-diabetic patients undergoing BIMA grafting.Methods and Results:Nineteen studies were included in the study, covering 21,143 different patients. Of these patients, 6,464 underwent CABG with BIMA, 10,264 underwent CAGB with SIMA, 11,584 had diabetes, and 6,717 did not. Compared with SIMA, BIMA had a significantly lower risk of in-hospital mortality (odds ratio [OR] 0.73, P=0.02), but a significantly higher risk of SWI (OR 1.30, P=0.04). However, compared with non-diabetic patients who underwent CABG with BIMA, diabetic patients with BIMA grafting did not have significantly higher risks of either mortality (OR 1.22, P=0.53) or SWI (OR 1.10, P=0.72). No significant differences were detected with different harvesting techniques. Longer term, BIMA was associated with a significantly higher rate of survival than SIMA (hazard ratio [HR] 0.76, P<0.001). CONCLUSIONS: Results from the 2 types of comparisons indicate that BIMA is a preferable option for diabetic patients, even though it has a higher risk of infection. CABG with BIMA is also associated with a long-term survival benefit.

Coronary Subclavian Steal Syndrome: A Contemporary Review.

Coronary subclavian steal syndrome (CSSS) is a rare cause of angina. It occurs in patients with prior coronary artery bypass grafting and, specifically, a left internal mammary artery (LIMA) to left anterior descending artery (LAD) graft and co-existent significant subclavian artery stenosis. In this context, there is retrograde blood flow through the LIMA to LAD graft to supply the subclavian artery beyond the significant stenosis. This potentially occurs at the cost of compromising coronary artery perfusion dependent on the LIMA graft. In this review, we present a case of a middle-aged female who suffered from CSSS and review the literature for the contemporary diagnosis and management of this condition.

Off-pump Revascularization with Bilateral versus Single Mammary Arteries-A Propensity Score-Matched Analysis.

BACKGROUND: Coronary artery bypass grafting is the first-line therapy for severe multivessel coronary artery disease. We aimed to investigate the clinical outcome in patients undergoing isolated off-pump surgery with the single or bilateral internal mammary artery (SIMA or BIMA) approach. METHODS: We performed a propensity score-matched analysis in 1,852 consecutive patients, aged 50 to 70 years, who underwent myocardial revascularization at our institution between July 2009 and August 2016. Primary end point was the probability of survival. RESULTS: Mean follow-up was 36.3 (range: 0.1-89.6) months. The probability of survival in the SIMA and BIMA groups was 98.6 and 99.0% at year 1, 92.0 and 92.5% at year 5, and 85.6 and 81.6% at year 7, respectively, with a hazard ratio (HR) of mortality for the BIMA group versus the SIMA group of 0.98 (95% confidence interval[CI]: 0.64-1.52; p = 0.94). There was evidence for interaction between diabetes and study group on mortality risk (HR = 2.59, 95% CI: 1.07-6.23; p = 0.034). Freedom from mediastinitis/wound infection was higher in the SIMA group than in the BIMA group (99.5 and 96.9%, respectively; HR of an event = 6.39, 95% CI: 2.88-14.18; p < 0.001). The corresponding values in the subgroups of diabetic patients were 98.6 and 90.9%, respectively (HR = 6.45, 95% CI: 2.24-18.58; p = 0.001). Mediastinitis/wound infection was associated with increased mortality risk (HR = 2.96, 95% CI: 1.29-6.78; p = 0.010). CONCLUSION: Overall, our data indicate similar probability of survival up to a maximum follow-up of 7 years by off-pump surgery with the SIMA or BIMA approach. However, in diabetic patients, the clinical outcome indicates caution regarding the use of the BIMA approach.

Bilateral Internal Thoracic Artery Grafting Concomitant With Other Cardiac Operations　- Insights From a European Multicenter Retrospective Study on 1,123 Consecutive Patients.

BACKGROUND: The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain unproven.Methods and Results:Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III-IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively. CONCLUSIONS: BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.

Hybrid Revascularization: A Review.

Hybrid coronary revascularization (HCR) combines surgical bypass with percutaneous coronary intervention (PCI) performed either during the same procedure or in a staged approach within 60 days. Coronary artery bypass grafting using the left internal mammary artery (LIMA) has shown excellent long-term patency with improved patient survival. It remains the gold standard treatment for the majority of patients with multivessel coronary artery disease. However, saphenous vein grafts have poor long-term patency. Advances in stent technology have resulted in reduced rates of thrombosis and restenosis, making PCI a viable alternative to coronary surgery in selected patients. HCR is attractive as a less invasive method of coronary revascularization which preserves the benefits of the LIMA performed with less invasive surgical techniques with the efficacy of newer generation stents.

Graft failure and recurrence of symptoms after coronary artery bypass grafting.

OBJECTIVES: Saphenous vein grafts (SVGs) most often used in coronary artery bypass grafting (CABG) are subject to graft disease and have poor long-term patency, however the clinical implication of this is not completely known. We aim to assess the influence of graft failure on the postoperative recurrence of coronary artery disease (CAD) symptoms in relation to the contribution from progression of atherosclerosis in the native coronary vessels. DESIGN: Within the SWEDEHEART registry we identified 46,663 CABG cases between 2001 and 2015 with patient age 40-80 years where single internal mammary artery (IMA) anastomosis (IMA), single IMA with one (1SVG) or multiple SVG anastomoses (2+ SVG) had been performed. Clinical characteristics as well as mortality and postoperative incidence of coronary angiography were recorded and multivariable adjusted hazard ratios were calculated. Indications for the angiographies and occurrence of graft failure were also registered. RESULTS: The adjusted hazard ratio for death was similar for the three groups. The adjusted hazard ratio for being submitted to angiography as compared to 2+ SVG was (95% CI) 1.24 (1.06-1.46) for IMA and 1.21 (1.15-1.28) for 1SVG. Failed grafts were found at the first postoperative angiography with preceding CAD symptoms in 21.4% of patients in the IMA group, 41.6% in the 1SVG group and 61.1% in the 2+ SVG group. CONCLUSIONS: A substantial amount of angiographies occur in patients without any graft failure and a large part of postoperative recurrence of CAD symptoms and are likely attributed to IMA failure or progression of atherosclerosis in the native coronary arteries.

Sequential Grafting of in Situ Skeletonized Left Internal Mammary Artery to the Left Coronary System.

Sequential grafting may be an effective way to maximize the benefits of the left internal mammary artery (LIMA) conduit. Despite increasing clinical application, the strategy of sequential LIMA grafting has not been proven its superiority. This single-center retrospective study aimed to evaluate the in-hospital and mid-term outcomes of sequential grafting of in situ skeletonized LIMA to the left coronary system.According to the use of sequential or separate LIMA grafting, 1505 eligible patients were assigned to a sequential group (n = 230) and a control group (n = 1275). According to sequential LIMA graft configurations, patients with sequential LIMA grafting were divided into a DOM subgroup (n = 113) and a DLAD subgroup (n = 117). The clinical outcomes and LIMA graft patency were investigated and compared.Sequential LIMA grafting compared with separate LIMA grafting was not an independent predictor either of in-hospital adverse events or follow-up survival free from repeat revascularization during the follow-up period of 32.4 ± 8.5 months. Sequential LIMA grafting had similar LIMA graft patency with separate LIMA grafting (99.5% of 1st sequential sites and 97.7% of 2nd sites versus 98.2% of LIMA-LAD grafts) at 32.3 ± 8.5 months after coronary artery bypass grafting (CABG) surgery. Additionally, the two subgroups received similar mid-term clinical outcomes and graft patency of LIMA segments.Sequential grafting of in situ skeletonized LIMA to the left coronary system resulted in excellent clinical outcomes and graft patency. The two sequential LIMA graft configurations received similar clinical outcomes and graft patency.

Frequency and Predictors of Internal Mammary Artery Graft Failure and Subsequent Clinical Outcomes: Insights From the Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV Trial.

BACKGROUND: The internal mammary artery (IMA) is the preferred conduit for bypassing the left anterior descending (LAD) artery in patients undergoing coronary artery bypass grafting. Systematic evaluation of the frequency and predictors of IMA failure and long-term outcomes is lacking. METHODS AND RESULTS: The Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial participants who underwent IMA-LAD revascularization and had 12- to 18-month angiographic follow-up (n=1539) were included. Logistic regression with fast false selection rate methods was used to identify characteristics associated with IMA failure (≥75% stenosis). The relationship between IMA failure and long-term outcomes, including death, myocardial infarction, and repeat revascularization, was assessed with Cox regression. IMA failure occurred in 132 participants (8.6%). Predictors of IMA graft failure were LAD stenosis <75% (odds ratio, 1.76; 95% confidence interval, 1.19-2.59), additional bypass graft to diagonal branch (odds ratio, 1.92; 95% confidence interval, 1.33-2.76), and not having diabetes mellitus (odds ratio, 1.82; 95% confidence interval, 1.20-2.78). LAD stenosis and additional diagonal graft remained predictive of IMA failure in an alternative model that included angiographic failure or death before angiography as the outcome. IMA failure was associated with a significantly higher incidence of subsequent acute (<14 days of angiography) clinical events, mostly as a result of a higher rate of repeat revascularization. CONCLUSIONS: IMA failure was common and associated with higher rates of repeat revascularization, and patients with intermediate LAD stenosis or with an additional bypass graft to the diagonal branch had increased risk for IMA failure. These findings raise concerns about competitive flow and the benefit of coronary artery bypass grafting in intermediate LAD stenosis without functional evidence of ischemia. CLINICAL TRIAL REGISTRATION: URL: http:/www.clinicaltrials.gov. Unique identifier: NCT00042081.

Favourable long-term outcome after coronary artery bypass grafting in a nationwide cohort.

OBJECTIVES: In a nationwide cohort, we analyzed long-term outcome following coronary artery bypass grafting, using the combined strategy of left internal mammary artery to the left anterior descending artery and saphenous vein as secondary graft to other coronary targets. METHODS: 1,507 consecutive patients that underwent myocardial revascularization during 2001-2012 in Iceland. Mean follow-up was 6.8 years. Major adverse cardiac and cerebrovascular events were depicted using the Kaplan-Meier method. Cox-regression was used to define risk factors. Relative survival was estimated by comparing overall survival to the survival of Icelanders of the same age and gender. RESULTS: Mean age was 66 years, 83% were males, mean EuroSCOREst was 4.5, and 23% of the procedures were performed off-pump. At 5 years, 19.7% had suffered a major adverse cardiac or cerebrovascular event, 4.5% a stroke, 2.2% myocardial infarction, and 6.2% needed repeat revascularization. Overall 5-year survival was 89.9%, with a relative survival of 0.990. Independent predictors of major adverse cardiac and cerebrovascular events were left ventricular ejection fraction ≤30%, a previous history of percutaneous coronary intervention, chronic obstructive lung disease, chronic kidney disease, diabetes, and old age. The same variables and an earlier year of operation were predictors of long-term mortality. CONCLUSIONS: The long-term outcome following myocardial revascularization, using the left internal mammary artery and the great saphenous vein as conduits, is favourable and improving. This is reflected by the 5-year survival of 89.9%, deviating minimally from the survival rate of the general Icelandic population, together with a freedom from major adverse cardiac and cerebrovascular events of 80.3%.

Urgent Coronary Revascularization with Bilateral Internal Thoracic Artery Grafting: Is the Risk Justified?

Background The frequent need of immediate institution of cardiopulmonary bypass because of ischemia and increased risk of bleeding and longer duration of surgery limit the use of bilateral internal thoracic artery (BITA) grafting in urgency. Patients and Methods Of 4,525 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution (1999-September 2015), 121 (2.7%) patients had an operation before the beginning of the next working day after decision to operate, which is the definition for emergency according to the European System for Cardiac Operative Risk Evaluation II. BITA and single internal thoracic artery (SITA) grafting were used in 52 and 46 of these patients, respectively; venous grafts alone were used in the remaining cases. BITA and SITA patients were compared as risk profiles, operative data, and outcomes. A propensity score (PS)-matched analysis was also performed. Results Between BITA and SITA patients, there was no significant difference as hospital mortality, both in the overall (3.8 vs. 6.5%; p = 0.66) and the PS-matched series (0 vs. 4.3%; p = 1). Among the postoperative complications, only bleeding (but not blood transfusion nor mediastinal re-exploration) was increased both in the overall (p = 0.037) and the PS-matched series of BITA patients (p = 0.092); duration of surgery was increased but not quite significantly (p = 0.12). Freedom from cardiac and cerebrovascular deaths, and major adverse cardiac and cerebrovascular events were higher in PS-matched BITA patients, even though not quite significantly (p = 0.11 for both). Conclusion BITA grafting may be performed even in urgency. With respect to SITA grafting, hospital mortality and postoperative complications other than bleeding are not increased; late outcomes seem to be better.

Exclusive Bilateral Internal Thoracic Artery Grafts for Myocardial Revascularization Requiring Four Anastomoses or More: Outcomes from a Single Center Experience.

Introduction Multivessel coronary artery bypass graft (CABG) with bilateral internal thoracic arteries (BITA) has only been uncommon and technically demanding. We describe our experience with BITA only CABGs requiring ≥ 4 anastomoses. Material and Methods The department's database was queried for patients undergoing isolated CABG with ≥ 4 anastomoses. The surgical technique included systematically a right internal thoracic artery (ITA) of left ITA Y graft. The multivariate model included variables with a p < 0.3 at univariate analysis. Results Between January 2006 and December 2009, 251 consecutive patients (71 ± 10 years) (on-pump: 130, off-pump: 121) had CABG with ≥ 4 anastomoses, representing 21% of total isolated CABGs for the same period; all patients received a totally arterial BITA only revascularization. Follow-up was 4.9 ± 1.6 years. Overall and cardiac cumulative survivals were 78 and 92%, respectively, at 5 years. The occurrence of any major postoperative complication was associated with overall and cardiac mortality (odds ratio [OR]: 3.6, 95% confidence interval [CI]: 1.3-9.9 and OR: 5.4, 95% CI: 1.3-21.9, respectively). Major sternal wound complication requiring surgical revision was not associated with impaired glucose control (n = 9; diabetics: 6/82, 7.3%; nondiabetics: 3/169, 1.8%, p = 0.06). Preoperative kidney failure was associated with incomplete revascularization (OR: 6.2; 95% CI: 1.2-33.5), that was unfailingly due to ungraftable right coronary artery targets. Discussion BITA only revascularization was a valuable and safe procedure, with favorable results in terms of morbidity and mortality at a 5 years' follow-up.

The Use of Bilateral Internal Mammary Artery Grafting in Different Degrees of Obesity.

Background Obesity is a limiting factor for the use of bilateral internal mammary arteries (BIMAs). Therefore, we assessed the safety of their use in different degrees of obesity. Patients and Methods We studied two groups of patients with obesity using propensity matching. The first group received single internal mammary artery and saphenous vein grafts (SIMA group, 526 patients) and the second group received bilateral internal mammary arteries (BIMA group, 526 patients). Patients were classified further according to their body mass index (BMI) into overweight (BMI = 25-29.9 kg/m2), obese (BMI = 30-34.9 kg/m2), and severely obese (BMI ≥ 35 kg/m2). Results Preoperative data were similar regarding age (62.78 ± 9.96 vs. 62.98 ± 9.66 years; p = 0.734), female sex (17.5 vs. 18.6%; p = 0.631), diabetes mellitus (26.3 vs. 27.2%; p = 0.74), EuroSCORE (3.21 ± 2.23 vs. 3.18 ± 2.41; p = 0.968), and COPD (16 vs. 16%; p = 1). No significant differences were noticed between the two groups regarding the number of peripheral anastomoses (3.09 ± 0.84 vs. 3.12 ± 0.83; p = 0.633), myocardial infarction (1.7 vs. 1.7%; p = 1), reexploration (1.3 vs. 2.1%; p = 0.34), deep sternal wound infection (DSWI) (2.1 vs. 2.9%; p = 0.43), and 30-day mortality (0.8 vs. 1.1%; p = 0.53). Multivariate analysis identified BMI and intensive care unit stay as independent predictors for DSWI. However, postoperative blood loss (694.56 ± 631.84 vs. 811.67 ± 688.73 mL; p < 0.001) and the incidence of pneumothorax (1 vs. 2.7%; p = 0.037) were higher in BIMA group. Conclusion Patients with obesity can benefit from BIMA grafting. However, postoperative blood loss and the incidence of pneumothorax can be higher using this technique.

14-Year Results of Bilateral versus Single Internal Thoracic Artery Grafts for Left-Sided Myocardial Revascularization in Young Diabetic Patients.

Objectives Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal wound complications. In the present study, early- and long-term outcomes of the use of left-sided BITA versus single internal thoracic artery (SITA) grafting in young (< 65 years of age) diabetic patients were reviewed retrospectively. Methods A total of 250 propensity score pair-matched diabetic patients, operated on between February 2000 and December 2011, receiving either BITA (n = 125) or SITA (n = 125) grafting were analyzed retrospectively. In each group, 104 patients were males, and mean age was 60.1 ± 5.3 years. Follow-up was 2.1 to 14.8 years (mean, 9.3 ± 3.5 years) and complete for 100%. Results Incidence of deep sternal wound infection was 2.4 versus 3.2% (p = 0.722). Rethoracotomy due to bleeding occurred in 4.8 versus 3.2% (p = 0.608). The 5-, 10-, and 14-year estimates of survival were 93.4, 76.6, and 67.5% (BITA) versus 89.5, 81.5, and 32.8% (SITA); p = 0.288. Freedom from reangiography/intervention (60.5 vs. 63.9%) during follow-up was comparable (p = 0.507) as well as infarction rate (93.8 vs. 95.1%, p = 0.833) and redoes (p = 0.672, exclusively valve surgery) were comparable. Freedom from thromboembolic or cerebrovascular events did not show any significant differences (94.0 vs. 94.0%, p = 0.78). Multivariate analysis identified poor ejection fraction as predictor for decreased long-term survival. Neither age nor gender or urgency had an influence on long-term mortality. Conclusion Left-sided BITA grafting may be performed routinely even in diabetic patients without increased incidence of postoperative wound-healing complications. Survival rates after 5, 10, and 14 years were comparable for BITA and SITA grafting.