Influence of diabetes and bilateral internal thoracic artery grafts on long-term outcome for multivessel coronary artery bypass grafting.
ABSTRACT Diabetes mellitus is a major independent risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). The aim of this study was to assess the effect of bilateral (B) internal thoracic artery grafting (ITA) in diabetic patients with multivessel CABG.
Between 1985 and 1995, 4382 patients underwent primary isolated multivessel CABG with ITA grafting and concomitant saphenous vein grafting (SVG). Outcome of diabetic and nondiabetic patients undergoing single (S) ITA+SVG (n=419 and 2079) and BITA+SVG (n=214 and 1594) grafting was obtained at a mean follow-up of 11+/-3 years.
Diabetic patients were older, included more women, and had more obesity, hypertension and peripheral vascular disease than nondiabetic patients. Deep sternal wound infection rate was 1.9% for diabetic patients vs 1.2% for nondiabetic patients (P=0.2) and 30-day mortality was 1.7 vs 1.8% (P=0.9). Cox regression analysis with interaction term and propensity scoring showed that BITA grafting decreased the risk of death (Hazard Ratio=0.72 [0.57-0.91, 95%CI]) and coronary reoperation (HR=0.38 [0.19-0.77]) in both diabetic and nondiabetic patients, with no significant interaction noted. BITA grafting decreased the risk of myocardial infarction at long-term follow-up in nondiabetic patients (HR=0.72 [0.60-0.86]) but not in diabetic patients. Ten-year freedom rate from myocardial infarction in diabetic patients was 80 and 76% for SITA and BITA grafting patients, respectively. However, survival following myocardial infarction was better for patients who underwent BITA grafting, in both diabetic and nondiabetic subgroups.
BITA+SVG grafting in diabetic patients improves survival and decrease coronary reoperation compared with SITA+SVG at long-term follow-up. Survival following myocardial infarction is improved with BITA grafting.
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ABSTRACT: Internal mammary artery (IMA) dissection may cause sternal devascularization and iszhemia resulting in sternal wound complication. To evaluate the effect of median sternotomy and IMA dissection on sternal vascular supply, sternal bone tomography was performed 7 days and 1 month after cardiac operation in 67 patients. Seventeen nondiabetic patients had single IMA grafts, 18 had double IMA grafts, and 12 had only saphenous vein grafts or valve replacement. Twenty diabetic patients were studied after any one of these operations. Seven patients were restudied 1 month after the operation. Sternal technetium-99m-methylene diphosphate tomography was performed. The sternum was visualized and focal zones of hypoactivity represented sternal hypoperfusion. The ratio of hypoactivity area over total sternal area was calculated for every patient. After median sternotomy without single or double IMA grafts, the averaged hypoperfusion ratio was 4% ± 1% compared with 13% ± 3% after single IMA grafts and 24% ± 6% after double IMA grafts (p < 0.0001). Diabetic patients without IMA, with single IMA, and with double IMAs showed hypoperfusion areas of 5% ± 3%, 15% ±5%, and 23% ± 9%, respectively, a result similar to that of nondiabetic patients. One month after operation the hypoperfusion area decreased to 2% ± 2% (p < 0.05) in restudied patients. Our results indicate that IMA dissection causes a significant although partial and temporary sternal ischemia, which is more severe after double IMA than single IMA mobilization and which may be incriminated in the development of sternal wound infection. This vascularization defect was not greater among patients with diabetes mellitus.The Annals of Thoracic Surgery 02/1992; · 3.45 Impact Factor
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ABSTRACT: Diabetes has not yet been investigated as a risk factor for early and late cardiac-related death. Patients operated on from January 1988 to December 1999 were considered; 767 were diabetic (group D) and 2593 were nondiabetic (group ND). Patients with preoperative hemodynamic deterioration were excluded. Early (30-day) mortality (any causes and cardiac causes) was evaluated with univariate analysis and stepwise logistic regression. Ten-year actuarial freedom from death of any cause and cardiac death was also assessed with univariate and Cox analyses. Early mortality was 2.2% (group D, 3.3%; group ND, 1.9%; P =.023). Early cardiac mortality was 1.3% (group D, 2.2%; group ND, 1.1%; P =.0016). Diabetes was an independent risk factor only for cardiac death and not for death of any cause. Five-year survival was 93.5% +/- 0.5% (group D, 92.5% +/- 1.1%; group ND, 93.9% +/- 0.6%; P =.0304). Diabetes was not an independent risk factor. Five-year freedom for cardiac death was 96.3% +/- 0.4% (group D, 94.9% +/- 0.9%; group ND, 96.6% +/- 0.4%; P =.0155). Diabetes was an independent risk factor. However, if only the patients who survived the first 30 days are considered, diabetes disappears as a risk factor (5-year freedom for cardiac death, 97.8% +/- 0.3%; group D, 97.3% +/- 0.8%; group ND, 97.9% +/- 0.4%; P = 0.2389). Diabetes is an independent risk factor for early cardiac death only. Long-term survival in patients who survive the first 30 days is not statistically significantly different for diabetic and nondiabetic patients. In fact, the rates appear very similar.Journal of Thoracic and Cardiovascular Surgery 02/2003; 125(1):144-54. · 3.53 Impact Factor
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ABSTRACT: Does the use of bilateral internal mammary artery (IMA) grafts provide incremental benefit relative to the use of a single IMA graft? Meta-analysis by qualitative and quantitative protocol of the studies published in the literature in the last 15 years. Only eight, out of 149 observational studies found, met our criteria: surgical results of bilateral versus single IMA, patient age range from 20 to 89 years, exclusion of emergency and diabetic patients, study group larger than 100 patients, minimal follow-up time. The final sample size included 16362 patients. Late survival was evaluated at 5 and 10 years. The hazard ratio (HR) was calculated from seven studies, the difference of survival was from six and five studies, respectively. The effect size was summarized using a random effect model, suggested by the results of statistical test for homogeneity of the HR (P < 0.05) and of the survival difference at 5 (P < 0.05) and at 10 years (P < 0.05). The bilateral IMA estimate of combined HR was 0.79 (95% confidence limits, C.L. = 0.66/0.91). The combined difference of survival probability at 5 years was 0.014 (95% C.L. = -0.03/0.06) and at 10 years was 0.07 (95% C.L. = 0.003/0.170). There is significant evidence in favor of decreasing death risk of bilateral versus single IMA procedure.European Journal of Cardio-Thoracic Surgery 11/2002; 22(5):781-6. · 2.67 Impact Factor