Bilateral Internal Thoracic Artery Grafting Is Associated With Significantly Improved Long-Term Survival, Even Among Diabetic Patients
Clinical Research Unit, Division of Cardiothoracic Surgery, Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia 30308, USA. The Annals of thoracic surgery
(Impact Factor: 3.85).
06/2012; 94(3):710-5; discussion 715-6. DOI: 10.1016/j.athoracsur.2012.03.082
This study examines if bilateral internal thoracic artery (BITA) grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting, in the modern era, in which diabetes mellitus and obesity are more prevalent.
The Society of Thoracic Surgeons database at a single large academic center was reviewed for all consecutive isolated coronary artery bypass grafting patients with two or more distal anastomoses from January 1, 2002, through December 31, 2010. Propensity-adjusted logistic and Cox regression models were used to estimate the effect of BITA on short-term outcomes and long-term survival for diabetic and nondiabetic patients.
A total of 3,527 coronary artery bypass grafting operations (812 BITA, 2,715 SITA) were performed. Fewer BITA than SITA patients had diabetes (28.6% vs 44.7% p<0.001). There was no significant difference in 30-day rates of death, stroke, or myocardial infarction between nondiabetic patients who had BITA vs SITA, or between diabetic patients who had BITA vs SITA. BITA grafting conferred a 35% reduction (95% confidence interval, 12% to 52%, p=0.006) in the long-term hazard of death equally for nondiabetic and diabetic patients (p=0.93). Deep sternal wound infection was more common among diabetic than among nondiabetic patients (1.5% vs 0.7%), but was similar within nondiabetic (1.0% vs 0.6%) and diabetic patients (1.7% vs 1.5%) who had BITA vs SITA. Overall, BITA and SITA patients had similar rates of deep sternal wound infection (1.2% vs 1.0%).
BITA grafting confers a long-term survival advantage and should be performed whenever suitable coronary anatomy exists and patient risk factors allow an acceptable risk of deep sternal wound infection.
Available from: Benedetto Umberto
- "e l s e v i e r . c o m / l o c a t e / i j c a r d utilising SIMA    . We aimed to investigate whether MAG offers survival benefit over DES-PCI in MVD. "
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ABSTRACT: The best revascularisation strategy for multivessel coronary artery disease (MVD) is still controversial. Percutaneous coronary intervention (PCI) utilising drug eluting stents (DES) has emerged as an acceptable alternative to conventional coronary artery bypass grafting (CABG) in the last decade. However, multiple arterial grafting (MAG) is superior revascularisation strategy compared with conventional CABG utilising single internal mammary artery and currently there is a paucity of comparison of DES and MAG. We aimed to investigate whether MAG offers advantage over DES-PCI in MVD.
A total of 6126 patients with MVD (≥2 vessel) underwent CABG (n=4652) or PCI (n=1474) at a single institution. MAG was performed in 1372 CABG cases and DES were implanted in 1222 PCI cases. Propensity score adjusted analysis was performed to investigate the potential survival advantage of MAG over PCI. Mean follow-up was 4.9years.
Risk for late death was comparable after DES-PCI and conventional CABG (HR 1.11; 95%CI 0.9 to 1.33; P=0.25). However, DES-PCI was associated with an increased risk for late death compared to MAG (HR 1.53; 95%CI 1.08 to 2.91; P=0.02). DES-PCI was also associated with a 3.51 fold increased risk for repeat revascularisation over MAG (95%CI 2.60 to 4.75; P<0.0001) and 2.66 fold increased risk for repeat revascularisation over conventional CABG (95%CI 2.11 to 3.36; P<0.0001).
MAG improved late survival and offered superior freedom from repeat revascularisation compared to DES-PCI. When feasible, MAG should be strongly recommended in patients with MVD.
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Available from: Petr Nemec
- "Puskas indicates statistically more significant long-term survival of patients (up to 35% higher) in whom both of the mammary arteries were used to surgically revascularise the myocardium. He found no difference in the DSWI incidence between patients after the harvesting of one, or both mammary arteries . In the retrospective study involving over 1.5 million patients, Itagaki "
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ABSTRACT: Median sternotomy is the most commonly performed surgical procedure in the treatment of heart conditions in both adults and children. Deep sternal wound infections (DSWI) present a serious complication occurring after surgery, highly demanding both of patients and surgery departments. The present study is a retrospective analysis of 9110 patients who underwent a cardiac surgery at the Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic, in the years 2005–12, and as its objective it has a definition of risk factors of DSWI after median sternotomy.
Available from: Giuseppe Gatti
- "In diabetic patients with multivessel coronary artery disease, coronary artery bypass graft (CABG) surgery offers better results than percutaneous coronary intervention  . The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization may additionally improve the long-term outcomes of surgery because of superior graft patency    . In diabetic patients, however, BITA grafting remains a controversial issue mainly due to the increased risk of sternal complications   . "
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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 complications. In the present study, early and long-term outcomes of the routine use of left-sided BITA grafting in insulin-dependent diabetic patients were reviewed retrospectively.
Among the 2701 consecutive patients who underwent isolated BITA grafting at the authors' institution from 1999 throughout 2012, 188 (mean age: 67 ± 9 years) were insulin-dependent diabetic patients. The mean expected operative risk, calculated according to the European System for Cardiac Operative Risk Evaluation II, was 11 ± 10.8%.
There were 6 (3.2%) hospital deaths. Prolonged invasive ventilation (17.6%), multiple transfusion (16.5%), deep sternal wound infection (DSWI, 11.7%) and acute kidney injury (10.6%) were the most frequent major postoperative complications. Chronic lung disease (P = 0.08), low cardiac output (P = 0.039), multiple transfusion (P = 0.034) and mediastinal re-exploration (P = 0.071) were risk factors for DSWI. The mean follow-up was 5.7 ± 3.6 years. The 10-year non-parametric estimates of overall survival, freedom from cardiac and cerebrovascular death, and major adverse cardiac and cerebrovascular events were 57.7 [95% confidence interval (CI): 45.1-66.2], 83.6 (95% CI: 76.6-90.7) and 55.4% (95% CI: 44.7-66.1), respectively. Predictors of decreased late survival were old age (P = 0.013), chronic lung disease (P = 0.004), renal impairment (P = 0.009) and left ventricular dysfunction (P = 0.035).
Left-sided BITA grafting may be performed routinely even in insulin-dependent diabetic patients. The increased rates of postoperative complications do not prevent low early mortality and good long-term outcomes.
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