Influence of diabetes and bilateral internal thoracic artery grafts on long-term outcome for multivessel coronary artery bypass grafting
Department of Surgery, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Que., Canada H1T 1C8. European Journal of Cardio-Thoracic Surgery
(Impact Factor: 3.3).
03/2005; 27(2):281-8. DOI: 10.1016/j.ejcts.2004.10.048
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.
Available from: Noboru Motomura
- "Possible delay in chest wound healing and a higher incidence of wound infection, particularly in diabetic patients  , are regarded as unresolved issues. It is sometimes technically more demanding to take IMAs in full skeletonized fashion, and this can result in longer operation times, so that the use of BIMA is still underutilized regardless of the clinical benefits. "
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To evaluate early outcomes of bilateral internal mammary artery (BIMA) compared with single IMA (SIMA) in patients who underwent isolated coronary artery bypass grafting (CABG).
Patients who received isolated CABG with SIMA or BIMA were retrospectively reviewed using the Japan Adult Cardiovascular Surgery Database from 210 institutions for 2008 and 2009. We performed a one-to-one matched analysis on the basis of estimated propensity scores for patients receiving either SIMA or BIMA and obtained two cohorts with 3851 patients in each group balanced for baseline characteristics out of 8136 SIMA and 4093 BIMA patients. We compared procedures actually performed, early outcomes including 30-day operative mortality and details of postoperative complications between the groups using Pearson's chi-square test, with P < 0.05 being statistically significant.
Preoperative profiles in both groups included 20% females and 50% diabetes mellitus patients with a mean age of 67 years. Off-pump CABG was similar in both groups, being performed 75% of the time, with the mean number of anastomosis being 3.1 and 3.4 in the SIMA and BIMA groups, respectively (P < 0.0001). Thirty-day operative mortality was 1.2% in both groups, and the overall incidence of postoperative complications also was similar, although deep sternal infection was more frequent with BIMA (1.3 of SIMA and 2.3% of BIMA patients; P = 0.0001), while prolonged ventilation and renal failure were more frequent with SIMA (P < 0.05).
The use of BIMA did not affect either short-term survival as postoperative mortality was low in both groups, or overall morbidity despite higher incidence of deep sternal infection.
Available from: Michel Carrier
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ABSTRACT: Despite of incessant progresses in management and treatment of surgical patients following cardiac surgery, mediastinitis remains a grave complication. Even treated, mortality is about 20 to 50 %. Its management is associated with a very important morbidity, necessitating a long and painful treatment, as for the patient as for the medical staff. It must be undertaken in a surgical department but consolidated by a serious medical support associating intensive care, antibiotherapy,and hyper nutrition. Differents technical procedures using muscular grafts and VAC may be applied with encourageous progresses, having hoped excellent long term results.
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