Impact of internal mammary artery conduits on operative mortality in coronary revascularization

Abstract

The long-term advantages of internal mammary artery (IMA) conduits in cotonary artery bypass graft (CABG) procedures are widely recognized, but the immediate short-term impact of IMA grafts is not well defined. The purpose of this study was to investigate the influence of IMA conduits on CABG operative mortality (OM). A retrospective study of two groups of patients undergoing isolated CABG was performed. Patients having at least one IMA graft (group 1) were compared with those with only venous conduits (group 2). The patient population was taken from The Society of Thoracic Surgeons National Cardiac Surgery Database, which contains a broad multiinstitutional experience. A total of 38,578 registered patients undergoing isolated CABG from 1987 through 1991 were studied. Of these, 18,614 patients had at least one IMA conduit (group 1), whereas 19,964 had CABG using entirety venous conduits (group 2). The OM for group 1 was 2.0% ( 365 / 18,614 ), whereas the mortality was 4.5% ( 903 / 19,964 ) for group 2 ( p < 0.005). Patient sub-groups were examined to determine if the improved OM associated with IMA grafting was present in these patient subsets. The population was broken down according to age, sex, ejection fraction, extent of coronary disease, and operative priority. For each subset, univariate analysis showed that group 1 OM was significantly less ( p < 0.005) than the OM for group 2. Numerous combinations of these patient parameters were also analyzed. Group 1 patients had a significant ( p < 0.05) improvement in OM in each combination except for patients more than 70 years of age requiring reoperations. Multivariate analysis also demonstrated that the use of an IMA was independently associated with improved patient survival ( p < 0.0025). To consolidate the net effect of numerous patient risk factors, a Bayesian risk model was used to stratify patients into risk quartiles. For the lowest risk quartile (predicted OM <1.14%) there was no significant difference in group 1 versus group 2 patients. For every other risk category, there was a significant improvement in OM associated with IMA use ( p < 0.005). We conclude that in the vast majority of patient subsets, IMA conduits are associated with a statistically significant improvement in OM when compared with use of venous conduits alone.