Abstract
BackgroundIn acute situations such as acute myocardial infarction (AMI) with indication for coronary artery bypass grafting (CABG), total arterial revascularization (TAR) is often rejected in favour of saphenous vein (SV) grafting, which is assumed to allow for quicker vessel harvesting, a simpler anastomosis technique, and thus quicker revascularization and fewer bleeding complications. The aim of this study was to evaluate whether reluctance to apply TAR in AMI is still justified from a technical point of view in the current era and whether superiority of TAR results is also evident in emergency patients with AMI undergoing CABG.MethodsIn this retrospective analysis of 434 consecutive patients undergoing CABG for AMI with either TAR or with a combination of one internal mammary artery and SV grafts between 2008 and 2014, procedural data, short-term and mid-term outcome were compared. Propensity score matching of the groups was performed.ResultsAfter propensity score matching, 250 patients were included in the analysis (TAR group: n = 98; SV group n = 152). The procedural time (TAR group: 211 min vs. SV group: 200 min, p = 0.46) did not differ between the groups. Erythrocyte transfusion rates were higher in the SV group (76% vs. 57%; p < 0.001). Rates of re-exploration for bleeding did not differ. Thirty-day mortality rates were comparable (TAR group: 3.4% vs. SV group: 4.5%, p = 0.68). Kaplan-Meier analysis until 7 years postoperatively revealed a tendency for improved survival after TAR (75% vs. 62%; log-rank p = 0.12).ConclusionTAR neither impairs rapid revascularization nor reduces its safety in patients with AMI. It may result in improved long-term outcome and should be preferred in the clinical setting of AMI.
Highlights
In acute situations such as acute myocardial infarction (AMI) with indication for coronary artery bypass grafting (CABG), total arterial revascularization (TAR) is often rejected in favour of saphenous vein (SV) grafting, which is assumed to allow for quicker vessel harvesting, a simpler anastomosis technique, and quicker revascularization and fewer bleeding complications
293 underwent CABG using a combination of one internal mammary artery and saphenous vein grafts, 3 underwent CABG with only vein grafts, and 138 underwent CABG using TAR
Baseline characteristics between the TAR group and the SV group differed significantly, with the TAR group having a lower proportion of female patients (17% vs. 29%; p = 0.011), a lower mean age (59 years vs. 71 years; p < 0.01), a lower rate of chronic kidney disease and a lower rate of patients with severely reduced left-ventricular ejection fraction (Table 1)
Summary
In acute situations such as acute myocardial infarction (AMI) with indication for coronary artery bypass grafting (CABG), total arterial revascularization (TAR) is often rejected in favour of saphenous vein (SV) grafting, which is assumed to allow for quicker vessel harvesting, a simpler anastomosis technique, and quicker revascularization and fewer bleeding complications. The use of arterial grafts for coronary artery bypass grafting surgery (CABG), bilateral internal mammary arteries (BIMA), is recommended due to the superior patency of these grafts compared with saphenous vein grafts (SV grafts) [1]. Reasons for reluctance to conduct total arterial CABG even in stable patients include the increased technical demand, the Grieshaber et al Journal of Cardiothoracic Surgery (2018) 13:2. It is currently unclear whether these concerns about the use of TAR in patients with AMI are valid in the current era of surgical myocardial revascularization. The possible effect of total arterial CABG on long-term outcome in AMI patients has never been explicitly investigated
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