Bilateral Internal Thoracic Artery Grafting Research Articles

Competitive flow of bilateral internal thoracic artery Y-graft: Insights from hemodynamics and transit time flow measurement parameters

Recent studies have demonstrated the superior efficacy of bilateral internal thoracic artery (BITA) grafts compared to other graft methods in treating coronary artery disease. Competitive flow (CF) is a primary factor contributing to graft failure in the long term. For the first time, the CF of the BITA-Y graft has undergone rigorous numerical analysis. Through the application of transit time flow measurement (TTFM) and hemodynamic parameters, this study provides a new perspective on graft performance. Simulation results indicate that average flow, TTFM, and hemodynamic parameters fall within the critical range for stenosis severities below 90%. Specifically, at 80% stenosis, the mean graft flow (MGF) and pulsatility index (PI) of the left internal thoracic artery (LITA) were 0.071 cc/s and 27, respectively, while those of the right internal thoracic artery (RITA) were 0.211 cc/s and 11. With increasing stenosis severity, TTFM parameters remained within the clinical permissible limit (MGF > 0.34 cc/s and PI < 5). At 95% stenosis severity, the MGF and PI for LITA were 0.526 cc/s and 1.2, respectively, while those for RITA were 0.790 cc/s and 0.9. The results indicate the presence of competitive flow within the BITA-Y graft for stenosis severities below 90% area reduction, suggesting a potential risk of graft failure in the long term. Additionally, the results indicated that when there are significant differences in stenosis severity between the two native arteries, the BITA-Y graft is not optimal due to CF, characterized by low MGF and high reverse flow.

Clinical and Angiographic Outcomes of Bilateral Internal Thoracic Artery Revascularization: In Situ vs Free Grafts

BackgroundBilateral internal thoracic artery (ITA) grafting is associated with improved long-term outcomes; however, the appropriate graft configuration remains controversial. We compared the long-term outcomes of different graft configurations. MethodsBetween 2009 and 2015, 1171 patients underwent isolated bilateral ITA grafting for left-sided complete revascularization at 4 Japanese cardiac surgery centers: underwent in situ left ITA to the left anterior descending artery plus in situ right ITA to the left circumflex artery (LR group, n = 278), in situ right ITA to the left anterior descending artery plus in situ left ITA to the left circumflex artery (RL group, n = 665), and in situ left ITA to the left anterior descending artery plus free right ITA to the left circumflex artery (free group, n = 228). Major adverse cardiovascular events (MACEs), including mortality, myocardial infarction and revascularization, and ITA patency, were compared. ResultsAmong the 3 groups, the free group showed significantly lower MACEs and overall mortality rates (P < .001). Nonfatal myocardial infarction and revascularization rates showed no marked differences among the groups. A weighted analysis revealed a decreased risk of MACEs and death in the free group. No marked difference was observed in the patency of the ITA anastomosed to the left anterior descending artery. Patency of the ITA grafted to the circumflex artery in the LR group was significantly lower relative to the other groups. Using a free right ITA grafted to the circumflex artery reduced the risk of graft failure. ConclusionsThe free right ITA configuration for left-sided revascularization might have better long-term outcomes and significantly better patency than other grafts.

Meta-analysis of BITA versus SITA grafting in diabetic patients: evidence from propensity score-matched studies.

It has been demonstrated that the use of bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) improves long-term survival in comparison to the use of a single internal thoracic artery (SITA) graft. However, the optimal transplantation technique for diabetic patients remains undetermined. The purpose of this meta-analysis was to compare the effectiveness and safety of BITA and SITA CABG in diabetic patients. A comprehensive search of Google Scholar, Science Direct, and PubMed was conducted for studies with propensity score-matched comparing between BITA and SITA grafting in diabetic patients. The main goal was to knowmid- to long-term mortality, and the supplementary results included incidence of deep sternal wound infection, 30-day mortality, and incidence of reoperation due to hemorrhage. The meta-analysis included 11 studies involving 3762 diabetic patients with matched propensity scores. Compared to SITA grafting, BITA grafting was associated with a significant reduction in long-term mortality (HR 0.78; 95% CI 0.67-0.91), P = 0.03, I2 = 54%. There were no significant differences between the two groups in terms of 30-day mortality, reoperation for bleeding, cerebrovascular accident, or renal failure. BITA grafting appears to provide better overall survival than SITA grafting in patients with diabetes. However, using BITA grafting is associated with a greater risk of deep sternal wound infection. These findings may help guide the choice of grafting technique in diabetic patients undergoing CABG.

Bilateral internal thoracic artery grafting in robotic beating-heart totally endoscopic coronary artery bypass: 10-year outcomes.

Multi-arterial grafting (MAG) with bilateral internal thoracic arteries (BITAs) is superior to single internal thoracic artery (ITA) and veins, however, sternal wound infection (SWI) is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally endoscopic coronary artery bypass (TECAB), may mitigate this risk. We reviewed outcomes of robotic TECAB with BITA grafting. A total of 871 patients underwent robotic TECAB at our institution from 7/2013 to 4/2024. Of these, 406 patients received BITA grafts and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with percutaneous coronary intervention (PCI) after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement. The mean age of the cohort was 67±9 years and 16% were female. The mean Society of Thoracic Surgeons (STS) risk was 1.47%±2.2%. Thirty-nine percent were diabetic (15% insulin-dependent) and 39% had a body mass index (BMI) ≥30 kg/m2. Twenty percent had an ejection fraction (EF) ≤40%. Ninety-eight percent of cases were completed off-pump and there were no conversions to sternotomy. The mean number of grafts per patient was 2.2±0.4. The mean intensive care unit (ICU) and hospital length of stay (LOS) were 1.22±0.62 and 2.44±0.83 days, respectively. Postoperative complications included atrial fibrillation in 13%, acute kidney injury (AKI) in 3.4%, return to theatre for bleeding in 0.7%, postoperative myocardial infarction (MI) in 0.2%, and stroke in 0.2%. Thirty-day mortality was 1.2% [observed/expected (O/E): 0.89]. Return to full activities and work occurred at mean of 14±8.6 and 17±13 days, respectively. Two hundred and two patients (50%) had 'advanced' hybrid revascularization (with at least two arterial grafts and stents). ITA early graft patency in this cohort of patients was 271/278 (98%) with 100% left ITA to left anterior descending artery (LITA-LAD) patency. Mid-term follow-up was complete in all patients at mean of 51±36 months (longest follow-up at 10 years). All-cause mortality was 13% and cardiac-mortality was 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 94%. Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system, with excellent 10-year outcomes.

Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass: Impact of Chest Wall Dimensions in Single and Multivessel Bypass.

There can be anatomical constraints on patient selection for minimally invasive surgery. For example, robot-assisted coronary artery bypass was reported to be more challenging when patients had a cardiothoracic ratio >50% and a sternum-vertebra anteroposterior and transverse diameter ratio <0.45. We sought to examine the impact of chest wall anatomic parameters on surgical outcomes in our totally endoscopic coronary artery bypass (TECAB) procedures. We retrospectively reviewed patients who underwent robotic TECAB, all of whom had a preoperative chest radiograph at our institution from July 2017 to October 2021. The cohort was divided into 2 groups, which were patients undergoing single-vessel grafting using the left internal thoracic artery (ITA; group 1) and patients undergoing multivessel grafting with bilateral ITA grafts (group 2). We measured several anatomical parameters from the preoperative chest radiograph. A total of 352 patients undergoing TECAB were retrospectively analyzed. After exclusions, 193 were included in this study. In group 1 (n = 91), no parameters correlated with operative time. In group 2 (n = 102), a significant negative correlation was observed between operative time and the sternum-vertebrae anteroposterior diameter (rs = -0.228, P = 0.022) and lung anteroposterior diameter (rs = -0.246, P = 0.013). To confirm these results in group 2, a propensity-matched analysis was performed and showed a statistically significant difference in surgical time based on chest anteroposterior diameters. In single-vessel robotic TECAB, chest wall anatomic dimensions measured on chest radiograph did not affect operative time. In multivessel cases with bilateral ITA grafts, larger anteroposterior diameter correlated with shorter operative times.

Long-term results following off-pump coronary-artery bypass grafting in left ventricular dysfunction

Severe left ventricular (LV) dysfunction is an independent risk factor for early and long-term mortality after coronary-artery bypass grafting (CABG). Off-pump CABG (OPCAB) significantly reduces the early incidence of major complications in high-risk patients. Moreover, bilateral internal thoracic artery (BITA) grafting after CABG is associated with improved long-term outcomes. We aimed to evaluate the impact of multivessel OPCAB with BITA grafting for complete revascularization on postoperative and long-term outcomes in patients with low LV ejection fraction (EF). We included 121 patients with EF ≤ 30.0% who underwent isolated multivessel OPCAB (average LVEF, 24.8%) between April 2007 and December 2019. Sixty-six patients received BITA grafts, while 55 had single internal thoracic artery (SITA) grafts. We conducted multivariate analyses to examine the correlation between perioperative data and late mortality rate. The early mortality rate was 1.65%. After excluding in-hospital mortality cases, we performed long-term follow-up of 119 patients. Early postoperative echocardiography showed significant LVEF improvement in 89 (75.2%) patients. However, LVEF remained ≤ 30.0% in 30 (24.8%) patients. We recorded 15 and 30 cases of cardiac death and cardiac events, respectively, during the long-term follow-up period. Postoperative LVEF ≤ 30.0% (P < 0.01) and no use of BITA grafting (P = 0.03) were significant predictors of cardiac death and events; moreover, hemodialysis was a significant predictor of all-cause mortality rather than cardiac death. Multivessel OPCAB in patients with severe LV dysfunction was associated with acceptable in-hospital mortality and early postoperative improvement in LV function. Additionally, OPCAB with BITA grafting may provide long-term benefits with respect to cardiac death and events. However, the long-term benefits were significantly limited in patients without early postoperative improvement in LV function and patients with chronic hemodialysis.Clinical registration number: 5590 (14/5/2020 Tokyo Women’s Medical University).

Single versus bilateral internal thoracic artery grafting in patients with impaired renal function.

The optimal strategy for surgical revascularization in patients with impaired renal function is inconclusive. We compared early and late outcomes between bilateral internal thoracic artery (BITA) and single ITA (SITA) grafting in patients with renal dysfunction. This is a retrospective analysis of all the patients with multivessel disease and impaired renal function (estimated glomerular filtration rate <60mL/min/1.73m2) who underwent isolated coronary artery bypass graft (CABG) in our center during 1996-2011, utilizing either BITA or SITA revascularization. Of the 5301 patients with multivessel disease who underwent surgical revascularization during the study period, 391 were with impaired renal function: 212 (54.2%) underwent BITA, 179 (45.8%) underwent SITA. Patients who underwent BITA were less likely to have comorbidities. Statistically significant differences were not observed between the BITA and SITA groups in 30-day mortality (5.6% vs. 9.0%, p = 0.2) and in rates of early stroke, myocardial infarction, and sternal infection (4.5% vs. 6.1%, p = 0.467; 1.7% vs. 2.8%, p = 0.517; and 2.2% vs. 5.7%, p = 0.088, respectively). Long-term survival of the BITA group was better: median 8.36 vs. 4.14 years, p<0.001. In multivariable analysis, BITA revascularization was associated with decreased late mortality (HR = 0.704, 95% CI: 0.556-0.89, p = 0.003). In analysis of a matched cohort (134 pairs), early outcomes did not differ between the groups; however, in multivariable analysis, BITA revascularization was associated with decreased late mortality ‎‎(HR = 0.35 (95%CI 0.18-0.68), p = 0.002)‎. BITA revascularization did not impact early outcome in patients with CRF, but demonstrated a significant protective effect on long-term survival ‎in the unmatched and matched cohorts.

Off-pump bilateral internal thoracic artery grafting in patients with left main coronary artery disease

BackgroundTo compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA).MethodsAmong 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting.ResultsAfter adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504–0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499–0.902; p = 0.008).ConclusionsBilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.

Long-term outcomes of complete bilateral internal thoracic artery grafting and traditional coronary bypass surgery in patients with multivessel coronary artery disease

Aim. To evaluate the long-term results of complete bilateral internal thoracic artery (BITA) grafting and traditional coronary bypass grafting (CABG) in patients with multivessel CAD.Material and methods. From June 2018 to December 2021, 646 CABG operations were performed in patients with multivessel CAD at the Federal Center for Cardiovascular Surgery (Krasnoyarsk). There were 178 patients receiving BITA grafting and 468 — traditional revascularization technique. After propensity score matching, 356 patients were selected, of which 99 had on-pump BITA (group 1), 178 — on-pump traditional revascularization (group 2), and 79 — off-pump BITA (group 3). There were more males (p=0,143 and p=0,547). The groups were comparable in age (p=0,343 and p=0,104), body mass index (p=0,532 and p=0,759), diabetes (p= 0,705 and p=0,667), the number of hemodynamically significant coronary stenoses (p=0,370 and p=0,595).Results. The follow-up period lasted 32,8±8,52 months. Long-term patient survival was 83,9% in group 2,93% in group 1 (p=0,041) and 94% in group 3 (p=0,039). Freedom from cardiovascular mortality was 100% in both groups of BITA grafting and 92,5% in group 2 (p=0,001 and p=0,039), freedom from major cardiovascular events was 94,2% in group 1, 85,1% in group 2 and 98,5% in group 3 (p=0,032 and p=0,03).Conclusion. BITA grafting is a modern effective and safe method of surgical myocardial revascularization both on- and off-pump. Up to 33 months. BITA grafting was associated with significantly better patient survival, complete freedom from cardiovascular mortality and a lower incidence of major cardiovascular events.

Coronary artery bypass grafting using bilateral internal thoracic arteries in patients with diabetes and obesity: A systematic review and meta-analysis

BackgroundPatients with diabetes and obesity are at higher risk of adverse long-term outcomes following coronary artery bypass grafting. The use of bilateral internal thoracic arteries (BITA) can potentially offer survival benefit in higherrisk patientscompared to single internal thoracic artery (SITA), but BITAisnotroutinelyused due tolack of clear evidence of efficacy andconcerns over sternal wound complications. MethodsMedline, Embase and the Cochrane Library were searched forstudies comparing the efficacy and safety of BITA and SITA grafting in patients with diabetes and obesity. Meta-analysis of mortality and sternal wound complications was performed. ResultsWe identified eight observational and ten propensity matched studies, and one RCT, comparing BITA and SITA which included patients with diabetes (n = 19,589); two propensity matched studies and one RCT which included patients with obesity (n = 6,972); mean follow up was 10.5 and 11.3 years respectively. Meta-analysis demonstrated a mortality reduction for BITA compared to SITA in patients with diabetes (risk ratio [RR] 0.79; 95% confidence interval [CI] 0.70–0.90; p = 0.0003). In patients with obesity there was a non-significant reduction in mortality in the BITA group (RR 0.73, 95% CI 0.47–1.12; p = 0.15). There was a significantly higher rate of sternal wound complications following BITA observed in patients with diabetes (RR 1.53, 95% CI 1.23–1.90; p = 0.0001) and obesity (RR 2.24, 95% CI 1.63–3.07; p < 0.00001). ConclusionsBITA is associated with better long-term survival in patients with diabetes. The effects of BITA grafting in patients with obesity are uncertain. BITA is associated with higher rates of sternal wound complications compared to SITA in both patients with diabetes and obesity.

Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts

IntroductionThe left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts. MethodsWe retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group. ResultsSociety of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent. ConclusionsGrafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.

IN-HOSPITAL OUTCOMES OF BILATERAL INTERNAL MAMMARY ARTERY GRAFTING

HighlightsThe present study was conducted to evaluate in-hospital outcomes of one of the most effective and simultaneously controversial surgical techniques for myocardial revascularization using two internal thoracic arteries (ITA).To this date, this is the most complete analysis that has been carried out at the Research Institute on the topic of studying bilateral internal thoracic artery grafting (BITA). The results obtained are of great importance for the subsequent evaluation of long-term results. AbstractAim. To analyze in-hospital outcomes of BITA.Methods. The study included 232 patients who were admitted to the Cardiac Surgery Department for coronary artery bypass grafting (CABG). All patients were divided into 2 groups depending on the use of either single or bilateral ITA conduits. Both groups included equal number of patients – 116. In-hospital outcomes were analyzed.Results. BITA and CABG with single ITA were proven to be comparable regarding myocardial infarction, stroke, the need for percutaneous coronary intervention, death, and composite endpoint. At the same time BITA patients significantly more often had longer hospital stay and required inotropic drugs.Conclusion. BITA is a safe procedure comparable to classic CABG in terms of in-hospital complications, but at the same time, this intervention is associated with longer hospital stay, and extended inotropic drugs use.

Bilateral Versus Single Internal Thoracic Artery Grafting for Elderly Patients Undergoing Coronary Revascularisation for Multivessel Disease: A Systematic Review and Meta-Analysis

International guidelines suggest that multiple arterial grafting is preferred for young patients undergoing coronary artery bypass graft (CABG) surgery for multivessel disease. Limited data exist comparing outcomes of single internal thoracic artery (SITA) with bilateral internal thoracic artery (BITA) grafting in elderly patients.

Redo mitral surgery after coronary artery bypass grafts under hyperkalemic hypothermia using thoracotomy and axillary artery cannulation in a patient with functioning bilateral internal thoracic arteries and atheromatous aorta

BackgroundRedo mitral valve surgery using resternotomy after coronary artery bypass grafting (CABG) is challenging as previous CABG with patent internal thoracic artery (ITA) poses a risk of injury due to dense adhesion. It is paramount to have alternative method to minimize this risk.Case presentation: We report a case of redo mitral and tricuspid valve repair via right thoracotomy under hypothermia and systemic potassium administration with axillary artery cannulation in a patient after CABG with patent bilateral ITA grafts crossing over the sternum. Herein, critical dissection around the aorta and functioning ITA grafts was avoided by performing the procedure under systemic hypothermia via thoracotomy. Furthermore, considering the presence of atheroma in the aorta, the axillary artery was used as a perfusion route to prevent stroke events. Postoperative course was uneventful and echocardiography demonstrated preserved cardiac function.ConclusionPerforming axillary artery cannulation and right thoracotomy under hypothermic cardiac arrest with systemic hyperkalemia without clamping the patent bilateral ITAs and aorta allowed us to perform redo mitral valve surgery after CABG without major postoperative cardiac or cerebral complications.

Off-Pump Bilateral Skeletonized Internal Thoracic Artery Grafting in Octogenarians.

We compared postoperative outcomes in octogenarians who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA). Among 1,532 patients who underwent isolated coronary artery bypass grafting between 2002 and 2021, 173 octogenarians were analyzed retrospectively. After inverse probability of treatment weighting, we found no statistically significant difference regarding patients' preoperative characteristics. No patient experienced deep sternal wound infection. More patients in the single than bilateral ITA group died within 30 days after surgery (5.0% vs. 0%, respectively; P=0.003). The mean follow-up duration was 4.2 years. At 5 years, the freedom from overall death following bilateral versus single ITA grafting was 78.2% and 53.7%, respectively (log-rank test, P=0.003), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 67.9% and 44.8% respectively (log-rank test, P=0.002). In multivariable Cox models, bilateral ITA grafting was significantly associated with a lower risk of overall death (hazard ratio [HR] 0.555; 95% confidence interval [CI] 0.342-0.903; P=0.018) and MACCE (HR 0.586; 95% CI 0.376-0.913; P=0.018). Compared with single ITA grafting, off-pump skeletonized bilateral ITA grafting is associated with lower rates of overall death and MACCE in octogenarians undergoing CABG and does not increase the risk of deep sternal wound infection.

Deep Sternal Wound Infection After Beating Heart Coronary Artery Bypass Surgery with Routine Use of Skeletonized Bilateral Internal Thoracic Artery.

Despite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). We observed the role of routine use of BITA and off-pump coronary artery bypass grafting (OPCABG) in the incidence of DSWI and associated risk factors. Between January 2010 and December 2020, 1,207 patients were treated with isolated coronary artery bypass grafting. In all cases, OPCABG was attempted, and BITA was used whenever there was a need for a second arterial graft for the left coronary artery. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple linear regression analysis was employed to model the risk of DSWI. The incidence of DSWI was 0.58%. Mortality rate was higher in DSWI group than in no-DSWI group (28.57% vs. 1.25%; P<0.001). No significant difference in DSWI incidence was observed when BITA (70.6%) or single internal thoracic artery (29.4%) were used (P=0.680). The prevalence of diabetes (100% vs. 40.7%; P=0.001), hyperlipidemia (100% vs. 85.9%; P=0.045), and obesity (71.4% vs. 26.8%; P-0.017) was significantly elevated in DSWI group, when compared with no-DSWI group. Diabetes (P=0.0001), unstable angina (P=0.0064), previous myocardial infarction > 30 days (P=0.0009), left ventricular ejection fraction < 50% (P=0.0074), and emergency surgery (P=0.0002) were independent risk factors. The results of routine use of skeletonized BITA after OPCABG were satisfactory regarding DSWI incidence and operative mortality in a single-center experience.

Bilateral versus Single Internal Thoracic Artery Grafting Strategies Supplemented by Radial Artery Grafting.

It is unclear if a second or third arterial graft can improve clinical outcomes in coronary artery bypass graft surgery. We compared the outcomes of bilateral internal thoracic artery (BITA) plus radial artery (RA) grafting versus left internal thoracic artery (LITA) plus RA grafting after off-pump coronary artery bypass grafting. Between January 2009 and December 2020, a total of 3007 patients with three-vessel coronary artery disease who underwent off-pump coronary artery bypass were analyzed. Among them, 971 patients received total arterial grafting using LITA. We divided the patients into two groups [group A, BITA+RA grafting (n=227) and group B, LITA+RA grafting (n=744)], and compared the survival and major adverse cardiac and cerebrovascular event (MACCE) rates between the two groups at 10 years. After risk adjustment with inverse probability treatment weighting methods, the freedom from all-cause mortality was 93.1% and 88.3% in groups A and B, respectively (p=0.140). The freedom from MACCE rates were 68.3% and 89.0%, respectively (p<0.0001). LITA plus RA grafting [hazard ratio (HR): 1.3, 95% confidence interval (CI): 1.05-2.37, p=0.025] and incomplete revascularization (HR 1.2, 95% CI: 0.70-2.15, p=0.046) were significant risk factors for MACCEs in multivariable Cox regression analysis. The rates of MACCEs were lower with LITA plus RA grafting than with BITA plus RA grafting in total arterial revascularization. Furthermore, complete revascularization improved long-term outcomes following total arterial grafting.

Impact of Graft Strategies on the Outcome of Octogenarians Undergoing Coronary Artery Bypass Grafting.

To analyse the outcome of coronary artery bypass grafting (CABG) in octogenarians with coronary multivessel disease and the impact of different graft strategies and other factors. Out of 1654 patients with multivessel disease who underwent CABG at our institution between January 2014 and March 2020, we investigated 225 consecutive patients with a median age of 82.1 years for survival prediction and need for coronary reintervention; a detailed outcome analysis was performed. At mean follow-up of 3.3 years, the overall survival was 76.4%. An indication for emergency operation (p = 0.002), age (p <0.001), chronic pulmonary disease (p = 0.024), and reduced renal or ventricular function (p <0.001) had the highest impact on limited survival. The combination outcome of survival and coronary reintervention was 1.7-fold improved (p = 0.024) after use of the bilateral internal thoracic artery (BITA) (66.2%). Off-pump CABG (12%) revealed no impact on survival. Smokers showed a poorer outcome (p = 0.004). The logistic European System for Cardiac Operative Risk Evaluation was highly effective for evaluating long-term outcomes (p <0.001). BITA grafting normalizes survival and reveals a better outcome in octogenarians with multivessel disease. However, patients at risk of poorer survival were operated under emergency conditions and those with pulmonary disease and reduced ventricular or renal function.

Multiarterial Coronary Artery Bypass Grafting Practice Patterns in the United States: Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database

BackgroundWe aimed to elucidate current national multiarterial coronary bypass grafting practice patterns and assess perioperative outcomes. MethodsIsolated primary nonemergent/nonsalvage coronary artery bypass grafting patients with at least 1 internal thoracic artery and 2 or more grafts in The Society of Thoracic Surgery Adult Cardiac Surgery Database (2018-2019) were divided into 3 cohorts: single-arterial, bilateral internal thoracic artery (BITA), and radial artery multiarterial grafting. Observed-to-expected ratios based on 2017 Society of Thoracic Surgery risk models were derived for 30-day perioperative mortality, composite major morbidity and mortality, and deep sternal wound infections for each grafting group overall and as a function of institutional multiarterial case volumes per study period: low (<10), intermediate (11-30), and high (>30). ResultsA total of 281,515 patients (BITA, 15,663 [5.6%]; radial, 23,905 [8.5%]) at 1013 centers showed distinct geographic grafting patterns: BITA and radial multiarterial grafting rates were lowest in the South (4% and 6%, respectively) and highest in the Northeast (9% and 11%, respectively). The median institutional number of BITA and radial cases per study period was 4 and 7, with only 14% and 21% of institutions performing >30 BITA and radial multiarterial cases per study period, respectively. The observed-to-expected mortality for single-arterial bypass grafting was similar to multiarterial: single-arterial, 1.00 (95% CI, 0.98-1.03); BITA, 0.98 (95% CI, 0.84-1.13; P = .711); and radial, 0.96 (95% CI, 0.86-1.07; P = .818). Observed-to-expected mortality and composite major morbidity and mortality were lower at high vs low multiarterial case-volume centers: 0.91 (95% CI, 0.75-1.08) vs 1.30 (95% CI, 0.89-1.79; P = .048) and 1.06 (95% CI, 0.99-1.13) vs 1.51 (95% CI, 1.32-1.71; P < .001), respectively, for BITA, and 0.82 (95% CI, 0.87-1.30) vs 1.67 (95% CI, 1.21-2.21; P < .001) and 0.91 (95% CI, 0.93-1.08) vs 1.42 (95% CI, 1.24-1.61; P < .001), respectively, for radial. ConclusionsMultiarterial bypass grafting remains underused and limited to select centers. Worse outcomes at low-volume BITA and radial institutions document a case-volume outcomes effect. Additional studies are warranted to improve multiarterial outcomes at low-volume institutions.

Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents.

Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention. From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization. The mean age of patients was 65±10years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26±1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311±54minutes, and the mean hospital length of stay was 2.7±1.1days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14±0.4, and the mean number of vessels stented was 1.23±0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39±26months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%. In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.