Internal Mammary Artery Graft Research Articles

Male-female differences following concomitant coronary artery bypass grafting and aortic valve replacement surgery.

Combined coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), and female sex are associated with increased perioperative mortality in clinical risk scores. This study investigated male-female differences in short-term outcome stratified by age groups. All patients undergoing AVR and CABG between January 2001 and June 2021 at our institution were included. 1963 patients were grouped by decades into: 59years and younger (n=127), 60-69 (n=471), 70-79 (n=1070), and 80years and older (n=295). The primary end points of this study were 30 and 180days mortality. Secondary end points were influence of preoperative risk factors and impact of sex on survival and postoperative major adverse events. Female patients showed higher 30 and 180days mortality after combined CABG and AVR surgery (8.3% vs. 4.2%, P<0.01; 15.8% vs. 9.4%, P<0.01). Stratified by age groups, 30 and 180days mortality remained significantly higher in septuagenarians (9.6% vs. 2.5%, P<0.01; 16.3% vs. 7.7%, P<0.01). Females were significantly older, had better preserved left ventricular function, and higher incidence of diabetes mellitus compared with male patients in this subgroup (P<0.01; P=0.01; P<0.01). Additionally, females received significantly less internal mammary artery (IMA) conduits (P<0.01). Female sex (OR: 3.33, 95% CI: [1.76-6.31]; 1.93, [1.22-3.06]), higher age (1.28, [1.13-1.45]; 1.16, [1.06-1.26]), diabetes mellitus (1.93, [1.03-3.60]; 1.70, [1.08-2.67]) and LVEF <30% (3.26, [1.48-7.17]; 2.23, [1.24-4.02]) were correlated with 30 and 180days mortality, respectively. Upon multivariable testing, sex (1.77, [1.21-2.58]) and LVEF <30% (3.71, [2.39-5.76]) remained independent predictors for major adverse postoperative events. Infrequent use of IMA grafts was associated with increased 30 and 180days mortality as well as adverse events (0.47, [0.25-0.87]; 0.46, [0.29-0.72]; 0.61, [0.42-0.88]). Sex disparities in baseline characteristics may delay operative intervention in female patients. The inherent risk profiles might be responsible for outcome differences in septuagenarians.

Drug-eluting balloon to treat immediate post-coronary artery bypass grafting (CABG) ST-elevation myocardial infarction (STEMI) - A case report

Abstract Background Coronary artery bypass graft (CABG) surgery represents a major cardiovascular operation and may be associated with post-operative ST-elevation myocardial infarction (STEMI) due to graft failure. This is challenging to diagnose and treat as the implanted grafts may be prone to complications when treated percutaneously with drug-eluting stents. Case Summary A man in his 60 s underwent CABG and developed new persistent ST elevations of 2 mm in anterior leads with no significant chest pain, although, administered with intravenous opiates post-operatively. Transthoracic echocardiography was non-diagnostic. Invasive angiography performed emergently showed a thrombotic occlusion of the mid-left anterior descending artery at the site of the anastomosis with the left internal mammary artery (LIMA) graft. Intervention via the graft was considered high risk of complications, therefore, native coronary arteries were used to approach the occlusion, which was successfully cleared with a combination balloon angioplasty with a semi-compliant and then a drug-eluting balloon. The LIMA started working again with the resolution of ST elevation and no immediate complications. Conclusion Early post-operative ST elevations in continuous leads should not be ignored as they often may be the only feature of new-onset ST-elevation myocardial infarction (STEMI). Drug-eluting balloons represent a feasible and possibly safer option than drug-eluting stents to treat these conditions.

Pre-Coronary Artery Bypass Grafting Computed Tomography-Based Fractional Flow Reserve Predicts Graft Failure: Implications for Planning Invasive Treatment of Coronary Artery Disease.

The aim of the study is to evaluate whether a pre-coronary artery bypass grafting (CABG) coronary computed tomography-based fractional flow reserve (FFR-CT) result at the site of a future anastomosis would predict the graft failure in patients undergoing CABG. In 43 patients who had coronary computed tomography angiography (CCTA) prior to the CABG, follow-up CCTA were acquired >12 months post-CABG procedure. The FFR-CT values were simulated on the basis of the pre-CABG CCTA. Based on follow-up CCTA, the anastomosis sites and the graft patency were determined. The graft failure was defined as either its stenosis >50% or occlusion. Ninety eight (44 saphenous, 54 left or right internal mammary artery) grafts were assessed. Eighteen grafts from 16 patients were dysfunctional on follow-up CCTA. The FFR-CT values at the location of future anastomosis were higher in dysfunctional than in normal grafts (0.77 [0.71-0.81] vs 0.60 [0.56-0.66], respectively, P = 0.0007). Pre-CABG FFR-CT (hazard ratio = 1.1; 95% CI: 1.012-1.1, P = 0.0230), and bypass graft to right coronary artery (hazard ratio = 3.7; 95% CI: 1.4-9.3 vs left anterior descending artery) were independent predictors of graft dysfunction during follow-up. The optimal threshold of FFR-CT to predict graft failure was >0.68 (sensitivity 88.9% (95% CI: 65.3-98.6), specificity 63.7% (95% CI: 52.2-74.2), positive predictive value 35.6% (95% CI: 28.3%-43.5%), negative predictive value 96.2% (95% CI: 87.2%-99.0%)). Pre-CABG functional FFR-CT predicts future coronary bypass graft failure. This shows utility of FFR-CT for guiding coronary revascularization and also suggests significance of physiological assessment prior to CABG.

Selecting conduits for coronary artery bypass grafting: caution regarding the right internal mammary artery

This narrative review summarizes the angiographic and clinical outcome results of the most common coronary artery bypass grafting (CABG) conduits. The left internal mammary artery is the preferred first conduit to bypass the left anterior descending artery due to superior long-term survival and graft patency. Recent studies suggest the radial artery may be the preferred second conduit for the circumflex or right coronary artery territories, challenging the belief that the right internal mammary artery is the best choice. Despite their historical high failure rates, saphenous vein grafts continue to be widely used as secondary conduits. Several recent studies report suboptimal rates of right internal mammary artery graft failure, with clinical outcomes comparable to or worse than saphenous veins. The suboptimal rates of RIMA graft failure may be attributed to several factors such as improvements in vein graft failure rates, the use of in situ and non-left anterior descending artery grafting configurations, and skeletonized harvesting techniques. While observational studies favor multiple over single arterial grafting, randomized studies are needed for confirmation. The ongoing Randomized comparison of the clinical Outcome of single vs. Multiple Arterial grafts (ROMA) trial aims to determine if multiple arterial grafting reduces major adverse cardiovascular events and mortality and how secondary conduit selection influences these outcomes. Greater adoption of arterial grafting strategies is likely to come from high-quality evidence of benefit and safety from ongoing and future large pragmatic trials.

Optimizing Internal Mammary Artery Harvest and Preparation

The left internal mammary artery (LIMA) graft plays a pivotal role in coronary artery bypass surgery, offering unparalleled efficacy in revascularization. This review paper delves into the multifaceted considerations surrounding LIMA utilization, aiming to provide a comprehensive understanding of optimal approaches. The study encompasses the alleviation of spasm, selection of graft harvesting techniques, identification of ideal vasodilators, and exploration of optimal delivery methods. Through an analysis of extensive research spanning the past three decades, this review elucidates critical insights for cardiac surgeons and researchers alike. The review emphasizes the ubiquity of severe spasms in harvested LIMA and examines interventions to mitigate this challenge. Studies highlighting the efficacy of papaverine administration through various routes underscore the need for tailored approaches based on clinical context. The debate between skeletonized and pedicled LIMA harvests is explored, revealing the advantages and complexities associated with each technique. Findings suggest that while skeletonized grafts offer enhanced flow, the decision remains multifaceted due to potential complications. Addressing the quest for the ideal vasodilator, the review juxtaposes papaverine and sodium nitroprusside, presenting both as viable options. Despite ongoing discussions, the cost-effectiveness and accessibility of papaverine have positioned it as the favored choice among clinicians. Optimal delivery methods emerge as a crucial factor in graft success, with perivascular injection showing promise in promoting sustained and improved flow rates. The clinical implications of these findings are substantial. By integrating the evidence presented, cardiac surgeons can make informed decisions, maximizing graft patency and patient outcomes. Further, research avenues are identified, encompassing refined delivery techniques, comprehensive comparisons of vasodilators, and long-term clinical outcome evaluations. In conclusion, this review underscores the intricate considerations essential for successful LIMA utilization. By addressing spasms, selecting graft techniques, choosing vasodilators, and refining delivery methods, practitioners can tailor their strategies to the individual patient, enhancing the efficacy of coronary revascularization.

Internal Mammary Artery Graft Flow Steal by a Large Dialysis Arteriovenous Fistula Characterized by Electrical Storm

Background: Steal syndrome describes a condition in which a dilated vessel distal to a smaller artery attempts to compensate for decreased blood flow by “stealing” from the smaller artery. Steal syndrome is not uncommon and can be seen in certain physiologic and pathologic states. The classic example is an occluded atherosclerotic coronary artery resulting in a misdirection of blood flow into the open channels that have developed over time resulting in downstream ischemia. Case Report: A 66-year-old male fourteen years post 4-vessel coronary artery bypass grafting using his left internal mammary artery to bypass a stenotic segment of the left anterior descending artery, along with three saphenous venous conduits to the right coronary artery. He also had a stent placement by PCI. He was on dual antiplatelet therapy with aspirin and clopidogrel. An electrophysiology study revealed inducible VF and he underwent implantation of a dual chamber ICD 9 months prior to presentation. He experienced an unprovoked fall at home and a workup revealed the flow volume through the patient’s fistula increased to such a degree that the patient developed a steal syndrome from his left internal mammary artery graft. In addition, went into a state of electrical storm caused by ischemic damage to cardiac tissue distal to the graft. By ligating the fistula, the patient’s steal syndrome resolved and he did not suffer further ventricular arrhythmias. Conclusion: Both coronary bypass grafting and fistula formation are common and necessary interventions and providers should take care to monitor for interactions between these proposed interventions to best serve their patients without causing additional harm. Increased vascular flow through any portion of the body can induce a steal syndrome from an upstream region. Patients who undergo arteriovenous (AV) fistula placement may develop a steal syndrome from ipsilateral bypass grafts.

Transient internal mammary artery graft stenosis on early angiography: navigating pitfalls in hybrid myocardial revascularization.

Left internal mammary artery (LIMA) graft stenoses detected at early coronary angiography may be reversible and consequently prompt unnecessary graft revision. We aim to investigate the frequency, natural course, and clinical significance of internal mammary artery graft stenosis upon early angiography in patients undergoing hybrid myocardial revascularization. In this retrospective sub-study of the Coronary Hybrid Revascularization Study, we compared graft appearance, ie, stenosis degree and flow, on early (in-hospital) and scheduled follow-up coronary angiography after 1 year. We assessed the change in graft patency using the Fitzgibbon classification (grade A: unimpaired runoff; grade B > 50% stenosis; grade O: occlusion), as well as graft association with adverse events (death, myocardial infarction, stroke, and repeat revascularization) at up to 5-year follow-up. We report clinical follow-up data for all 131 patients included in the Coronary Hybrid Revascularization Study. Change in graft patency was analyzed in 86 patients with satisfactory visualization of the LIMA graft on early and follow-up coronary angiography. All LIMA grafts were patent at discharge and follow-up. Twenty-seven of 37 (73%) grade B graft stenoses at early angiography resolved to grade A during follow-up of median 12 months (range, 8-83 months) after surgery. Angiographically significant graft stenoses at early coronary angiography were not associated with adverse clinical outcome up to 5-year follow-up. Our results suggest that the majority of clinically silent LIMA graft stenoses resolve during follow-up and are not associated with adverse clinical outcomes.

From a Position of Known Angiographic Perfect Patency: What Happens Next?

The biological behaviour of coronary graft conduits over time may be considered by serial angiography. A single institution retrospective cohort received mostly clinically indicated angiography between 1997 and 2020, following coronary bypass surgery. Only perfectly patent grafts (absence of any lumen irregularity) for each conduit type at the first postoperative angiogram were selected for a later comparison. The latest angiograms were at least 5 years postoperatively, and at least 1 year after first postoperative angiogram. Analysis was done according to each graft (anastomosis). Comparisons used generalised estimating equations, adjusted for binary logistic regression. Of 143 patients, there were 410 of 468 (87.6%) perfectly patent grafts at the first angiogram, analysed at 6.8±4.0 years postoperative, of which 157 were internal mammary arteries, 228 were radial arteries, and 25 were saphenous veins. At the latest angiogram (12.2±3.8 years postoperative), comparison with the first angiogram for each individual graft found preserved perfect patency for internal mammary arteries 156 of 157 (99.4%), and for radial arteries, 227 of 228 (99.6%) but saphenous veins deteriorated considerably 13 of 25 (52.0%). The two arterial grafts (internal mammary and radial) were superior to vein grafts (odds ratio 163; 95% confidence interval [CI] 22-1,211; p<0.001), but not different from each other (odds ratio 0.95; 95% CI 0.78-1.16; p=0.584). From a position of known angiographic perfect patency post-CABG, internal mammary artery and radial artery grafts retained their perfect patency in the longer term, but saphenous vein grafts did not.

Radial artery vs right internal mammary artery as a second conduit during coronary artery bypass grafting

To compare the clinical outcomes of radial artery (RA) grafts during CABG to those of right internal mammary artery (RIMA) grafts. This was a retrospective, single-institution cohort study of isolated CABG with multiple grafts between 2010-2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:1 match ratio. Long-term postoperative survival was compared among RA and RIMA groups. Similarly, major adverse cardiac and cerebrovascular events (MACCE) were compared among both cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for mortality, while cumulative incidence estimation was utilized for MACCE. A total of 8,774 patients underwent CABG. Of those, 1,674 (19.1%) patients who underwent multi-arterial CABG were included in this analysis. 326 (19.5%) patients received RA grafts and 1,348 (80.5%) received RIMA grafts. PSM yielded a cohort of 323 RA patients and 323 RIMA patients. After matching, groups were well-balanced across all baseline variables. No significant differences were observed in immediate postoperative complications or long-term survival, with 5-year survival estimates of 89.5% for the RA group vs 90.1% for the RIMA group. There was a non-significant trend toward a higher incidence of MACCE at 5 years in the RA group compared to the RIMA group (31.3% in the RA group vs. 24.1% in the RIMA group), especially after 1-year follow-up (21.6% in the RA group vs. 15.1% in the RIMA group). Specifically, for RA patients, there were higher rates of repeat revascularization in the 5-year postoperative period (14.7% in the RA group vs. 5.3% in the RIMA group), particularly in the territory revascularized by the RA during the index operation (45.7% in the RA group vs. 10.3% in the RIMA group). Overall, RA and RIMA secondary conduits for CABG were associated with comparable immediate postoperative complications, 5-year MACCE, and 5-year survival after PSM. RA grafting was associated with significantly higher rates of repeat coronary revascularization at 5 years, specifically in the territory revascularized by the RA during the index operation.

Fifteen-year results of bilateral and unilateral internal mammary artery grafting

To evaluate the clinical effectiveness of bilateral internal mammary artery grafting over long-term (15 years) postoperative period. There were 276 patients divided into two groups: 135 patients (group A) underwent bilateral internal mammary artery grafting and 141 patients (group B) underwent unilateral internal mammary artery grafting together with venous bypass grafts. On-pump surgeries and cardioplegia, parallel CPB and on-pump procedures were performed in equal proportions. Mean age of patients was 57.3±7.6 years. Diabetes mellitus was detected in 21 (15.5%) and 24 (19.1%) patients, respectively (p>0.05). Mean LV ejection fraction was 55.4±9.9%, revascularization index - 3.1±0.8 and 3.0±0.7, respectively. In the 1st group, 43 patients underwent bilateral internal mammary artery grafting alone. Autovenous grafts were additionally used in other 84 patients. Ten-year survival exceeded 90% in both groups. Freedom from adverse cardiac events after 15 years was significantly higher in group A (77.3% vs. 59.3%, p=0.018). In group A, 16 patients died throughout this period due to cancer (50%), myocardial infarction (12.5%), stroke (18.8%) and complications of diabetes mellitus (6.3%). In group B, 22 patients died mainly from cardiac causes (myocardial infarction - 40.9%, cancer - 27.3%). Bilateral internal mammary artery grafting has obvious advantages over traditional coronary artery bypass grafting. If we take into account higher proportion of cardiac causes in structure of mortality in group B, we can talk about positive impact of bilateral internal mammary artery grafting not only on the quality of life, but also on life expectancy in long-term postoperative period.

The relationship between prognostic nutritional index and long-term mortality in patients undergoing emergency coronary artery bypass graft surgery for acute-ST elevation myocardial infarction.

Malnutrition and the prognosis of coronary artery disease (CAD) are shown to be correlated. The significance of nutritional status has been evaluated in patients with ST elevation myocardial infarction (STEMI), stable CAD, and elective coronary artery bypass graft (CABG) surgery. However, the prognostic impact of poor nutritional status on STEMI patients who underwent emergent CABG is not known. In this study, we aimed to investigate the relationship between nutritional status assessed by the prognostic nutritional index (PNI) and long-term mortality in STEMI patients who underwent emergent CABG. To the best of our knowledge, our study is the first one to evaluate the PNI effect on this specific population. 131 consecutive patients with STEMI who did not qualify for primary percutaneous coronary intervention and required emergent CABG between 2013 and 2018 were included in our study. The study population was divided into two groups: survivors and non-survivors. The PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3) for both groups, using the preoperative data. The optimal cut-off value was obtained by receiver operating characteristic (ROC) analysis. According to the cut-off value, we investigated the relationship between PNI and long-term mortality. The mean age of the study population was 57.0±10.6. During the median 92.7 (70.0-105.3)-month follow-up, 32 of the 131 patients (24.4%) died. Regression analysis showed a significant association between glucose levels (hazard ratio (HR), 1.007; 95% confidence interval (CI), 1.002-1.012; p=0.011) and PNI (HR, 0.850; 95% CI, 0.787-0.917; p<0.001) and long-term mortality. Accord-ing to the ROC analysis, the cut-off value for PNI to predict all-cause mortality was found to be 44.9, with a sensitivity of 81.3% and a specificity of 89.9%. In addition, age, ejection fraction, glomerular filtration rate, Killip classification, and left anterior descending-left internal mammary artery graft use are significantly associated with long-term all-cause mortality in STEMI patients undergoing emergency CABG. The PNI was significantly associated with long-term mortality in patients with STEMI who underwent emergent CABG. PNI can be used to improve the accuracy of the risk assessment of STEMI patients undergoing emergent CABG.

Multi-slice CT coronary angiography versus invasive coronary angiography in the assessment of graft patency after coronary artery bypasses graft surgery

BackgroundThe long-term patency of arterial and venous grafts is crucial for the success of CABG. This study was designed to investigate graft patency using 128-slice coronary computed tomography angiography (CCTA) and compared the results with those obtained using invasive coronary angiography (ICA). In this observational cross-sectional study, we included 40 symptomatic post-CABG patients underwent CCTA and ICA within the same month.ResultsFifty-five percent were aged more than 60 years, and 80% were males. 67.5% had diabetes, 90% had hypertension, and 30% were smokers. Mean body mass index was 28.89 ± 5.17 kg/m2. Mean duration since CABG was 5.25 ± 4.04 years. In total, 124 native vessels and 97 grafts were assessed using CCTA and ICA. CCTA delineated 8 non-cannulated venous grafts and 6 non-cannulated left internal mammary artery grafts. CCTA required a significantly lower radiation dose (1165.77 ± 123.54 vs. 47,589.78 ± 6967.53, p < 0.001).ConclusionCCTA can be as accurate as ICA in assessing bypass grafts with less radiation dose, providing a non-invasive reliable tool for evaluation.

Radial artery graft in coronary artery bypass surgery 1 week to 1 year postoperation.

The actual patency rate of the radial artery (RA) grafts 1 week and 1 year after coronary artery bypass grafting (CABG) has not been extensively reported on. We used coronary computed tomography angiography (CCTA) to evaluate the patency rate of RA grafts and compared it with that of saphenous vein (SV) grafts. In this observational cohort study, 80 patients who underwent urgent or elective CABG with RA and SV grafts at Ruijin Hospital from August 2019 to June 2021 were included. Follow-up CCTA scans were completed about 1 year postoperation in the out-patient clinic. We graded the grafts into four classes: A, excellent; B, graft diameter <50% of target coronary artery; O, occluded; and S, string sign. Both S and O were defined as graft failure. The patients' mean age was 58.48±8.06 years, and 87.5% (70/80) of the patients were male. The 1-week patency rate of the left internal mammary artery (LIMA), RA, and SV grafts were 98.7% (75/76), 76.3% (61/80), and 93.8% (75/80), respectively. At 1 year, the patency rate of the LIMA, RA, and SV grafts were 97.4% (74/76), 80.0% (64/80), and 81.3% (65/80), respectively. The RA graft patency rate was lower than was the SV graft patency rate perioperatively [relative risk (RR): 0.918; 95% confidence interval (CI): 0.852-0.990; P=0.007]. Moreover, 63.6% (7/11) of RA grafts graded S and 25.0% (2/8) of RA grafts graded O were defined as patent (graded A or B) at 1 year postoperation. Compared with SV grafts, more RA grafts improved (RA: 12/80, 15.0%; SV: 0%) and fewer RA grafts deteriorated (RV: 10/80, 12.5%; SV: 19/80, 23.8%) from 1 week to 1 year (P=0.001). The patency rate of the 2 types of grafts became similar at 1 year postoperation (RR: 0.560; 95% CI: 0.113-2.781; P>0.99). RA grafts had a lower patency rate than did SV grafts 1 week after operation. However, because of the "revival" phenomena and lower attrition rate, the patency rate of the two kinds of grafts did not show any significant difference at 1 year.

Thoracoscopic (non-robotic) harvesting of bilateral internal mammary artery grafts

Minimally invasive coronary surgery offers benefits to the patient. Harvesting the internal mammary artery remains a challenging part of this procedure. We describe our technique for thoracoscopic harvesting of the left and right mammary arteries using routine endoscopic instruments. This is a non-robotic technique that might facilitate a more widespread growth of minimally invasive coronary surgery.

Feasibility and accuracy of real-time 3D-holographic graft length measurements.

Mixed reality (MR) holograms can display high-definition images while preserving the user's situational awareness. New MR software can measure 3D objects with gestures and voice commands; however, these measurements have not been validated. We aimed to assess the feasibility and accuracy of using 3D holograms for measuring the length of coronary artery bypass grafts. An independent core lab analyzed follow-up computer tomography coronary angiograms performed 30 days after coronary artery bypass grafting in 30 consecutive cases enrolled in the FASTTRACK CABG trial. Two analysts, blinded to clinical information, performed holographic reconstruction and measurements using the CarnaLife Holo software (Medapp, Krakow, Poland). Inter-observer agreement was assessed in the first 20 cases. Another analyst performed the validation measurements using the CardIQ W8 CT system (GE Healthcare, Milwaukee, Wisconsin). Seventy grafts (30 left internal mammary artery grafts, 31 saphenous vein grafts, and 9 right internal mammary artery grafts) were measured. Holographic measurements were feasible in 97.1% of grafts and took 3 minutes 36 s ± 50.74 s per case. There was an excellent inter-observer agreement [interclass correlation coefficient (ICC) 0.99 (0.97-0.99)]. There was no significant difference between the total graft length on hologram and CT [187.5 mm (157.7-211.4) vs. 183.1 mm (156.8-206.1), P = 0.50], respectively. Hologram and CT measurements are highly correlated (r = 0.97, P < 0.001) with an excellent agreement [ICC 0.98 (0.97-0.99)]. Real-time holographic measurements are feasible, quick, and accurate even for tortuous bypass grafts. This new methodology can empower clinicians to visualize and measure 3D images by themselves and may provide insights for procedural strategy.

Feasibility and accuracy of real-time 3D-holographic graft length measurement, a sub-study of the FAST-TRACK CABG trial

Abstract Background 3D Hologram is an emerging tool for intuitively manipulating and visualizing CT images. Mixed reality (MR) technology can display high-definition 3D holograms while preserving situational awareness. The new MR software offers the possibility to measure 3D objects using hand gestures and voice commands. However, these measurements made on 3D holograms have not been validated. Purpose We aimed to assess the feasibility and accuracy of using CT-derived 3D holograms for bypass graft length measurement. Methods Twenty-seven consecutive cases in the FAST TRACK CABG trial were included. The post-operative CT images performed at 30 days follow-up were analyzed in an independent core lab. Two analysts blinded to clinical information performed Holographic reconstruction and measurement using the CanaLife Holo software (Medapp, Krakow, Poland). (Figure 1) Inter-observer agreement was assessed in the first 20 cases. Another analyst with full access to clinical information performed the validation measurements on the CardIQ W8 system (GE Healthcare, Milwaukee, Wisconsin). (Figure 1) Results A total of 62 grafts (27 left internal mammary artery grafts, 27 saphenous vein grafts, and 8 right internal mammary artery grafts) were measured. There was an excellent inter-observer agreement between the analysts in the first 47 grafts analyzed (interclass correlation 0.9879 [0.9783-0.9933]). (Figure 2A, 2B) On average, holographic reconstruction and measurement of a case took 3 minutes and 36 seconds± 50.74 seconds compared to around 10 minutes per vessel on the traditional CT system. There was no significant difference between the graft length measured by hologram and CT (188.59±51.63 mm vs. 183.95±50.93 mm, p=0.616). The length measured by hologram and CT were similar across different graft types. The measurements of hologram and CT are highly correlated (r=0.973, p &amp;lt;0.001) with an excellent agreement (interclass correlation 0.9928 [0.9880-0.9957]). (Figure2C, 2D) Conclusion Holographic vessel length measurement is feasible, fast, and accurate even for tortuous coronary bypass grafts. This new methodology can empower surgeons to visualize and measure the results of their work by themselves and may provide insights for procedure evaluation. 3D Holograms can eventually empower surgeons to plan the precise length of the arterial and venous grafts to be harvested for every individual case.

Abstract 18926: Skeletonization Mitigates Risk of Deep Sternal Wound Infection in Patients With Diabetes Undergoing CABG With Bilateral Internal Mammary Arterial Grafting

Background Bilateral internal mammary artery (BIMA) grafting may provide benefits compared to single artery coronary artery bypass grafting (CABG). However, many surgeons cite deep sternal wound infections (DSWI) as a deterrent for use of BIMA in patients with diabetes (DM). Aim To evaluate the effect of DM and skeletonization on the incidence of DSWI in patients with BIMA grafting. Hypothesis Skeletonization reduces risk of DSWI in DM patients with BIMA. Methods A retrospective analysis from 11 hospitals in the Maryland Cardiac Surgery Quality Initiative was performed. Of 27,930 adult non-emergent CABGs between 2017 and 2022, 2,010 patients (7%) received BIMA grafting among whom 764 (38%) had DM. Effect of DM and skeletonization of ≥ 1 IMA on DSWI in BIMA patients was evaluated by chi-square analyses and multivariable logistic regressions adjusting for DSWI-specific STS risk score. Results There was no significant difference in preoperative glycosylated hemoglobin (HgbA1c) level for DM patients with and without BIMA (7.2 [6.5-8.4] vs 7.2 [6.5-8.5], P=0.842. BMI was significantly higher in DM vs non-DM patients (30 [27 - 33] vs 28 [25 - 31], respectively, P&lt;0.001]. Skeletonization of ≥ 1 IMA in DM patients reduced DSWI vs. no skeletonization (0.3% vs 4.1%, respectively, P=0.023) but did not alter DSWI in non-DM patients (0.4% vs 1.2%, P=0.280). In patients with skeletonization of ≥1 IMA, there was no difference in DSWI between patients with and without DM (0.3% vs 0.4%, respectively, P&gt;0.999; Figure 1). After adjusting the DSWI-specific STS risk scores, skeletonization remained independently associated with reduced DSWI risk in DM patients with BIMA (OR=0.09, P =0.044). Conclusions Skeletonization of ≥1 IMA was associated with lower risk of DSWI in BIMA patients with DM. This supports the use of BIMA with skeletonization in patients with DM barring other prohibitive risk factors, and may encourage its increased usage in skeptical surgeons.

Nationwide Trends and Outcomes for Coronary Artery Bypass Grafting in End-Stage Kidney Disease and Stable Coronary Artery Disease

Patients with end-stage kidney disease (ESKD) on dialysis have an increased burden of coronary artery disease (CAD). This study assessed the trend and outcomes for coronary artery bypass surgery (CABG) in patients with ESKD and stable CAD. We conducted a longitudinal study using the United States Renal Data System of patients with ESKD and stable CAD who underwent CABG from the years 2009 to 2017. The outcomes included in-hospital, long-term mortality, and repeat revascularization. The follow-up was until death, end of Medicare AB coverage, or December 31, 2018. A total of 11,952 patients were identified. The mean age was 62.8years, 68% were male, and 67% were white. The common co-morbidities included hypertension (97%), diabetes mellitus (75%), and congestive heart failure (53%). A significant decrease in CABG procedures from 2.9 to 1.3 procedures per 1,000 patients with ESKD (p <0.001) was noted during the years studied. The overall in-hospital mortality rate was 5.9%, and there was a significant decrease over the study period (p=0.01). Although the 30-day mortality rate was 6.9% and remained steady (p=0.14), the 1-year mortality rate was 22.8% and decreased significantly (p <0.001). At 5years, the overall survival rate was 35%, and patients with internal mammary artery grafts showed better survival than those without (36% vs 25%). In conclusion, there has been a decrease in CABG procedures performed in patients with ESKD with stable CAD with decreasing in-hospital and 1-year mortality. Those with an internal mammary artery graft do better, but the overall long-term survival remains dismal in this population. There remains need for caution and individualization of revascularization decisions in this high-risk population.

Effect of skeletonisation and pedicled bilateral internal mammary artery grafting in coronary artery bypass surgery on post-operative wound infection: A meta-analysis.

The results showed that different internal thoracic artery (ITA) was associated with the rate of postoperative wound infection and the severity of pain following coronary artery bypass grafting (CABG). In order to ascertain if there was any genuine difference in the rate of postoperative infection and severity of the pain, we conducted a meta-analysis to evaluate if there was any actual difference in the wound complication that had been identified with the ITA method. Through EMBASE, Cochrane Library and Pubmed, and so forth, we systematically reviewed the results by August 2023, which compared the impact of skeletonised versus pedicled internal mammary artery (IMA) on wound complications following CABG. The trial data have been pooled and analysed in order to determine if a randomisation or fixed-effect model should be applied. The meta-analysis of data was performed with Revman 5.3 software. The results of this meta-study included 252 related articles from four main databases, and nine articles were chosen to be extracted and analysed. A total of 3320 patients were treated with coronary artery transplantation. Based on current data analysis, we have shown that the rate of postoperative wound infections is reduced by the use of the skeletonised internal mammary artery (SIMA) (OR, 1.84; 95% CI, 1.13, 3.01; p = 0.01). But the results showed that there were no statistically significant differences in the post-operation pain score of the patients (MD, 0.09; 95% CI, -0.58, 0.76; p = 0.79). Furthermore, the duration of the operation was not significantly different between the SIMA and pedicled internal mammary artery (PIMA) (MD, 3.30; 95% CI, -3.13, 9.73; p = 0.31). Overall, the SIMA decreased the rate of postoperative wound infection in CABG patients than the PIMA.

Total arterial revascularization using robot assisted minimally invasive coronary artery bypass: an Indian experience.

The aim of this study is to analyze the early outcomes of Total Arterial Revascularization using Robot Assisted Minimally Invasive Coronary Artery Bypass at our center between June 2019 and January 2023. This is a retrospective analysis of 195 patients who underwent Total Arterial Coronary Revascularization through Robot Assisted Minimally Invasive Coronary Artery Bypass procedure (RA-CABG) during the period of June 2019 and January 2023 in a quaternary care center in India. Primary outcome variables were in-hospital and 30-day mortality. Secondary outcome variables included duration of surgery, length of intensive care unit (ICU) stay, in-hospital stay and perioperative morbidity. The entire patient population was divided into two groups for a subgroup analysis based on when the surgery was conducted i.e. the years since the robotic program was begun at our institution with 81 patients in group I (2019-2021), and 114 patients in group II (2022-2023). 195 patients [88.7% male, mean age of 61.34 ± 9.58years] underwent RA-CABG during the 5-year period (2019-2023) by a single experienced surgeon and his team. Conversion to larger thoracic incisions was required in 5 cases (2.59%). In-hospital and 30-day mortality was 1.02% each. The average length of ICU stay and hospital stay were 2.82 ± 1.17days and 5.84 ± 1.71days respectively. The duration of ICU stay correlated with the number of internal mammary artery grafts procured (p = 0.0022). Median duration of follow-up was 11months. Overall mortality was 3.62% and cardiac related mortality was 2.07%, and 5 patients (2.59%) underwent percutaneous coronary intervention. Results of the sub-group analysis revealed a statistically significant difference between the groups in terms of number of internal mammary artery grafts procured (p = 0.010), need for transfusions (p = 0.00031), ICU stay (p = 0.0005) and in-hospital stay (p = 0.0006). Total Arterial Coronary Revascularization through RA-CABG is a viable procedure in select patients. An experienced surgeon and team are required. Further studies in the form of randomized trials with long term follow-up are required to establish the overall utility, effectiveness and benefits to the patients.