Reoperative Coronary Artery Bypass Research Articles

Acute Occlusion of a “Protected” Left Main Coronary Artery Manifesting as an Acute Coronary Syndrome with Heart Failure: How much Protected it is?

Despite the progress made in technological advancements, the utilization of stenting for both protected and unprotected left main coronary artery (LMCA) disease remains associated with elevated rates of long-term mortality and significant adverse clinical events, sometimes manifesting as cardiogenic shock. A considerable number of individuals retain the opportunity to receive catheter-based interventional therapy as a viable substitute for re-operative coronary artery bypass grafting (CABG). Despite the changed appearance, patients with acute blockage of the protected LMCA still have major adverse cardiac events (MACE) at a similar rate. Acute occlusion of the unprotected LMCA as an acute coronary syndrome (ACS) is uncommon, but that of the protected LMCA is relatively rare. We present a case of a post-CABG patient who developed ACS as a posterior wall myocardial infarction and acute left ventricular failure due to obstruction of a protected LMCA with substantial stenosis across its distal segment extending to the left circumflex (LCx) artery. The pharmaco-invasive management of the protected LMCA thrombotic occlusion with primary percutaneous coronary intervention resulted in significant patient improvement. These lesions are amenable to complex and high-risk coronary intervention with current technology, and the results have been quite encouraging in terms of long-term survival.

Early cardiac contractility outcome of reoperative coronary artery bypass grafting using right gastroepiploic artery.

Reoperative coronary artery bypass grafting (redo CABG) still carries higher mortality and increased morbidity compared with primary CABG. In this study, we retrospectively reviewed our operative outcome of redo CABG to evaluate the impact of the left anterolateral thoracotomy approach using the right gastroepiploic artery (RGEA). Between 1994 and 2020, 11 patients (mean age 60.3 ± 13.1 years; nine men, two women) underwent isolated redo CABG using the RGEA via the left anterolateral thoracotomy. The mean duration from the initial CABG was 128.3 ± 88.4 months. Redo CABG was performed because of graft occlusion in six patients (54.5%), graft stenosis in one patient (9.1%), and progressive disease of previously ungrafted vessels in four patients (36.4%). The total number of bypasses using RGEA (including Y-composite vein grafts) was 16 (four left anterior descending branches, two diagonal branches, five circumflex branches, five right coronary arteries). No residual graft injury, major comorbidity, or in-hospital death was observed. Changes in echocardiographic values before and after redo CABG were 210.9 ± 48.2 ml and 175.0 ± 41.4 ml in left ventricular end-diastolic volume, 130.2 ± 49.2 ml and 94.4 ± 33.0 ml in left ventricular end-systolic volume, and 45.6 ± 11.0% and 52.2 ± 10.7% in left ventricular ejection fraction, respectively. These parameters significantly improved after redo CABG. Redo CABG with RGEA grafting via the left anterolateral thoracotomy approach is a safe and effective surgical procedure especially in improving cardiac contractility in patients who required revascularization.

Expanding the armamentarium for reoperative coronary artery bypass grafting.

Expanding the armamentarium for reoperative coronary artery bypass graftingShort title : Expanding the armamentarium for redo CABGMaria Currie, MD PhD11 Department of Cardiothoracic Surgery, Stanford University School of Medicine

Analysis of direct results of reoperative coronary artery bypass surgery

Aim. To compare the immediate results of treatment of patients after redo coronary artery bypass grafting (reCABG) off pump and with cardiopulmonary bypass.Methods. The retrospective study included 138 patients who underwent isolated reCABG for recurrence of angina pectoris in the period of 2013 to 2019 at the Almazov Research Centre. The operation was performed with cardiopulmonary bypass using isothermal blood cardioplegia in 74 cases (group A). Sixty-four operations were performed without cardiopulmonary bypass (group B). The primary endpoint was a major adverse cardiovascular event (e.g. myocardial infarction, acute cerebrovascular accident, cardiovascular death) during hospitalisation. Secondary endpoints were cardiovascular failure, respiratory failure, renal failure, and wound healing complications during hospitalisation.Results. Redo CABG with cardiopulmonary bypass compared with CABG off pump was more often complicated by cardiovascular failure (39.2% versus 20.3%, p = 0.043), respiratory failure (7.8% versus 2.7%, p = 0.047), and postpericardiotomy syndrome (13.5% versus 0%, p = 0.047). The revascularisation index was higher in the group of reCABG off pump (2.9) compared to the group of reCABG with cardiopulmonary bypass (2.4). In the early postoperative period there was a decrease in the duration of inpatient treatment and stay in the intensive care unit, the duration of surgery, as well as a lower incidence of postoperative complications in group B.Conclusion. Redo CABG showed satisfactory results in the early postoperative period. Performing reCABG off pump was advantageous and was associated with a decrease in the incidence of postoperative complications. Received 23 June 2020. Revised 9 September 2020. Accepted 10 September 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributions Conception and design: I.K. Ismail-zade, V.K. GrebennikData collection and analysis: I.K. Ismail-zade, D.G. Zavarzina, N.R. AbutalimovaDrafting the article: I.K. Ismail-zade, I.Yu. Ivanov, G.I. IshmukhametovCritical revision of the article: V.K. Grebennik, M.l. GordeevFinal approval of the version to be published: M.L. Gordeev, V.K. Grebennik, I.K. Ismail-zade, G.I. Ishmukhametov, I.Yu. Ivanov, N.R. Abutalimova, D.G. Zavarzina

Trends in Reoperative Coronary Artery Bypass Graft Surgery for Older Adults in the United States, 1998 to 2017.

BackgroundThe likelihood of undergoing reoperative coronary artery bypass graft surgery (CABG) is important for older patients who are considering first‐time CABG. Trends in the reoperative CABG for these patients are unknown.Methods and ResultsWe used the Medicare fee‐for‐service inpatient claims data of adults undergoing isolated first‐time CABG between 1998 and 2017. The primary outcome was time to first reoperative CABG within 5 years of discharge from the index surgery, treating death as a competing risk. We fitted a Cox regression to model the likelihood of reoperative CABG as a function of patient baseline characteristics. There were 1 666 875 unique patients undergoing first‐time isolated CABG and surviving to hospital discharge. The median (interquartile range) age of patients did not change significantly over time (from 74 [69–78] in 1998 to 73 [69–78] in 2017); the proportion of women decreased from 34.8% to 26.1%. The 5‐year rate of reoperative CABG declined from 0.77% (95% CI, 0.72%–0.82%) in 1998 to 0.23% (95% CI, 0.19%–0.28%) in 2013. The annual proportional decline in the 5‐year rate of reoperative CABG overall was 6.6% (95% CI, 6.0%–7.1%) nationwide, which did not differ across subgroups, except the non‐white non‐black race group that had an annual decline of 8.5% (95% CI, 6.2%–10.7%).ConclusionsOver a recent 20‐year period, the Medicare fee‐for‐service patients experienced a significant decline in the rate of reoperative CABG. In this cohort of older adults, the rate of declining differed across demographic subgroups.

Long-term Outcomes After Reoperative Coronary Artery Bypass Grafting

Reoperative coronary artery bypass grafting (CABG) surgery has an established increasedoperative risk with worse perioperative morbidity and mortality. However, contemporary propensity-matched outcomes are limited in the existing literature. All patients who underwent CABG from 2011 to 2017 at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania were included. Propensity matching yielded risk-adjusted patient populations. Cox regression analysis was performed to identify independent predictors of 30-day, 1-year, and 5-year mortality and readmission. The total population consisted of 7615 patients who underwent CABG; 7265 of these patients had first-time CABG, and 350 patients had reoperative CABG. After propensity score matching, blood product transfusion (45.5% vs 56.4%; P= .002) and delayed sternal closure (0.2% vs 2.5%; P < .001) remained significantly higher for reoperative CABG. There was no difference in 30-day (5.3% vs 7.5%; P= .19) or 1-year (12.1% vs 14.8%; P= .23) mortality for first-time vs reoperative CABG. Five-year mortality was significantly higher for the reoperative cohort (28.5% vs 38.3%; P= .03). There was no difference in 30-day, 1-year, or 5-year hospital readmissions. On Cox multivariable regression analysis, reoperative CABG was not a predictor of mortality or readmission at 30 days, 1 year, or 5 years. After propensity score matching, there was no difference in postoperative mortality or readmission for reoperative CABG up to 1-year. This trend continued for 5-year readmissions; however, 5-year mortality was higher for the reoperative cohort. Risk adjustment did not identify reoperative CABG as a risk factor for long-term mortality.

Risk Factors and Outcomes in Redo Coronary Artery Bypass Grafting

Reoperative coronary artery bypass grafting (redo-CABG) has declined during the last decade, while use of percutaneous coronary intervention (PCI) has increased. The aim of this retrospective study was to evaluate risk factors, in-hospital mortality, and long-term survival between first-time CABG and redo-CABG. From January 2009 to December 2015, 2,581 patients underwent first-time CABG procedures while 132 underwent isolated redo-CABG. Logistic regression was used to identify risk factors predictive of redo-CABG and after propensity matching the in-hospital morbidity and long-term all-cause mortality were compared. Risk factors for redo-CABG were prior PCI, dyslipidaemia, diabetes and hypertension. After propensity matching there were no significant differences between the redo-CABG (n = 126) and first-time CABG groups (n = 232) in baseline characteristics. The adjusted in-hospital mortality was 3.1% for redo-CABG and 2.1% for first-time CABG (p = 0.55). Redo-CABG required significantly more intraoperative red blood cells (p = 0.03), platelets (p < 0.001), cryoprecipitate (p < 0.007) and fresh frozen plasma (p < 0.001) than first-time CABG. There was no significant difference in reoperation for bleeding (p = 0.72), prolonged ventilation (p = 0.98), postoperative stroke (p = 0.92) or dialysis (p = 0.44). The survival at 1, 3 and 5 years for redo-CABG was 93.5%, 90%, and 85% respectively, and 95.5%, 94.5%, 93% for first-time CABG, respectively (p = 0.2). Prior PCI after first time CABG and the risk factors for atherosclerotic disease are predictive for redo-CABG. An increased use of blood products is required during redo-CABG. After propensity matching, in-hospital mortality and long-term survival for redo-CABG is comparable to first-time operation. Re-sternotomy does not impact the survival in redo-CABG.

Reoperative Coronary Artery Bypass Grafting: Review of Changing Pattern and Outcomes

Reoperative Coronary Artery Bypass Grafting: Review of Changing Pattern and Outcomes

Re-operative Coronary Artery Bypass Grafting: A Review of Changing Pattern and Outcomes

Re-operative coronary artery bypass grafting (CABG) prevalence had markedly changed over the last decades. This change had been also noticed in patients’ risk profile and outcomes. The aim of this review is to highlight large multi- and single-center studies investigating the change in pattern, techniques, and outcomes of re-operative CABG globally. It is meant to be a reference that can help cardiac surgeons for a better understanding of our current situation with this challenging operation.

Changing trends of reoperative coronary artery bypass grafting: A 16 year study

Changing trends of reoperative coronary artery bypass grafting: A 16 year study

Does off-pump coronary revascularization confer superior organ protection in re-operative coronary artery surgery? A meta-analysis of observational studies.

Off-pump coronary artery bypass surgery (OPCAB) has been hypothesised to be beneficial in the high-risk patient population undergoing re-operative coronary artery bypass graft surgery (CABG). In addition, this technique has been demonstrated to provide subtle benefits in end-organ function including heart, lungs and kidney. The aims of this study were to assess whether OPCAB is associated with a lower incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and other adverse outcomes in re-operative coronary surgery. Twelve studies, incorporating 3471 patients were identified by systematic literature review. These were meta-analysed using random-effects modelling. Primary endpoints were MACCE and other adverse outcomes including myocardial infarction, stroke, renal dysfunction, low cardiac output state, respiratory failure and atrial fibrillation. A significantly lower incidence of myocardial infarction, stroke, renal dysfunction, low cardiac output state, respiratory failure and atrial fibrillation was observed with OPCAB (OR 0.58; 95% CI (confidence interval) [0.39-0.87]; OR 0.37; 95% CI [0.17-0.79]; OR 0.39; 95% CI [0.24-0.63]; OR 0.14; 95% CI [0.04-0.56]; OR 0.36; 95% CI [0.24-0.54]; OR 0.41; 95% CI [0.22-0.77] respectively). Sub-group analysis using sample size, matching score and quality score was consistent with and reflected these significant findings. Off-pump coronary artery bypass grafting reduces peri-operative and short-term major adverse outcomes in patients undergoing re-operative surgery. Consequently we conclude that OPCAB provides superior organ protection and a safer outcome profile in re-operative CABG.

Multiple Left Internal Mammary Artery-to-Pulmonary Artery Fistulae 15 Years after Coronary Artery Bypass Grafting

Left internal mammary artery (LIMA)-to-pulmonary artery fistulae rarely develop after coronary artery bypass grafting. Fewer than 30 cases of these fistulae have been reported since 1947. Nevertheless, this entity should be considered as a cause of recurrent angina after bypass surgery, in the absence of other causes. We present the case of a 67-year-old man with cardiac symptoms in whom multiple LIMA-to-pulmonary artery fistulae were found, 15 years after he had undergone coronary artery bypass grafting. The diagnosis was confirmed by means of coronary angiography with selective catheterization of the LIMA and by computed tomographic angiography of the heart. The patient underwent reoperative 2-vessel coronary artery bypass grafting and ligation of multiple fistulae; 16 months postoperatively, he was asymptomatic and doing well. In addition to reporting this case, we discuss relevant diagnostic and treatment considerations.

Improved Short-Term Outcomes with Off-Pump Reoperative Coronary Artery Bypass Grafting

Reoperative coronary surgery patients are usually sicker and older, and the procedure is more technically demanding. Comparisons between coronary surgery with (coronary artery bypass [CAB] surgery on cardiopulmonary bypass [CPB]) and without (off-pump CAB [OPCAB]) the pump have been conducted; however, few studies showed results in reoperative cases. We investigate the potential superiority of one technique over the other in redo coronary surgeries. Our institutional Society of Thoracic Surgery database was used to gather the data for 266 isolated reoperative coronary artery surgeries from January 2004 to July 2011. These were divided into the CAB surgery in CPB group (n = 204) and the OPCAB group (n = 62). Baseline characteristics of the two groups were similar, except for a significantly higher prevalence of cerebrovascular disease among the off-pump group (P = 0.01). There was also a trend toward fewer vessels bypassed among the same group (P = 0.07). Risk adjustment was done using multivariable analyses for detection of independent effects. The use of CPB was an independent predictor of increased rates of postoperative events (odds ratio, 3.9; P = 0.004) and atrial fibrillation (odds ratio, 5.9; P < 0.005) and longer intensive care unit (0.006) and hospital stay (0.004). Redo OPCAB seems to offer favorable short-term outcomes compared with redo CAB. Our results suggest a reduced rate of overall postoperative events, decreased new postoperative atrial fibrillation, reduced hours stayed in the intensive care unit, and fewer days stayed from surgery to discharge. This was not associated with an increase in morbidity and mortality. A randomized study with a larger number of patients and with a longer follow-up is needed.

Improved Short-Term Outcomes with Off-Pump Reoperative Coronary Artery Bypass Grafting

Improved Short-Term Outcomes with Off-Pump Reoperative Coronary Artery Bypass Grafting

Does off-pump coronary revascularization reduce mortality in re-operative coronary artery surgery? A meta-analysis of observational studies

Re-operative coronary artery bypass grafting (CABG) is a challenging operation that is often performed in a high-risk patient group. Avoiding cardiopulmonary bypass (CPB) in these patients is hypothesised to be advantageous due to the reduced invasiveness and physiological stress of off-pump coronary artery bypass grafting (OPCAB). The aims of this study were to assess whether OPCAB may improve outcomes in patients undergoing re-operative CABG. Twelve studies, incorporating 3471 patients, were identified by systematic literature review. These were meta-analysed using random-effects modelling. Primary endpoints were 30-day and mid-term mortality. Secondary endpoints were completeness of revascularization, mean number of grafts per patient and the effect of intra-operative conversion on mortality. A significantly lower rate of 30-day mortality was observed with OPCAB (OR 0.51, 95% CI [0.35, 0.74]), however, no difference was demonstrated in mid-term mortality. Significantly less complete revascularization and mean number of grafts per patient were observed in the OPCAB group. Meta-regression revealed no change in 30-day mortality when the effect of conversion from one technique to the other was assessed. Off-pump techniques may reduce early mortality in selected patients undergoing re-operative CABG; however, this does not persist into mid-term follow-up. OPCAB may also lead to intra-operative conversion and, although this did not affect outcomes in this study, these results are constrained by the limited data available. Furthermore, OPCAB may increase target vessel revascularization and, consequently, incomplete revascularization which, whilst not reflected in the short-term outcomes, requires longer-term follow-up in order to be fully assessed.

Twenty-five-year outcomes after multiple internal thoracic artery bypass

Coronary artery bypass grafting with multiple internal thoracic artery grafts is currently controversial. This study assessed single institutional outcomes with multiple internal thoracic artery grafting for guidance with future clinical decisions. In 19,482 patients undergoing multivessel coronary artery bypass grafting (1984-2009), baseline characteristics were recorded in a prospective databank, and follow-up was obtained by questionnaires, phone contact, or National Death Index. Outcomes examined were subsequent myocardial infarction, percutaneous coronary intervention, reoperative coronary artery bypass grafting, all-cause death, and a composite of the 4. Three groups were defined: (1) no internal thoracic artery graft (1874/19,482 or 9%); (2) single internal thoracic artery grafts and adjunctive venous conduits (single internal thoracic artery; 16,881/19,482 or 87%); and (3) multiple internal thoracic artery grafts (728/19,482 or 4%). Multivariable Cox modeling adjusted for differences in baseline characteristics, and comparisons were performed using area under the curve analysis. Differences in baseline characteristics for the no internal thoracic artery graft, single internal thoracic artery, and multiple internal thoracic artery groups were as follows: median age 66, 64, and 59 years, respectively; congestive heart failure 22%, 18%, and 13%, respectively; ejection fraction 0.50, 0.52, and 0.51, respectively; reoperation 10%, 3%, and 7%, respectively; diabetes 27%, 30%, and 15%, respectively; and female gender 33%, 28%, and 20%, respectively. No differences existed in the median number of diseased vessels (3, 3, and 3, respectively) or number of grafts per patient (3, 3, and 3, respectively). Composite outcome improved with increasing internal thoracic artery grafts, whether assessing unadjusted or risk-adjusted data. Compared with no internal thoracic artery graft, the adjusted hazard ratio was 0.79 (confidence interval, 0.74-0.83) for single internal thoracic artery grafting and 0.70 (confidence interval, 0.62-0.80) for multiple internal thoracic artery grafting (both P < .001), reducing risk by 21% and 30%, respectively. This study confirms improved patient outcomes with multiple internal thoracic artery grafting, achieving half again as much benefit as single internal thoracic artery grafting alone. The data suggest that increasing application of multiple internal thoracic artery grafting should be encouraged to mitigate the inherent risks and costs of long-term cardiac events.

Evolving trends of reoperative coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

The present study evaluated the evolving trends and outcomes of patients undergoing isolated reoperative coronary artery bypass grafting at Society of Thoracic Surgeons Adult Cardiac Surgery Database-participating institutions. From 2000 to 2009, 72,431 patients underwent isolated reoperative coronary artery bypass grafting and 1,497,254 patients underwent isolated primary coronary artery bypass grafting at Society of Thoracic Surgeons-participating institutions. The demographics, operative characteristics, and risk-adjusted postoperative outcomes were assessed and compared during the study period. As a percentage of overall coronary artery bypass grafting volume, reoperative coronary artery bypass grafting decreased from 6.0% (8820/137,267) in 2000 to 3.4% (5734/160,997) in 2009. The unadjusted operative mortality declined from 6.1% (542/8820) in 2000 to 4.6% (261/5734) in 2009 (P < .05). Patients now more frequently present with left main disease (35.1% vs 25.7%; P < .05), myocardial infarction (60.9% vs 55.9%; P < .001), and heart failure (18.4% vs 14.2%; P < .001). Patients also now present more frequently for urgent or emergent surgery (51.6% vs 39%; P < .001) and after previous percutaneous coronary intervention (51% vs 35%; P < .001). They also have a greater incidence of other comorbidities such as increased weight (88 vs 84 kg; P < .001), diabetes (42.5% vs 31.7%; P < .001), hypertension (90.9% vs 73.4%; P < .001), hypercholesterolemia (90.9% vs 73.4%; P < .001), renal failure (2.2% vs 0.7%; P < .001), and cerebrovascular disease (12.4% vs 8.5%; P < .001). Risk-adjusted mortality decreased from 6.0% to 4.6%, a relative risk reduction of 23.7% (P < .001). Risk-adjusted postoperative stroke decreased from 1.9% to 1.6% (P < .001). Surgical coronary revascularization has evolved during the past decade, with reoperative coronary artery bypass grafting now uncommonly performed in contemporary practice. Despite treating patients with more complex coronary artery disease and greater medical comorbidities, significant improvements have occurred in operative morbidity and mortality in this challenging population.

Reoperative coronary artery bypass grafting

Reoperative coronary artery bypass grafting (redo CABG) operation is associated with a high rate of mortality up to 11.4%. It has been estimated that 10-20% of patients with history of coronary artery bypass grafting (CABG) operation need redo CABG operation within 10 years. Due to high operation risk percutaneous coronary interventions have emerged as the preferred treatment for the patients with a history of CABG operation and presenting with acute coronary syndrome. Here, we reported percutaneous coronary intervention in a patient needed redo CABG operation.

Reoperative Coronary Artery Bypass Surgery: The Role of On-Pump and Off-Pump Techniques on Factors Affecting Hospital Mortality and Morbidity

Short term results of on-pump and off-pump techniques in patients undergoing reoperative coronary artery bypass grafting (redo CABG) were investigated in this study. A total of 14.430 patients have undergone isolated coronary artery bypass grafting in our clinic from 1998 to 2010. Of these patients, 105 patients who have undergone redo CABG, 53 (50.5%) were operated with cardiopulmonary bypass (on-pump) and 52 (49.5%) without cardiopulmonary bypass (off-pump). Early results for which on or off-pump techniques were independent risk factors were determined with logistic regression analysis. Overall mortality in patients undergoing redo CABG was 12.3% with a 11.5% mortality in the off-pump group and 13.2% mortality in the on-pump group and the difference was not statistically significant (p >0.05). Blood product transfusion requirement (p <0.05, OR: 3.620, 95% CI: 1.295-10.119), new onset atrial fibrillation rhythm (AFR) (p <0.05, OR: 13.357, 95% CI: 1.656-107.721), prolonged ventilation (p <0.05, OR: 9.066, 95% CI: 1.091-75.323) and duration of hospitalization (p <0.01, OR: 5.252, 95% CI: 1.784-15.459) were significantly higher in the on-pump group. The number of patients with postoperative low cardiac output was significantly higher in the off-pump group (p <0.05, OR: 5.337, 95% CI: 1.094-26.043). The ratio of complete bypass was significantly higher in the on-pump group compared to the off-pump group (p <0.05, OR: 2.913, 95% CI: 1.204-7.046). Despite the lower morbidity and mortality in the off-pump group, the rate of target vessel bypass grafting was lower. Off-pump technique may be considered as a safer option for cardiopulmonary bypass in the high risk population.

Value of Internal Thoracic Artery Grafting to the Left Anterior Descending Coronary Artery at Coronary Reoperation

The study sought to determine if left internal thoracic artery (LITA) grafting of the left anterior descending (LAD) at reoperative coronary artery bypass grafting (CABG) improves patient outcomes. LITA grafting to the LAD is the gold standard for primary CABG, but its value for reoperative CABG is unknown. From January 1985 to January 2007, reoperative CABG was performed in 3,473 patients who did not receive a LITA during their primary CABG and whose anterior myocardium (LAD) was at risk at reoperation: 2,389 had LITA grafting and 1,084 saphenous vein (SV) grafting to the LAD. Propensity matching (908 matched pairs) was used for balanced comparison of outcomes. Follow-up was continued to 20 years post-operatively, with a mean follow-up of 11 ± 8.2 years. Unadjusted hospital mortality was 2.2% and 6.5% in the LITA and SV groups, respectively (p < 0.001), but 3.1% and 5.6% in propensity-matched groups (p = 0.008). Unadjusted survival at 1, 5, 10, 15, and 20 years was 94%, 82%, 64%, 46%, and 32% for the LITA group, but 88%, 73%, 50%, 32%, and 18% for the SV group (p <.0001), respectively. For propensity-matched groups, both early (p = 0.01) and late survival was greater (p = 0.005) in the LITA group. At 20 years, LITA grafting of the LAD at reoperation resulted in an absolute mortality risk reduction of 6.0% and a hazard ratio of 0.85, with number needed to treat of 16 patients. LITA-to-LAD grafting at reoperation is safe and confers a risk-adjusted survival advantage. When appropriate, a LITA should be used to revascularize the LAD at coronary reoperations.