Single Internal Thoracic Artery Group Research Articles

Comparison of early postoperative left ventricular function with 3d ef and strain measurements according to graft selection

BackgroundGraft choices other than left anterior descending artery (LAD)–internal thoracic artery (ITA) anastomosis in coronary artery bypass grafting (CABG) surgery are still controversial. Although 2-dimensional transthoracic echocardiography (2D TTE) is still the most commonly used method, more is needed to diagnose myocardial dysfunction. Ventricular strain values obtained by speckle tracking echocardiography (STE) or tissue Doppler imaging (TDI) methods can much better detect subclinical changes. This study aims to detect early postoperative myocardial function changes compared to single ITA/Bilateral Internal Thoracic Artery (BITA) use by measuring 3-dimensional ejection fraction (3D EF) and ventricular strain values and comparing them according to graft preference.MethodsThe study included 35 isolated CABG patients. All patients underwent on-pump CABG via sternotomy. The patients were divided into two groups using single ITA and BITA. Preoperative and postoperative 1st-week 3D EF and ventricular strain values of the patients were calculated using semi-automatic software. The recorded data were compared and evaluated between the two groups.ResultsOf The 35 patients participating in the study, 74.3% (n = 26) were male, 25.7% (n = 9) were female, and their average age was 62.7 ± 7.9 years. Preoperative 3D EF values of the patients were 54.4 ± 8.3% and postoperative 49.5 ± 8.2%. The mean preoperative Apical Long Axis Longitudinal Strain (APLAX LS) was calculated as − 16.2 ± 5.0%, 4 Chambers Longitudinal Strain (4CH LS)–16.8 ± 4.6%, 2 Chambers Longitudinal Strain (2CH LS) − 17.0 ± 4.9%, and Global Longitudinal Ventricular Strain (GLVS) − 16.7 ± 4.2%. Postoperative strain values were measured as − 15.1 ± 4.8%, − 14.7 ± 4.9%, − 14.6 ± 5.6% and − 14.8 ± 4.6%, respectively. When the groups were evaluated within themselves, the mean preoperative 3D EF of the patients in the single ITA group was 52.5 ± 8.8%, while the postoperative mean was 47.7 ± 6.0%. In the BITA group, preoperative 3D EF was 56.3 ± 7.5 and postoperative 51.4 ± 9.8. A decrease in strain values was detected in all groups except APLAX planes.ConclusionsIn our study, no statistically significant difference was observed in terms of myocardial function changes according to the use of ITA/BITA. However, the decline in postoperative strain values of patients in the BITA group was more remarkable, and it was thought that this may be due to prolonged aortic cross clamp (CC) and cardiopulmonary bypass (CPB) times.

Efficacy of atrial fibrillation predictors including MVP ECG risk score compared between single or bilateral internal thoracic artery use

BackgroundAtrial fibrillation (AF) is the most common complication after Coronary Artery Bypass Surgery (CABG). Despite advanced treatment methods, primary prevention is crucial. Many factors have been investigated as markers for AF, but further research is required.CABG is currently superior to Primary Coronary Intervention (PCI) in some cases due to Left Anterior Descending Artery (LAD)- Internal Thoracic Artery (ITA) anastomosis. However, graft choice for non-LAD vessels is still controversial. Our study compared the incidence of arrhythmia between patients with single ITA or bilateral ITA (BITA).MethodsThe study included 84 isolated CABG patients. The patients were divided into two groups: single ITA and BITA. Patients who developed AF were recorded and compared.Results73.8%(n = 62) of the patients were male and 26.2%(n = 22) were female. While single ITA was used in 48.8%(n = 41) of the patients, BITA was used in 51.2%(n = 43). AF was detected in 15.5%(n = 13) of the patients. AF was observed in 5(12.2%) patients in the single ITA group and 8(18.6%) in the BITA group. 76.9%(n = 10) of the patients with AF rhythm had Diabetes Mellitus (DM)(p = 0.011). Biphasic P wave, length of P wave duration, and total Morpholog-Voltage-P Wave ECG (MVP ECG) score height were statistically significantly different.ConclusionsThe development of AF was similar in both groups. The presence of DM, high blood glucose levels, and ECG findings can detect a predisposition to postoperative AF. MVP ECG risk score is effective as an AF marker and can be used in surgical patient groups.

Bilateral versus single internal thoracic coronary artery bypass grafting: the ART RCT

Background There is debate whether the use of more arterial grafts during coronary artery bypass graft surgery provides advantages to the standard operation using the left internal thoracic artery plus vein grafts. We review data from the Arterial Revascularisation Trial to determine whether there is support for the multiple arterial graft hypothesis. Methods Patients undergoing coronary artery bypass graft for clinical reasons and who provided written informed consent were randomised to standard coronary artery bypass graft using the single internal thoracic artery or use of bilateral internal thoracic arteries. Additional vein grafts could be used. The primary outcome was all-cause mortality at 10 years and exploratory analyses were carried out to test the multiple arterial graft hypothesis. Results A total of 3102 patients were enrolled (1548 bilateral internal thoracic artery and 1554 single internal thoracic artery). Follow-up to 10 years for vital status was 98% complete. In the bilateral group, 14% of patients received a single internal thoracic artery only and use of radial artery grafts occurred in about 20% of patients in both groups. Aspirin was used in 81% of the patients, beta-blockers in 74%, statins in 90% and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 73%. At 10 years, death rates were 20.3% and 21.2% in the bilateral internal thoracic artery and single internal thoracic artery groups, respectively (hazard ratio 0.96, 95% confidence intervals 0.82 to 1.12; p = 0.62) and composite of all-cause mortality, myocardial infarction or stroke 24.9% and 27.3%, respectively (hazard ratio 0.90, 95% confidence interval 0.79 to 1.03; p = 0.12). Exploratory analyses using the ‘as-treated’ approach indicate that outcomes were better in patients who received multiple arterial grafts (adding the right internal thoracic and/or radial arteries) compared with a single arterial graft. This effect appeared to be greater in patients with diabetes and those aged 70 years or less. Use of total arterial grafting without vein grafts may provide the best outcomes. Limitations The elevated cross-over rate between bilateral internal thoracic artery and single internal thoracic artery and the non-randomised use of radial artery grafts may have contributed to a loss of power to detect a difference in mortality between the two groups. Moreover, secondary analyses are prone to bias as they compare non-randomised groups. Conclusions The Arterial Revascularisation Trial is one of the largest long-term studies in cardiac surgery. The primary analysis did not show a mortality benefit for bilateral internal thoracic artery at 10 years, perhaps due to high crossover rates in the bilateral internal thoracic artery group and concomitant use of the radial artery. Secondary analyses suggest a mortality benefit for patients receiving multiple arterial grafts compared with single arterial graft with possible greater effects in patients with diabetes and separately in patients aged 70 years or above. The trial will follow patients to 15 years and the continuing Randomized Comparison of the Clinical Outcome of Single versus Multiple Arterial Grafts trial will further test the multiple arterial graft hypothesis. Trial registration This trial is registered as ISRCTN46552265. Funding This project was funded by the British Heart Foundation, the UK. Medical Research Council and the National Institute for Health and Care Research (NIHR) Efficacy and Mechanism Evaluation programme and will be published in full in Efficacy and Mechanism Evaluation; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

Aortic Valve Replacement and Concomitant Multi-Vessel Coronary Artery Bypass: The Impact of Using the Bilateral Internal Thoracic Arteries on Early and Late Clinical Outcomes.

The survival benefit of coronary artery bypass grafting (CABG) using the bilateral internal thoracic arteries (BITA) is well known; however, the role of BITA in concomitant aortic valve replacement (AVR) and CABG has not been studied. We retrospectively reviewed patients who underwent concomitant AVR and CABG. Cases not using an internal thoracic artery and less than 2 bypass grafts were excluded. We enrolled 114 patients in this study. The mean follow-up duration was 61.5±43.5 months. Forty patients (35.1%) underwent CABG with a single internal thoracic artery (SITA) and 74 patients (64.9%) underwent CABG with BITA. The preoperative clinical characteristics were not significantly different between the 2 groups, with the exception of a higher prevalence of atrial fibrillation in the SITA group. Postoperative mortality and morbidity were not significantly higher in the BITA group than in the SITA group. In the univariable analysis, the survival of the BITA group was similar to that of the SITA group (p=0.157). Multivariable analysis showed that only mean age was a predictor of death (p=0.042), but using BITA was not an independent predictor (p=0.094). In low-risk patients whose preoperative ejection fraction was >45%, the survival of the BITA group was significantly better than that of the SITA group (p=0.043). BITA use in concomitant AVR and CABG showed no difference in mortality compared to using SITA. Although its impact on long-term survival was inconclusive, BITA use can be considered for low-risk patients.

Bilateral internal thoracic artery coronary grafting: risks and benefits in elderly patients.

Whether bilateral internal thoracic artery (BITA) grafting benefits elderly patients in coronary artery bypass grafting (CABG) remains unclear since they tend to have a limited life expectancy and severe comorbidities. We aim to evaluate the outcomes of BITA vs. single internal thoracic artery (SITA) grafting in elderly patients. A meta-analysis was performed by database searching until May 2021. Studies comparing BITA and SITA grafting among elderly patients were included. One randomized controlled trial, nine propensity score matching, and six unmatched studies were identified, with a total of 18146 patients (7422 received BITA grafting and 10724 received SITA grafting). Compared with SITA grafting, BITA grafting had a higher risk of deep sternal wound infection (DSWI) [odds ratio: 1.67; 95% confidence interval (CI): 1.22-2.28], and this risk could not be significantly reduced by the skeletonization technique. Meanwhile, BITA grafting was associated with a higher long-term survival [hazard ratio: 0.83; 95% CI: 0.77-0.90], except for the octogenarian subgroup. Reconstructed Kaplan-Meier survival curves revealed 4-year, 8-year, and 12-year overall survival rates of 85.5%, 66.7%, and 45.3%, respectively, in the BITA group and 79.3%, 58.6%, and 34.9%, respectively, in the SITA group. No significant difference was observed in early mortality, perioperative myocardial infarction, perioperative cerebral vascular accidents, or re-exploration for bleeding. Compared with SITA grafting, BITA grafting could provide a long-term survival benefit for elderly patients, although this benefit remained uncertain in octogenarians. Meanwhile, elderly patients who received BITA were associated with a higher risk of DSWI and such a risk could not be eliminated by the skeletonization technique.

Bilateral internal thoracic artery grafting in haemodialysis patients with diabetic nephropathy.

To compare postoperative outcomes in patients with diabetic nephropathy receiving haemodialysis and undergoing isolated coronary artery bypass grafting (CABG) using bilateral or single skeletonized internal thoracic artery (ITA). Among 1441 consecutive patients undergoing isolated CABG between 2002 and 2019 at our university hospital, we retrospectively analysed data for 107 patients with diabetic nephropathy receiving haemodialysis. After inverse probability of treatment weighting, we found no statistically significant differences regarding patients' preoperative characteristics. All patients underwent myocardial revascularization using the off-pump technique. There was no statistical significance in postoperative deep sternal wound infection (P = 0.902) and 30-day mortality (P = 0.755). However, the bilateral ITA group had a lower rate of postoperative stroke versus the single group (0% vs 5.5%, respectively; P = 0.021). Follow-up was completed in 95.3% (102/107) of the patients, and the mean follow-up duration was 3.3 years. Thirty-eight deaths occurred in the bilateral ITA group and 18 in the single ITA group. There was no significant difference in all-cause death (P = 0.558) and cardiac death rates (P = 0.727). Multivariable Cox regression models showed that the independent predictors of all-cause death were age [hazard ratio (HR) 1.031; P = 0.010], previous percutaneous intervention (HR 1.757; P = 0.009) and gastroepiploic artery grafting (HR 0.582; P = 0.026). Bilateral ITA grafting in patients with diabetic nephropathy receiving haemodialysis did not improve mid-term outcomes.

Single versus bilateral internal thoracic artery grafting in patients with low ejection fraction.

Coronary artery bypass grafting (CABG) is the standard of care for the treatment of complex coronary artery disease. However, the optimal surgical treatment for patients with reduced left ventricular function with low ejection fraction (EF) is inconclusive. In our center, left-sided coronary grafting with bilateral internal thoracic artery (BITA) is generally the preferred method for surgical revascularization, also for patients with low EF. We compared early and long-term outcomes between BITA grafting and single internal thoracic artery (SITA) grafting in patients with low EF.We evaluated short- and long-term outcomes of all patients who underwent surgical revascularization in our center during 1996 to 2011, according to EF ≥30% and <30%. Univariate and multivariate analyses were performed. In addition, patients who underwent BITA and SITA grafting were matched using propensity score matching.In total, 5337 patients with multivessel disease underwent surgical revascularization during the study period. Of them, 394 had low EF. Among these, 188 underwent SITA revascularization and 206 BITA grafting. Those who underwent SITA were more likely to have comorbidities such as chronic obstructive pulmonary disease, diabetes, congestive heart failure, chronic renal failure, and a critical preoperative condition including preoperative intra-aortic balloon pump insertion.Statistically significant differences were not observed between the SITA and BITA groups in 30-day mortality (8.5% vs 6.8%, P = .55), sternal wound infection (2.7% vs 1.0%, P = .27), stroke (3.7% vs 6.3%, P = .24), and perioperative myocardial infarction (5.9% vs 2.9%, P = .15). Long-term survival (median follow up of 14 years, interquartile range, 11.2–18.9) was also similar between the groups. Propensity score matching (129 matched pairs) yielded similar early and long-term outcomes for the groups.This study did not demonstrate any clinical benefit for BITA compared with SITA revascularization in individuals with low EF.

Bilateral internal thoracic artery grafting in elderly patients: Any benefit in survival?

The purpose of the present study was to compare survival outcomes in propensity score-matched patients aged 70years or greater receiving a bilateral internal thoracic artery graft with patients receiving a single internal thoracic artery graft. Among 4083 consecutive patients with isolated coronary artery bypass grafting who underwent operation between January 2001 and December 2018, we identified 1300 patients aged 70years or greater; of these, 968 received a bilateral internal thoracic artery (bilateral internal thoracic artery group) and 332 received a single internal thoracic artery (single internal thoracic artery group). Propensity score matching was used to reduce the preoperative patient differences. The 10-year survival and postoperative complications were compared between the 2 groups. A Kaplan-Meier curve at 10years of follow-up showed that crude survival was significantly superior in patients with bilateral internal thoracic artery grafts than in patients with single internal thoracic artery grafts (67.0%±2.5% vs 56.0%±3.4%, respectively; P<.016). In the actuarial survival, estimates for propensity score-matched patients with a bilateral internal thoracic artery showed a significantly higher rates of survival than patients with a single internal thoracic artery by the end of follow-up (66.0%±5.3% vs 53.0%±3.9%, respectively; hazard ratio, 0.64; 95% confidence interval, 0.44-0.94; P=.022, univariable Cox Model and multivariable analysis hazard ratio, 0.66; 95% confidence interval, 0.45-0.97; P=.036 Cox model). Postoperative complications were all similar between the single internal thoracic artery and bilateral internal thoracic artery groups. The use of bilateral internal thoracic artery grafting in older patients improves 10-year survival, with similar postoperative morbidity. This surgical technique might have beneficial effects in survival in patients aged more than 70years. Its use could be considered more frequently.

Is the Use of BITA vs SITA Grafting Safe and Beneficial in Octogenarians?

Bilateral internal thoracic artery (BITA) grafting is questionable in octogenarians because of shorter life expectancy and increased risk of perioperative complications. The aim of this study was to examine the safety and effectiveness of performing BITA and single internal thoracic artery (SITA) grafts in patients older than 80 years of age. This study compared outcomes in 201 consecutive octogenarians who underwent isolated BITA grafting with those of 280 consecutive octogenarians who underwent SITA and saphenous vein grafting during 1996 to 2011. Insulin-dependent diabetes, ejection fraction <30, and emergency operations were more common among patients who underwent SITA, and the prevalence of left main coronary artery disease was lower. Propensity score matching was used to control for these differences, thus generating well-matched groups of 190 patients each. There were no significant differences in early mortality between the unmatched groups: 3.2% in the BITA group and 8.6% in the SITA group (P= .12). Rates of sternal wound infection were also similar, 1.5% vs 1.7%, respectively. Differences were not observed in the occurrences of perioperative stroke (3.5% vs 2.5%; P= .999) and myocardial infarction (1.5% vs 3.6%; P= .166). The results were similar for the matched groups. Long-term survival between the unmatched groups and survival between the matched groups were not significantly different. This study shows equal long-term survival for BITA and SITA grafting in octogenarians. BITA is an acceptable alternative to SITA grafting in low-risk octogenarians and in the presence of a calcified aorta or poor-quality saphenous vein graft.

Bilateral internal thoracic artery grafting in patients with left main disease: a single-center experience.

We compared early and long-term outcomes between bilateral internal thoracic artery (BITA) grafting and single internal thoracic artery (SITA) grafting in patients with LM disease. We evaluated the outcomes of all patients with LM disease who underwent revascularization in our center during 1996-2011. Variables that were adjusted for in a multivariate analysis and in propensity matching included age, sex, comorbid diseases, repeat operation, the number of diseased vessels, other conduits used, the use of sequential grafting, the number of grafts constructed, and the operative era (1996-2000 vs. 2001-2011). In total, 949 patients with LM disease underwent BITA grafting and 564 underwent SITA grafting during the study period. SITA patients were more often female and more likely to have comorbidities such as chronic obstructive pulmonary disease, ejection fraction <30%, recent myocardial infarction, diabetes, congestive heart failure, chronic renal failure, and peripheral vascular disease, and to have undergone an emergency operation. We found no statistically significant difference between the SITA and BITA groups in 30-day mortality (4.8% vs. 3.3%, P = 0.136), sternal wound infection (2.0% vs. 2.4%, P = 0.548), and stroke (3.2% vs. 4.4%, P = 0.234). BITA patients had improved long-term survival (70.1% vs. 52.0% p<0.001), median follow-up of 15 years. In multivariate analysis, after propensity score matching (477 matched pairs), this finding was not statistically significant (P = 0.135). This study did not demonstrate a clear benefit of BITA grafts among patients with LM disease.

Quality of life in patients after coronary artery bypass grafting with bilateral internal thoracic artery versus single internal thoracic artery.

IntroductionThe left internal thoracic artery to the left anterior descending artery graft is recognized as the gold standard for coronary revascularization. We compared quality of life (QoL) in patients who received bilateral internal thoracic arteries (BITA) and those with a single internal thoracic artery (SITA) graft.AimTo assess QoL during a 10-year follow-up in patients who underwent coronary artery bypass grafting (CABG) with BITA vs. SITA.Material and methodsWe recruited 300 patients with multivessel coronary artery disease who underwent CABG from January 2005 to October 2010. Mean duration (standard deviation – SD) of follow-up was 3568 ±409 days. QoL was measured subjectively using a Likert scale and objectively by the WHOQOL-BREF questionnaire. Patients were interviewed by telephone.ResultsBITA patients reported marked improvement and improvement more often than SITA patients (58% vs. 43.3%, p = 0.02). Marked deterioration was noted by 2% of BITA patients and 3.3% of SITA patients (p = 0.03). Summarized results of the WHOQOL-BREF questionnaire showed significantly better QoL in the BITA group (median: 15.0) vs. SITA group (median: 14.75) (p = 0.02). There were more angina-free patients in the BITA group (84%) compared to SITA patients (72.7%) (p = 0.006). QoL did not correlate with patients’ body mass index (p = 0.10) or residence status (p = 0.51), but there was a weak negative correlation between QoL and patients’ age (r = –0.14, p = 0.01).ConclusionsSurgical coronary revascularization using BITA improves QoL, particularly when measured by a Likert scale.

Bilateral versus single internal thoracic artery grafting in hemodialysis patients.

The use of the bilateral internal thoracic arteries (BITAs) during myocardial revascularization reportedly provides a survival benefit over using a single internal thoracic artery (SITA). However, the advantages in chronic hemodialysis patients, who generally have multiple comorbidities, is unclear. Outcomes of chronic hemodialysis patients who underwent isolated coronary artery bypass grafting (CABG) using a SITA with additional saphenous vein grafts (SVGs) (n = 33) or BITAs (n = 30) for left-side revascularization were retrospectively reviewed. With the exception of the rate of diabetes mellitus (SITA vs. BITA: 84.8% vs. 50.0%; p = 0.003), the two groups showed similar patient characteristics. Using the off-pump technique, revascularization was completed without manipulation of the ascending aorta in 45.7% of patients in the BITA group, whereas all patients in the SITA group required aortic manipulation (p < 0.001). Of note, the incidence of extensive aortic calcification (>50% of ascending aorta circumference) was not uncommon (14.3%). The in-hospital mortality (3.0% vs. 0%, p = 0.336) and complication rates (including deep wound infection, re-exploration and stroke) were similar in both groups. The 5-year estimated survival rates for freedom from overall death in the SITA and BITA groups were 42.4% and. 57.4%, respectively (p = 0.202). BITA grafting was able to achieve revascularization with minimal manipulation of the diseased ascending aorta without increasing the complication rate. The long-term survival benefit of BITA grafting, however, was unclear in dialysis patients, especially because such patients have a relatively short life expectancy.

Bilateral internal thoracic artery versus single internal thoracic artery: a meta-analysis of propensity score-matched observational studies.

The lack of benefit in terms of mid-term survival and the increase in the risk of sternal wound complications published in a recent randomized controlled trial have raised concerns about the use of bilateral internal thoracic artery (BITA) in myocardial revascularization surgery. For this reason, we decided to explore the current evidence available on the subject by carrying out a meta-analysis of propensity score-matched studies comparing BITA versus single internal thoracic artery (SITA). PubMed, EMBASE and Google Scholar were searched for propensity score-matched studies comparing BITA versus SITA. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The DerSimonian and Laird method was used to compute the combined risk ratio of 30-day mortality, deep sternal wound infection and reoperation for bleeding. Forty-five BITA versus SITA matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival in favour of the BITA group [HR 0.78; 95% confidence interval (CI) 0.71-0.86]. These results were consistent with those obtained by a pooled analysis of the matched populations comprising patients with diabetes (HR 0.65; 95% CI 0.43-0.99). When compared with the use of SITA plus radial artery, BITA did not show any significant benefit in terms of long-term survival (HR 0.86; 95% CI 0.69-1.07). No differences between BITA and SITA groups were detected in terms of 30-day mortality or in terms of reoperation for bleeding. Compared with the SITA group, patients in the BITA group had a significantly higher risk of deep sternal wound infection (risk ratio 1.66; 95% CI 1.41-1.95) even when the pooled analysis was limited to matched populations in which BITA was harvested according to the skeletonization technique (risk ratio 1.37; 95% CI 1.04-1.79). The use of BITA provided a long-term survival benefit compared with the use of SITA at the expense of a higher risk of sternal deep wound infection. The long-term survival advantage of BITA is undetectable when compared with SITA plus radial artery.

Does bilateral versus single thoracic artery grafting provide survival benefit in female patients?

Bilateral internal thoracic artery (BITA) grafting is associated with improved survival, but this technique is reluctantly used in women due to an increased risk of sternal wound infection. The aim of this study was to compare the long-term survival of women who underwent BITA grafting and single internal thoracic artery (SITA) grafting. We performed a retrospective analysis of 556 consecutive female BITA patients and 685 female SITA patients. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic lung disease, chronic renal failure, peripheral vascular disease and cerebral vascular disease). Operative mortality showed a trend towards a benefit for BITA (2.9% vs 5.0% for SITA, P = 0.06). The sternal wound infection rates were similar (3.4% vs 2.9%, P = 0.6); however, the occurrence of stroke was significantly lower in the SITA group (3.4% vs 1.2%, P = 0.007). The median survival of the BITA group was significantly better {13.8 years [95% confidence interval (CI) 12.8-14.9] vs 10.3 years [95% CI 9.6-11.1], P = 0.001}. After propensity score matching (491 pairs), the assignment to BITA was not associated with increased early mortality or complication rates, and the choice of BITA grafting was associated with better survival [14.5 years (95% CI 13.3-15.6) vs 11.8 years (95% CI 10.7-12.9)]. Only the choice of conduits was associated with increased late mortality (multivariable analysis, hazard ratio 1.28, 95% CI 1.024-1.591; P = 0.03). The low early mortality and complication rate, and the long-term survival benefit of BITA compared to SITA grafting, support the use of BITA grafting in women.

Bilateral Internal Thoracic Artery Grafts in Hemodialysis: A Single-Center Propensity Score Analysis

Clinical evidence comparing the surgical risk and long-term effectiveness of the bilateral internal thoracic artery (BITA) and single internal thoracic artery (SITA) for coronary artery bypass grafting (CABG) in hemodialysis patients is limited. We sought to clarify the short-term and midterm outcomes of CABG using BITA or SITA grafts in hemodialysis patients. Between October 2000 and December 2015, 161 hemodialysis patients underwent isolated CABG by internal thoracic artery grafting; 67 received BITA grafts and 94 SITA grafts. Propensity score matching was used to compare 59 BITA and SITA patient pairs. BITA and SITA grafts resulted in comparable 30-day mortality (1.7% vs 0%, p= 1.00), incidence of deep sternal wound infection (5.1% vs 1.7%, p= 0.62), stroke (3.4% vs 3.4%, p= 1.00), and respiratory failure (8.5% vs 11.9%, p= 0.75). The Kaplan-Meier model showed the survival rate in the BITA and SITA groups was 83.4% ± 5.1% vs 87.0% ± 4.6% at 1 year, 69.1% ± 7.3% vs 68.5% ± 6.9% at 3 years, and 47.4% ± 10.45% vs 58.2% ±8.1% at 5 years of follow-up, respectively. There were no statistical differences in survival (p= 0.81), freedom from cardiac death (p= 0.51), or freedom from cardiac events (p= 0.85). CABG using BITA grafts showed no advantages in midterm outcome among hemodialysis patients; however, there were no adverse effects on perioperative morbidity or death. For hemodialysis patients with limited available conduits, BITA may be an important option for multivessel revascularization.

Perioperative outcomes of off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries under direct vision†.

We previously introduced techniques to harvest and use the right internal thoracic artery in minimally invasive coronary artery bypass grafting (CABG) via a single left thoracotomy for revascularization with bilateral internal thoracic arteries (BITA). We report our short-term outcomes of patients who underwent minimally invasive CABG using BITA and a single internal thoracic artery (SITA). Consecutive patients who underwent minimally invasive CABG using BITA or SITA at a Japanese medical center between February 2012 and December 2015 were reviewed retrospectively. Preoperative, intraoperative and 30-day postoperative outcomes were analysed. Perioperative data for the SITA cohort is presented to provide a context in which the outcomes of the BITA cohort can be evaluated. A total of 25 and 37 patients underwent BITA and SITA revascularization, respectively. The mean duration of the operation was longer in the BITA group than in the SITA group (265 ± 104 vs 336 ± 73 min). There were no deaths in the BITA group and one death in the SITA group. There were no strokes in either cohort, and new haemodialysis was required in one patient in each group. All BITA grafts were harvested without major complications and were all patent on computed tomography angiograms 1 week following the operations. BITA can be safely harvested in a reproducible manner under direct vision via a small left thoracotomy. The potential advantages of minimally invasive CABG using BITA, although yet to be established, include a long-term survival benefit conferred by BITA grafts and elimination of the risk of sternal wound infection, in addition to the established advantages of minimally invasive coronary artery surgery. This approach has the potential for further optimization with hybrid revascularization strategies.

One or Two Internal Thoracic Grafts? Long-Term Follow-Up of 957 Off-Pump Coronary Bypass Surgeries

The potential survival benefit of bilateral internal thoracic artery (BITA) grafting in patients undergoing off-pump coronary artery bypass graft surgery (OPCABG) is controversial owing to the technical complexity of these operations. Our objective was to compare the outcome of patients undergoing OPCABG with BITA to the outcome of patients undergoing OPCABG with a single internal thoracic artery (SITA) and saphenous vein grafts or radial artery. Five hundred and thirty-five consecutive patients who underwent OPCABG BITA at our institute between 2000 and 2008 were compared with 422 patients who underwent OPCABG with SITA. Propensity score matching was used to account for differences between groups in preoperative characteristics. Being female (20.9% versus 36.0%, p < 0.001), having diabetes mellitus (36.6% versus 55.7%, p > 0.001), recent myocardial infarction (23.6% versus 33.2%, p>0.001), aged 70 years or more (41.1% versus 49.8%, p=0.001), peripheral vascular disease (26.1% versus 46.7%, p > 0.001), and chronic renal failure (7.9% versus 15.9%, p > 0.001) were less frequent in the BITA group than in the SITA group, respectively. The European System for Cardiac Operative Risk Evaluation score was significantly higher for the SITA group (7.62, versus 5.46 for BITA group, p= 0.001), whereas operative mortality (1.7% BITA versus 2.6% SITA) and sternal wound infections (1.7% BITA versus 2.1% SITA) were similar. The mean follow-up was 11.6 ± 3.5 years. The BITA patients' 10-year survival (Kaplan-Meier) was better (72.2% versus 55.1% for SITA, p> 0.001). However, after propensity matching, survival for BITA and SITA were similar. This large cohort study suggests that long-term outcomes for patients undergoing OPCABG are not better with BITA grafting.

Abstract 520: Should Bilateral Internal Thoracic Artery Grafting be Used in Patients with Peripheral Vascular Disease?

Background: The potential survival benefit of Bilateral Internal Thoracic Artery (BITA) compared to Single Internal Thoracic Artery (SITA) grafting in peripheral or cerebral vascular disease (PVD) patients is questionable, due to their short life expectancy and increased risk of sternal wound infection. Methods: Six hundreds and four Patients with PVD who underwent BITA grafting between 1996 and 2010 were compared with 478 PVD patients who underwent SITA grafting. Results: Patients undergoing SITA were older, more often female, more likely to have chronic obstructive lung disease, EF&lt;30% ,Diabetes, renal insufficiency, congestive heart failure and emergency operation. Euroscore of SITA patients was significantly higher(10.1 ±3.1vs. 8.1± 3.3 %,p&lt;0.001) Operative mortality (4.4% vs. 5.0% in BITA and SITA)and sternal wound infections (4.4% vs. 3.6%) were not significantly different between groups. Median follow-up was 9.50 (95%CI 8.83-10.16) years. Ten-year survival (Kaplan-Meier ) of the SITA and BITA groups were not significantly different (45.1±4.7% vs. 50.1±3.4%, P =0.736, Log Rank test) and assignment to the BITA group was not associated with better propensity-adjusted survival (HR 1.050, 95% CI: 0.875-1.261, P =0.600) ( Stratified COX model. ) Conclusions: This study shows. that, early and long-term outcomes of BITA grafting in patients with PVD are not better than those of SITA grafting. Early mortality from non-cardiac causes ,reduces the influence of the type of conduit used(BITA or SITA) on survival. Selective use of BITA in lower-risk PVD patients might un-mask the benefits of BITA grafting

Abstract 19433: Should Bilateral Internal Thoracic Artery Grafting be Used in Patients After Recent MI?

Introduction: Bilateral internal thoracic artery(ITA) grafting is associated with improved survival. However, many surgeons are reluctant to use this revascularization technique in patients after myocardial infarction (MI) due to the risk of sternal infection and the excellent survival benefit obtained with single ITA (SITA). Hypothesis: Long-term outcome of bilateral ITA (BITA) grafting, might be superior to single ITA and other conduits such as saphenous veins (SVG) and radial artery (RA) in patients with multi-vessels disease after recent MI. Methods: 871 patients who underwent BITA grafting after recent MI (&lt;3 months prior to surgery), between 1996 and 2010, Were compared with 527 who underwent CABG with SITA and SVG or RA. Results: Patients undergoing SITA were older, more often female, more likely to have COPD, EF&lt;30%, preoperative critical state, Diabetes, chronic renal failure (CRF), peripheral vascular disease (PVD) and emergency operation. In contrast, patients undergoing BITA grafting were more likely to have triple vessel disease and more often underwent CABG with three or more grafts and sequential grafts. Operative mortality of BITA patients was lower (3.0 % vs. 5.7%, in the SITA group p=0.01), Occurrences of sternal wound infection (3% vs 2%) and strokes (2.6% vs. 3%) were similar. Mean follow-up was 11.8 (95%CI 10.95-12.56) years. Kaplan Meier survival of BITA patients was better (70.3% vs.52.6% p&lt;0.001). Propensity score matching was used to account for differences between groups in preoperative characteristics. The 293 matched pairs thus created had similar preoperative characteristics. Kaplan Meier 10 year survival (67.3% versus 59%, p=0.325 log-rank test), and the Cox adjusted survival of the matched groups did not reach statistical significance (HR 1.57, p=0.091). However, survival of non- emergent BITA patients was better (HR 1.256 p=0.038). Age, COPD, CHF, CRF, PVD and left main were independent predictors of decreased survival. Off-pump operations were associated with improved survival (Cox model) Conclusions: This study suggests that long-term outcome of arterial revascularization with BITA can be better than that of SITA in non-emergency cases after recent MI with proper patient selection

Double versus single internal thoracic artery in coronary artery bypass grafting: role in sterna wound healing

Objective To investigate the effect of double versus single internal thoracic artery on sterna wound healing in coronary artery bypass grafting (CABG). Methods Patients undergoing CABG were randomly divided into experimental group (double internal thoracic artery group) and control group (single internal thoracic artery group) according to the number of internal thoracic artery used in operations. Experimental group: skeletonized double internal mammary arteries were harvested in all 50 cases (37 males and 13 females). Control group: skeletonized left internal mammary artery was harvested in all 50 cases (34 males and 16 females). Sterna wound healing and post-operational complications were observed. Results The incidence of poor sterna wound healing and volume of drainage after operation in the experimental group were more than those in the control group [volume of drainage on the first day: (350.67±56.86)ml vs (240.72±48.35)ml; total volume of drainage: (595.65±102.35)ml vs (398.85±75.84)ml; poor sterna wound healing rate: 20% vs 0; P<0.05 or P<0.01]. The sterna wound healing rate of high-risk patients between two groups had significant difference (8 cases vs 0 case, P<0.05). Conclusions Compared to the single internal mammary artery grafting, the double internal mammary artery grafting increased the risk of sternal wound healing. Key words: Coronary artery bypass/MT; Mammary arteries/SU; Sternum/IN/SU; Fracture healing