Single Internal Thoracic Artery 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.

Long term follow-up of bilateral internal thoracic artery use in young coronary artery bypass grafting patients: 29 year single surgeon experience.

Improved long term survival has demonstrated by grafting left internal thoracic artery (LITA) to the left anterior descending artery (LAD). This study investigated the prognostic benefits of BITA versus single LITA with common anastomotic configurations of BITA. Elective patients age below 60years, undertaken by a single surgeon, between 1992 and 2014 were explored. Cox regression models were fitted to investigate prognostic benefits of BITA. Specific comparisons were made with BITA subgroups who received LITA to LAD or RITA to LAD to establish long-term prognostic difference with the use of the RITA to LAD as compared to the LITA to LAD anastomosis. Comparisons were made with other BITA configurations to establish long-term difference in survival as a result of the actual targets bypassed with BITA grafts. Both groups had similar baseline patient characteristics. Following risk adjustment, the use of a second ITA conferred a significant 48% reduction in long-term mortality to BITA group [HR 0.52 (95%CI: 0.36-0.74) p < .001]. The use of the RITA to LAD, instead of LITA, resulted in no difference in the long-term prognostic benefit. The targets grafted with second ITA conferred a significant prognostic benefit for common configurations it was used in for bypass surgery. The use of BITA confers long term prognostic benefit to patients. Grafting RITA to LAD instead of more common LITA to LAD made no difference in long term prognosis when compared to CABG patients with single ITA. The use of a second ITA conduit in common configurations for CABG confers prognostic benefits irrespective of distal target grafted.

How to Use a Right Internal Thoracic Artery Graft in On- and Off-Pump Coronary Artery Bypass Grafting

In coronary artery bypass grafting, internal thoracic artery grafts and other arterial grafts have shown superior results compared with saphenous vein grafts. The right internal thoracic artery (RITA) has been reported as one of these various arterial graft options. However, there are some limitations and concerns associated with using the RITA. This review presents the current topics and scientific evidence on the use of RITA grafts in coronary artery bypass grafting. The reviewed papers mainly focus on the operative results of using the RITA, graft configurations and target vessels, and the comparison between on- or off-pump coronary artery bypass procedure. The results of these studies suggest the followings. The method of using the RITA (either in situ or as a free graft) should be selected based on the need to reach crucial targets and the number of required target vessels. A free RITA graft anastomosed to the aorta with modified proximal anastomosis allows for the revascularization of multiple vessels with acceptable flow characteristics. For revascularization of the right coronary artery system with low-grade proximal stenosis, the RITA should not be used. The decision to use cardiopulmonary bypass depends on the patient's condition, target vessels, as well as the experience of institution. Skeletonized harvesting is more effective in preventing sternal wound infections in coronary artery bypass grafting using bilateral internal thoracic arteries compared with using a single internal thoracic artery.

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.

A decade of robotic beating-heart totally endoscopic coronary bypass (TECAB) at a single institution: Outcomes with 10-year follow-up

ObjectiveRobotic beating-heart totally endoscopic coronary bypass (TECAB) is performed using single or bilateral internal thoracic arteries with good results. Despite slow adoption and limited industry support, we have evolved our practice and continue to routinely perform TECAB. We describe our series of 874 patients undergoing robotic beating-heart TECAB with up to 10-year follow-up. MethodsA retrospective review of all patients (n = 874) undergoing robotic beating-heart TECAB (July 2013 to April 2024) was performed. Patients were contacted for midterm follow-up, and angiographic data were collected in those undergoing hybrid revascularization. Multivariate regression analysis and Cox proportional hazard modeling were used to analyze risk factors for early/midterm outcomes. Primary end points were midterm all-cause mortality and major adverse cardiac/cerebrovascular events. ResultsMean Society of Thoracic Surgeons score was 1.5 ± 2.2%. In total, 470 (54%) underwent multivessel TECAB, of whom 86% received bilateral internal thoracic arteries. There was 1 intraoperative conversion (0.11%). Mean length of stay was 2.3 ± 0.8 days. Hospital mortality was 0.80% (observed/expected 0.54). A total of 393 patients (45%) underwent hybrid revascularization. Early graft patency was 97% (left internal thoracic artery-left anterior descending artery patency 98%). Midterm follow-up was 100% at mean 48 months (longest 10.6 years). Cardiac-related mortality and all-cause mortality were 2.2% and 18%, respectively. Freedom from major adverse cardiac/cerebrovascular events was 93%. In multivariate analysis, left-main disease ≥70% was a risk factor for midterm cardiac mortality (odds ratio, 6.7; confidence interval, 1.9-24, P = .003). ConclusionsIn this series of 874 patients with up to 10-year follow-up, we show that robotic TECAB can be performed with excellent early and midterm results using an iterative approach, despite significant challenges. Further industry support and wider surgeon adoption are necessary to ensure sustainability of this procedure.

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

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

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

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

EARLY RESULTS OF MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING

Abstract Coronary artery bypass grafting (CABG) is the benchmark in elective revascularization for Coronary Artery Disease (CAD), particularly for complex or multivessel CAD, left main coronary involvement, diabetes, or impaired heart function. Traditional CABG, via median sternotomy using cardiopulmonary bypass (CPB), has limitations like CPB–related morbidity and sternal complications. Alternatives like Minimally Invasive Cardiac Surgery (MICS CABG) and Hybrid Revascularization (HR) aim to address these drawbacks. We present a series of 215 consecutive patients (mean age 67±9 years, 27.9% females, EuroSCORE II 1.5±1.3%) between 2017–2023 who underwent elective minimally invasive surgical revascularization. Among the cohort, 164 (76.3%) had Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) via anterolateral left mini–thoracotomy (ALMT) at the fifth intercostal space (IS), with 140 (85.4%) receiving a single left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and 24 (14.6%) an additional distal anastomosis. Thirty–four (20.7%) had HR via percutaneous coronary intervention (PCI) on the right coronary artery (RCA). Of the total cohort, 35/215 patients (16.3%) underwent multivessel MICS CABG via ALMT, with mean 2.3±0.5 distal anastomoses using LITA, right ITA, radial artery, or saphenous vein. Heart manipulation was via a subxiphoid device. Four MICS CABG patients (11.4%) had HR. More than half of MICS CABG cases were performed with planned peripheral CPB, without cross–clamping the Aorta. Of the total cohort, 16/215 patients (7.4%) received MICS CABG in an endoscopic fashion, using 3D thoracoscopy for LITA and RITA harvesting via bilateral ports in the 2nd, 3rd, and 4th IS, employing peripheral CPB and aortic clamping by Chitwood clamp at the second IS, with cardioplegia delivery via a 4 cm right anterior MT. Distal anastomoses were performed via left anterior MT, with easy subxiphoid manipulation of the emptied heart. Transit time flowmetry was used in all cases. Conversion to sternotomy was needed in 3 cases, all were MIDCAB. Thirty–day mortality was 1.4%, median ventilation was 4 [2–5] hours, and Intensive Care Unit–stay was 1 [1–2] days. All patients received graft evaluation via computerized tomography before hospital discharge. Mean follow–up was 2.9±1.9 years (max 5 years), with no deaths and 4 (1.9%) requiring follow–up PCI. MICS CABG is a promising future technique for heart revascularization by dedicated teams.

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

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

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

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

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

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

Coronary Artery Bypass Grafting Using a Single Internal Thoracic Artery in Patients with Hemodialysis

Coronary Artery Bypass Grafting Using a Single Internal Thoracic Artery in Patients with Hemodialysis

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.

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

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

IN-HOSPITAL OUTCOMES OF BILATERAL INTERNAL MAMMARY ARTERY GRAFTING

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

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

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

Reconstruction Technique Options for Achieving Total Arterial Revascularization and Multiple Arterial Grafting.

Ischemic heart disease is the leading cause of morbidity and mortality worldwide and may require coronary revascularization when more severe or symptomatic. Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure and can be performed with different bypass conduits and anastomotic techniques. Saphenous vein grafts (SVGs) are the most frequently used conduits for CABG, in addition to the left internal thoracic artery. Outcomes with a single internal thoracic artery and SVGs are favorable, and the long-term patency of SVGs may be improved through novel harvesting techniques, preservation methods, and optimal medical therapy. However, increasing evidence points towards the superiority of arterial grafts, especially in the form of multiple arterial grafting (MAG). Nevertheless, the uptake of MAG remains limited and variable, both as a result of technical complexity and a scarcity of conclusive randomized controlled trial evidence. Here, we present an overview of CABG techniques, harvesting methods, and anastomosis types to achieve total arterial revascularization and adopt MAG. We further narratively summarize the available evidence for MAG versus single arterial grafting to date and highlight remaining gaps and questions that require further study to elucidate the role of MAG in CABG.

Bilateral Internal Thoracic Arteries Improve 10-Year Outcomes of Coronary Artery Bypass Grafting

BackgroundThis observational cohort study was designed by the PRIORITY (PRedictIng long-term Outcomes afteR Isolated coronary arTery bypass surgery) steering committee to evaluate the 10-year follow-up outcome of bilateral internal thoracic arteries (BITA) versus single internal thoracic artery. MethodsThe PRIORITY project was designed to evaluate long-term outcome of 2 large prospective multicenter cohort studies of coronary artery bypass grafting. Clinical data on isolated coronary artery bypass grafting were merged with administrative data to collect follow-up information. The primary endpoint was the composite outcome of major adverse cardiac and cerebrovascular events at 10-year follow-up. Secondary endpoints were individual components of major adverse cardiac and cerebrovascular events at 10 years and surgical site complications or infections. A propensity score–based inverse probability treatment weighting (IPTW) was used to overcome the selection bias related to the observational nature of the study. ResultsThe study population consisted of 10,988 patients who underwent isolated coronary artery bypass grafting. BITA was used in 23.5%. The use of BITA is related to lower incidence of major adverse cardiac and cerebrovascular events at 10 years (adjusted hazard ratio [HR] 0.88, 95% CI 0.79-0.98, P < .001). BITA correlated with better 10-year survival (IPTW adjusted HR 0.87, 95% CI 0.78-1.00, P = .05), re-revascularization (IPTW adjusted HR 0.83, 95% CI 0.74-0.92, P < .001), and myocardial infarction (IPTW adjusted HR 0.86, 95% CI 0.77-0.95, P = .005) but to increased incidence of surgical site complications or infections (HR 2.12, 95% CI 1.39-3.24, P < .001). ConclusionsIn propensity-matched patients, use of BITA was associated with improved 10-year survival, freedom from repeat revascularization, and myocardial infarction but also higher incidence of surgical site complications.

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.

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

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