Total Arterial Revascularization Research Articles

Mid-term outcomes of coronary artery bypass surgery with left radial artery bypassed to right main coronary artery of severe stenosis

Objective: To evaluate the mid-term outcomes of coronary artery bypass grafting (CABG) with left radial artery (RA) graft bypassed to right main coronary artery (RCA) of severe stenosis. Methods: Between September 2014 and April 2019, a total of consecutive 47 patients who had severe stenosis (≥90%) of RCA underwent total arterial revascularization, with left RA bypassed to RCA. There were 31 males and 16 females, with a mean age of (56.5±9.7) years old. The perioperative outcomes were observed and mid-term results were followed up. Results: A total of 46 left internal mammary artery (LIMA) grafts, 47 left radial artery (LRA), and 40 right RA grafts (RRA) were harvested with pedicles. LIMA was bypassed to LAD in 43 patients, RRA was to diagonal branches, ramus or oblique marginal in 37 cases, and LRA was to RCA. All grafts (except 3 composite Y or T grafts) were single. Mean graft number was 2-4 (2.7±0.9). There was one death due to cardiac tamponade. Three patients had postoperative atrial fibrillation, 1 had a forearm hematoma, 1 had acute renal insufficiency, and 2 had acute myocardial infarction. The mean tracheal intubation duration was 3.5-20.3 (8.3±4.7) hours, and the mean hospital stay was 6-13 (7.1±2.9) days. The average follow-up was 3-47 (23.3±7.5) months, with a follow-up rate of 86.96% (40/46). There were no major cardiovascular events during the follow-up. Three month after surgery, the mean left ventricular ejection fraction was significantly improved than that of pre-operation (60.0%±4.0% vs 42.4%±7.5%, P=0.003). Computed tomography angiography (CTA) examination showed that 58.7% (27/46) of patients had patent LRA after a mean follow-up duration of (19.5±7.3) months. Conclusion: CABG with LRA bypassed to RCA of severe stenosis proves to be safe and effective, with good mid-term outcomes.

What will surgical coronary revascularization look like in 25 years?

Coronary artery bypass grafting evolved in incremental but significant steps since its introduction. Here, we provide an update on operative techniques, choice of conduits, patient selection/decision-making and primary and secondary prevention measures with potential of influencing the future of coronary artery bypass grafting (CABG) surgery. Associated mortality of off-pump CABG (OPCAB) procedures performed in high-volume OPCAB centers (≥164 cases per year) and by experienced surgeons (≥48 cases per year) was reduced compared with on-pump CABG with two or more grafts suggesting a volume-based dependency of outcomes in CABG procedures with high-technical complexity. Ten-year results from the recent Arterial Revascularization Trial showed no significant between-group difference for the primary and secondary outcome. Total arterial revascularization using composite bilateral internal mammary artery-Y-conduits through a limited access mini-thoracotomy was not only shown to be feasible but a safe and reproducible procedure with excellent midterm outcomes. The most recent Randomized Trial of Endoscopic or Open Vein-Graft Harvesting for Coronary-Artery Bypass (REGROUP) trial demonstrated no significant difference between open vein-graft harvesting and endoscopic vein-graft harvesting in the occurrence of major adverse cardiac events. Adherence to the most recent guidelines on myocardial revascularization is a key component for providing state-of the CABG surgery. Trends to lesser invasiveness in surgical coronary revascularization will gain momentum and is expected - with further improvements - to be the mainstay of future surgical coronary revascularization strategies.

Minimally invasive total arterial off-pump coronary revascularization: A reproducible technique.

Minimally invasive total arterial off-pump coronary revascularization: A reproducible technique.

Long-Term Outcome of Total Arterial Myocardial Revascularization Versus Conventional Coronary Artery Bypass in Diabetic and Non-Diabetic Patients: A Propensity-Match Analysis

ObjectiveDespite the improved survival in patients with multi-vessel coronary disease compared to conventional myocardial revascularization associated with the use of multiple arterial grafting for myocardial revascularization, it has been adopted in the minority of centers. We sought to evaluate the long-term outcome of patients with and without diabetes undergoing total arterial versus conventional myocardial revascularization. MethodsAmong 1000 consecutive patients undergoing CABG, we performed a propensity-match analysis to compare patients with multi-vessel disease receiving total arterial (G1 = 618 pts) versus conventional myocardial revascularization (LIMA-LAD plus vein grafts, G2 = 382 pts). The primary end-point was survival free from all-cause and cardiac-related mortality, while the secondary end-point was the occurrence of major cardiac and cerebrovascular accidents. ResultsHospital mortality was similar (G1: 0 pts. vs G2: 1 pts., 0.3%, p = .91). At a median follow-up of 101 months (range 11–185 months), total arterial grafting was associated with significantly improved survival free from overall (G1 = 76.5 ± 3.0% vs G2 = 66.0 ± 3.1%; p < .001) and cardiac mortality (general population: G1 = 90.8 ± 2.1% vs G2 = 84.2 ± 1.9%, p = .043; diabetics:G1 = 84.7 ± 2.1 vs G2: 79.3 ± 3.4; p = .035) as well as occurrence of MACCEs (general population:G1 = 80.1 ± 3.2% vs G2 = 70.8 ± 2.9%; p > .001; diabetics:G1 = 77 ± 6 vs G2 = 53 ± 5.8; p < .001). Cox regression analysis identified diabetes (HR = 1.94, CI 95% = 1.12–2.93; p < .001) and the use of veins (HR = 1.81, CI 95% = 1.32–2.65; p < .001) as independent predictors for all-cause mortality; among diabetics, vein grafts was the strongest predictor of MACCEs (HR = 2.41, CI 95% = 1.27–4.59; p = .007) and cardiac mortality (HR = 3.24, CI 95% = 1.69–6.23; p < .001). ConclusionsLong-term survival following total arterial CABG is remarkably improved compared to conventional grafting with vein grafts especially in diabetic patients.

P4592Total arterial revascularization in severe coronary artery disease: a 25-years single-center experience

Abstract Objective To evaluate very long-term survival of Total Arterial Revascularization (TAR) in patients with severe coronary artery disease (CAD) undergoing Coronary Artery Bypass Grafting (CABG). Methods Between January 1992 and December 2017, 13798 patients aged 70 years or less underwent primary isolated CABG with at least two grafts in our department. Patients receiving TAR were matched by propensity-score analysis to the rest of the population. All pre- and peri-operative data were collected prospectively in our institutional database. Long-term survival was assessed using provincial vital statistics data. The primary outcome was very-long time survival, secondary outcomes were operative mortality and early complications. Results Propensity-score matching identified 602 pairs with similar preoperative characteristics. In the matched control group, 65.4% and 30.9% of patients received 1 and 2 arterial grafts, respectively, whereas 3 or more arterial grafts were used in 3.6%. Less distal anastomoses (2.57±0.77 vs 3.39±0.97, p&lt;0.0001) were performed in TAR patients, who therefore had a shorter cross-clamping time (44.2±14.7 vs 52.9±19.6, p&lt;0.0001). Operative mortality was similar (0.5% vs 1.0%, p=0.51) and there was no difference in the rate of mediastinitis (2.5% vs 0.8%, p=0.28)for the TAR and matched control groups, respectively. TAR patients were less likely to receive blood transfusions (34.9% vs 40.7%, p=0.04). The average follow-up was 13.4±6.7 years. Cox-adjusted survival was significantly better in patients receiving TAR compared to the matched population, up to 25 years postoperatively (HR 0.87 [0.86–0.88], p&lt;0.0001, Figure 1). Figure 1 Conclusion Total arterial revascularization is not associated with increased perioperative risk of complications and provides long-term survival benefits up to 25 years postoperatively.

Reducing delirium and cognitive dysfunction after off-pump coronary bypass: A randomized trial

BackgroundNeuropsychiatric complications of surgical coronary revascularization are inconspicuous but frequent and clinically relevant. So far, attempts to reduce their occurrence, such as the introduction of off-pump coronary artery bypass (OPCAB) grafting method, have not brought the desired results. The aim of this trial was to determine whether using any of the 2 selected modifications of OPCAB could decrease the incidence of these undesired sequelae. MethodsIn this single-center, assessor- and patient-blinded, superiority, randomized controlled trial, 192 patients scheduled for elective isolated OPCAB were randomized to 3 parallel arms. The control arm underwent “conventional” OPCAB with vein grafts. The first study arm underwent anaortic OPCAB (ANA) with total arterial revascularization. The second study arm underwent OPCAB with vein grafts using carbon dioxide surgical field flooding (CO2FF). Outcomes included the incidence of postoperative delirium (PD) and early postoperative cognitive dysfunction (ePOCD). ResultsThe incidence of PD was 35.9% in the control (OPCAB) arm, 32.8% in the CO2FF arm, and 12.5% in the ANA arm (χ2 [2, N = 191] = 10.17; P = .006). Post hoc tests revealed that the incidence of PD in the ANA arm differed from that in the OPCAB arm (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.09-0.68; P = .002). The incidence of ePOCD was 34.4% in the OPCAB arm, 28.1% in the CO2FF arm, and 9.5% in the ANA arm (χ2 [2, N = 191] = 11.58; P = .003). Post hoc tests revealed that the incidence of ePOCD differed between the ANA and OPCAB arms (OR, 0.20; 95% CI, 0.06-0.58; P < .001). ConclusionsPerforming ANA significantly decreases the incidence of PD and ePOCD compared with “conventional” OPCAB with vein grafts, whereas CO2FF is inconsequential in this regard. These results, which probably reflect decreased delivery of embolic load to the brain in ANA, may have practical applicability in daily practice to improve clinical outcomes.

Giant Saphenous Vein Graft Pseudoaneurysm and Total Arterial Redo Coronary Revascularization in A High-Risk Patient

Giant Saphenous Vein Graft Pseudoaneurysm and Total Arterial Redo Coronary Revascularization in A High-Risk Patient

Total arterial off-pump coronary revascularization: The Holy Grail?

Coronary artery bypass grafting (CABG) remains the standard of care for patients with complex multivessel coronary artery disease. However, conventional CABG utilizing left internal mammary artery and supplemental vein grafts performed on cardiopulmonary bypass is marred by questionable long-term patency of vein grafts and risk of neurological injury. Total arterial off-pump CABG is a strategy associated with avoidance of neurological injury and vein graft failure. The aim of this review is to summarize recent evidence on safety and effectiveness of total arterial off-pump CABG. Two key studies have been published recently. One describes a dual inflow technique that achieves anaortic, off-pump complete revascularization using arterial grafts only. The other is single centre study that reports 10-year survival of 89.33%, rate of freedom from repeat revascularization of 91.33% and early stroke rate of 0.9% after total arterial off-pump CABG. Total arterial off-pump CABG with its advantages of improved survival, enhanced freedom from repeat revascularization and low stroke rate can be regarded as the Holy Grail of myocardial revascularization. However, the results of a large, multicenter, prospective trial are required to substantiate this status.

Total arterial revascularization strategies: A meta-analysis of propensity score-matched observational studies.

We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy. PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding. Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR withthe bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77). TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection.

In situ skeletonized bilateral thoracic artery for left coronary circulation: a 20-year experience.

Our goal was to analyse the outcomes in a patient population using a standardized technique for coronary artery bypass grafting (CABG) consisting of total arterial myocardial revascularization utilizing the in situ skeletonized bilateral thoracic artery for left coronary circulation. We also explored potential predictors of long-time unfavourable outcomes. Patients undergoing total arterial myocardial revascularization using in situ skeletonized bilateral thoracic artery for left coronary circulation between January 1997 and May 2017 were included prospectively in this study. The median follow-up (100% complete) was 103 months (interquartile range 61-189 months) and ranged from 1 to 245 months. A total of 1325 consecutive patients were recruited. During the follow-up period, there were 131 deaths (9.8%), 146 repeat revascularizations (11.0%) and 229 major adverse cardiac events (17.2%). The 18-year freedom from major adverse cardiac events was 62.6 ± 9.3%, 62.5 ± 6.3% and 53.9 ± 11.0%, respectively. Multivariable models showed that a left ventricular ejection fraction ≤35%, chronic obstructive pulmonary disease, peripheral vascular disease (P < 0.001), chronic kidney disease and age ≥80 years (P = 0.002) were independent predictors of diminished long-term survival. Moreover, peripheral vascular disease and off-pump coronary artery bypass (both, P < 0.001) predicted repeat revascularization. Finally, age ≥80 years, peripheral vascular disease, left ventricular ejection fraction ≤35%, off-pump coronary artery bypass and chronic pulmonary obstructive disease were independent predictors of major adverse cardiac events during the long-term follow-up period (all, P < 0.001). Coronary artery bypass using the in situ skeletonized bilateral thoracic artery for left coronary circulation configuration for total arterial myocardial revascularization resulted in satisfactory long-term results with a low incidence of death and late events and may represent a technique of choice in selected patients having CABG. Larger and long-term prospective studies are, however, warranted.

Clinical outcomes of total arterial off-pump coronary revascularization in patients with left ventricular dysfunction

Objective: To compare the advantages and disadvantages of total arterial revascularization (TAR) and conventional off-pump coronary artery bypass (OPCAB) grafting in patients with left ventricular dysfunction (LVD). Methods: Between January 2008 and March 2015, 76 patients who were scheduled to undergo selective OPCAB were selected for cardiac surgery in Zhongshan Hospital, Fudan University. The left ventricular ejection fraction of enrolled patients was less than 35%. Among those patients, 38 patients in TAR group underwent total arterial OPCAB with bilateral internal mammary artery, left and/or right radial artery, and another 38 patients in control group underwent conventional OPCAB with left internal mammary artery and great saphenous vein. The clinical data of all patients were collected. The follow-up was performed within 36 months. Results: There was no significant difference in preoperative clinical data between the two groups (all P>0.05). Additionally, there was no significant difference in the application rate of internal mammary artery, positive inotropic drugs and intra-aortic balloon pump (IABP) use between the two groups (all P>0.05). The operation time of TAR group was longer than that of control group [(278.3±31.2) min vs (196.7±19.1) min, P<0.01]. There was no significant difference in perioperative mortality between the two groups (5.3% vs 7.9%, P=0.64). The volume of operative drainage and blood transfusion in TAR group increased significantly at 24 hours after operation [(895.0±236.2) ml vs (585.4±172.5) ml, (656.3±84.4) ml vs (433.3±62.9) ml, both P<0.01]. There was no significant difference in perioperative complications such as heart, kidney and lung failure between the two groups (all P>0.05). At 12 months after operation, there were no significant differences in survival rate, cardiac death rate, angina recurrence, myocardial infarction, re-treatment rate of revascularization, re-hospitalization rate from cardiac insufficiency, graft patency rate, cardiac function and echocardiographic data between the two groups (all P>0.05). From 24 to 36 months after operation, all the above indexes in TAR group were better than those in control group except for echocardiographic data (all P<0.05). Conclusions: For LVD patients, the early clinical efficacy of the two surgical methods is similar, but for the long-term outcomes, the whole arterial OPCAB operation is obviously superior. However, the shortcomings of total arterial OPCAB are that operative drainage and the use of blood products increased significantly after operation.

Mid-term multi-center outcomes of bilateral radial artery as conduits in coronary artery bypass grafting

Objective: To evaluate the mid-term outcomes of bilateral radial artery (BRA) grafts in coronary artery bypass grafting (CABG). Methods: All perioperative medical records and follow-up results of CABG with BRA grafts in multi-centers of China were analyzed retrospectively. Results: A total of 211 patients (170 males and 41 females) underwent CABG grafting with BRA conduits between August 2013 and September 2018, with a mean age of (56.5±9.7) years old (rang 41 to 73 years). There were 161 cases of triple-vessel disease and 50 cases of two-vessel disease. Ninety patients had diabetes mellitus (DM), 35 patients with peripheral vascular disease, 4 patients with chronic obstructive pulmonary disease and 11 with heart valve disease. Two patients underwent off-pump CABG and 209 patients accepted on-pump CABG with commitment valve surgery. There were 210 cases of total arterial revascularization and 161 cases using left thoracic artery conduits, with a graft number of 2-4 (2.7±0.9). No operation-related death occurred, atrial fibrillation happened in 12 patients, hemothorax in 7 cases, and forearm hematoma in one case, hypoxemia in 13 cases and pneumonia in one case. The duration of mechanical ventilation was (8.3±4.7) hours and the mean hospital length of stay was (7.1±2.9) days. Follow-up was completed in 191 patients (90.52%) with a duration of 3-59 (35.5±9.3) months. The mean left ventricular ejection fraction at 3 months after operation was significantly improved, compared to that of the pre-operation (61.0%±7.2% vs 47.1%±5.3%, P=0.017). All patients survived, except that one died from brain injury. No major cardiac events occurred, with a cumulative survival rate of 100% at 1 year and 99.53% at 3 year after operation, respectively. It was showed in coronary CT angiography (CTA) examination that all grafts in 132 patients were patent at the mean follow-up duration of (21.5±6.4) months. Conclusions: BRA grafts as arterial conduit in CABG are proved to be safe, easy for total arterial revascularization and have good mid-term clinical results.

Early clinical outcomes of minimally invasive coronary surgery-total arterial coronary revascularization

Objective: To summarize the early experience and clinical value of minimally invasive coronary surgery-total arterial coronary revascularization (MICS-TACR) through the left anterior small incision. Methods: Between May 2015 and June 2018, a total of 31 consecutive cases [21 males and 10 females, aged (63.2±9.3) years] in Peking University Third Hospital who were performed MICS-TACR with bilateral internal mammary artery and radial artery were enrolled. Meanwhile, 1 489 cases of conventional median sternal incision off-pump coronary artery bypass grafting (OPCABG) were matched as control group. According to exclusion criteria and matching score, 90 cases [55 males and 35 females, aged (63.8±9.5) years] were selected as the control group, and the perioperative data of the two groups were compared. All patients in MICS-TACR group underwent postoperative angiography and the graft patency was evaluated. Results: There were no statistically significant differences in baseline data between the two groups. The perioperative blood transfusion of MICS-TACR group was less than control group [0(0,0) U vs 0(0,4) U, P=0.003]. There were no statistically significant differences in operative mortality, intraoperative and postoperative intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) use, re-operation rate, perioperative major adverse cardiac and cerebrovascular events (MACCE), new-onset renal failure, atrial fibrillation, and multiple organ failure between the two groups. Postoperative angiography showed that there was no significant difference in the patency rate between the MICS-TACR group and control group(all P>0.05). Conclusion: Total arterial coronary revascularization can be successfully accomplished under the left anterior small incision, and the early clinical outcome is satisfied.

Total arterial myocardial revascularization using bilateral internal mammary arteries and the role of postoperative sternal stabilization to reduce wound infections in a large cohort study.

Total arterial myocardial revascularization using bilateral internal mammary arteries shows improved results for mortality, long-term survival and superior graft patency. It has become the standard technique according to recent guidelines. However, these patients may have an increased risk of developing sternal wound infections, especially obese patients or those with diabetes. One reason for the wound complications may be early sternum instability. This situation could be avoided by using a thorax support vest (e.g. Posthorax® vest). This retrospective study compared the wound complications after bilateral internal mammary artery grafting including the use of a Posthorax vest. Between April 2015 and May 2017, 1613 patients received total arterial myocardial revascularization using bilateral internal mammary artery via a median sternotomy. The Posthorax support vest was used from the second postoperative day. We compared those patients with 1667 patients operated on via the same access in the preceding 26 months. The end points were the incidence of wound infections, when the wound infection occurred and how many wound revisions were needed until wound closure. The demographic data of both groups were similar. A significant advantage for the use of a thorax support vest could be seen regarding the incidence of wound infections (P = 0.036) and the length of hospital stay when a wound complication did occur (P = 0.018). As seen in this retrospective study, the early perioperative use of a thorax stabilization vest, such as the Posthorax vest, can reduce the incidence of sternal wound complications significantly. Furthermore, when a wound infection occurred, and the patient returned to the hospital for wound revision, patients who were given the Posthorax vest postoperatively had a significantly shorter length of stay until wound closure.

How do surgeons decide? Conduit choice in coronary artery bypass graft surgery in the UK†.

Conduits used in coronary artery bypass grafting may have significant impact on outcomes, but evidence is mixed and there is large variation in practice. This study provides insights into the opinions of the UK surgeons on conduit use and their decision-making processes. A questionnaire was created using the Ottawa Decision Support Framework to elicit the importance that surgeons placed on bilateral internal mammary artery grafting, skeletonization, total arterial revascularization and sequential anastomoses on a scale of 1-10. Scores ≥8 were deemed 'important' and ≤3 'not important'. Surgeons were asked to specify changes to practice in frail patients or emergencies. Additional questions included conduit type used, factors affecting decision-making and vein harvesting methods. Questionnaires were administered in person with data analysed centrally. Ninety-seven consultant cardiac surgeons from 25 centres responded. Thirty-two percent surgeons routinely used radial arteries and 36% used right internal mammary artery. High-quality evidence contributed most to decision-making receiving a total of 328/960 points, with consultant experience being the second (255/960 points). There was a bimodal distribution of perceived importance of bilateral internal mammary artery use, with 29 (30%) 'important' and 'not important' scores each. 23% of surgeons found total arterial revascularization important. Most surgeons (64%) preferred pedicled mammary arteries. Twenty-six percent of surgeons considered sequential grafting to be important. Low uptake of total arterial revascularization and bilateral internal mammary artery among the UK consultants may be due to the lack of high-quality evidence demonstrating a significant benefit. It is also possible that reluctance to use certain conduits may stem from low levels of exposure to conduits or inadequate training, particularly given the importance of consultant experience on decision-making.

Total Arterial Revascularization and The Future of Long Saphenous Vein

Coronary artery bypass grafting (CABG) is one of the most common cardiac surgery procedures being performed nowadays [1].

Bilateral Internal Thoracic Artery Grafting in Women: A Word of Caution.

Despite the superior hemodynamic performance of internal thoracic arteries, total arterial revascularization with exclusive bilateral internal thoracic arteries (BITA) is less frequently used especially in specific subsets of patients, including females. We report our experience with total arterial revascularization with exclusive BITA regardless of sex and analyze the impact of female sex on the early and midterm outcomes. Total arterial revascularization with exclusive BITA was performed with equal frequency in females (79/99, 80%) and males (392/477, 82%; P = .68) undergoing isolated CABG for 3-vessel disease. Pre, intra and postoperative data were compared between these two groups. Complete revascularization was achieved in 77% of females and 72% of males (P = .08). Early mortality did not differ between the groups (6.3% versus 4.6%, P = .7). The incidence of re-sternotomy for bleeding, postoperative stroke, myocardial infarction, new onset atrial fibrillation, and hemofiltration for renal failure did not differ between the two groups. However, there were significantly more wound revision for combined superficial and deep sternal wound infection in females (26.5% versus 5.1%, P = .0001). Nevertheless, midterm survival, freedom from repeat revascularization, myocardial infarction, stroke, and major adverse cardiovascular and cerebral events at five years were very good and compared favorably between females and males. Our findings suggest that total arterial myocardial revascularization with exclusive internal thoracic arteries in females carries the same midterm benefits as in males. Early outcomes are comparable except for a higher incidence of wound revision for combined superficial and deep sternal wound infections in females compared to males. Benefits of bilateral internal thoracic artery grafting in females should be weighed against increased risk of early wound revision.

Total arterial myocardial revascularization

The review presents the current concept oftotal arterial myocardial revascularization, main studies focusing on it, recent guidelines and commonly used techniques, which let speak about high efficacy this kind procedure. However, in medical society there is a certain part of disbelief with respect to performance of coronary artery bypass grafting using only arterial conduits, and even in justifiable cases when the choice is obvious, the percentage of mentioned operations is still low. It can be explained by both technically much more difficult manipulations and particular risk factors, which contribute discreet approach in the wide use of total arterial myocardial revascularization.

Twenty-year outcomes of coronary artery bypass grafting utilizing 3 in situ arterial grafts

ObjectiveThe added value of total arterial revascularization in coronary artery bypass grafting becomes particularly apparent when evaluating long-term results. We previously reported on our 10-year outcomes of total arterial revascularization using bilateral internal thoracic and gastroepiploic arteries as in situ grafts in patients with 3-vessel disease. This study aimed to increase the follow-up period to 20 years. MethodsWe updated clinical outcomes of 201 patients operated on between 1992 and 2002. At that time, the technique was primarily performed in patients with a longer life expectancy. Primary end points were overall survival and freedom from the composite of major adverse cardiac events. Secondary end points were the separate cardiac events. ResultsExtended follow-up included all patients. The median follow-up time was 19.2 years (interquartile range, 16.2-20.0). The respective 15- and 20-year Kaplan-Meier estimated survival probabilities were 73.9% (95% confidence interval [CI], 67.2%-79.5%) and 63.5% (95% CI, 55.7%-70.4%) for overall survival and 57.9% (95% CI, 50.7%-64.5%) and 47.9% (95% CI, 40.1%-55.3%) for freedom from major adverse cardiac events. The respective estimated cumulative incidences at 15 and 20 years were 7.0% (95% CI, 3.5%-10.6%) and 7.8% (95% CI, 4.0%-11.6%) for myocardial infarction, 8.6% (95% CI, 4.7%-12.5%) and 9.3% (95% CI, 5.2%-13.3%) for percutaneous reintervention, 7.0% (95% CI, 3.5%-10.5%) and 7.0% (95% CI, 3.5%-10.5%) for reoperation, 8.6% (95% CI, 4.7%-12.6%) and 12.9% (95% CI, 7.6%-18.2%) for cardiac death, and 10.8% (95% CI, 6.5%-15.2%) and 15.2% (95% CI, 9.8%-20.6%) for death from other causes. ConclusionsThe use of in situ bilateral internal thoracic and gastroepiploic arteries provides outstanding 15- and 20-year survival and cardiac event-free survival probabilities. Further studies are needed in older patients with more severe comorbidities. Nevertheless, the results from this and scarce other studies on 15- to 20-year outcomes of total arterial revascularization suggest that cardiac surgeons should embrace the application of total arterial grafting to further reduce the risks of long-term cardiac events, especially during the second decade after surgery.

A single center's experience with total arterial revascularization and spiral aneurysmorrhaphy for ischemic cardiac disease.

The restoration of left ventricular (LV) geometry in combination with coronary artery bypass grafting for the treatment of ischemic cardiac disease remains controversial. We hereby present the experience of our center with total arterial myocardial revascularization (TAMR) and spiral aneurysmorrhaphy for ischemic heart disease. A retrospective analysis of 101 patients with advanced cardiovascular disease who underwent TAMR and spiral aneurysmorrhaphy was performed. Spiral aneurysmorrhaphy is a modification of the linear aneurysmorrhaphy and was applied to patients who had a LV aneurysm with a diameter of less than 5cm. Peri-operative and in-hospital data were retrieved. The majority of the patients were male (87.13%) with a mean age of 63.1years. Mean pre-operative ejection fraction (EF) was 35.7% ranging between 20 and 65%. An average of 3.23 grafts was required per patient. Early mortality was 6.93% (one intra-operative and six in-hospital deaths). Addition of concomitant valve surgery was associated with prolonged total operative, cardiopulmonary bypass and cross-clamp time (p < 0.001), increased need for blood (p = 0.012) and plasma (p = 0.038), longer intensive care unit (ICU) stay (p = 0.045) and higher rate of post-operative cerebrovascular accident (p = 0.011). Furthermore, patients with a pre-operative EF between 30 and 50% had a shorter ICU stay (p = 0.045) and LoS (p = 0.029) compared with patients with EF <30%. Early mortality and post-operative complication rates following this combined procedure are in consistency with the relevant available data suggesting its feasibility regardless of the EF or addition of concomitant surgeries. Data from the follow-up of these patients are required to examine the long-term efficacy of this surgical modality.