Use Of Bilateral Internal Thoracic Artery Grafting Research Articles

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).

Superiority of bilateral internal thoracic artery grafting in long-term survival after coronary artery bypass through the lenses of a bedside risk score

ObjectiveRisk algorithms for the prediction of long-term survival after coronary artery bypass grafting (CABG) do not include the use of bilateral internal thoracic artery (BITA) grafting among the independent predictors. We sought to reveal the superiority of BITA grafting in the long-term outcome through the lenses of an existing bedside risk score (BRS). MethodsThis study analyzed data from 5,666 consecutive patients undergoing isolated (n = 4,715 – BITA = 2,792) and combined (n = 951 – BITA = 246) CABG. The mean follow-up period was 10.3 years (interquartile range, 9.9 years). All the predictors of an existing BRS were available for analysis (age, body mass index, ejection fraction, unstable hemodynamic state, left main disease, cerebrovascular disease, peripheral arterial disease, congestive heart failure, malignant ventricular arrhythmia, chronic obstructive pulmonary disease, diabetes, and previous heart surgery). Furthermore, a modified BRS was constructed taking into account the use of BITA grafting and combined CABG. ResultsThe good discriminatory ability and satisfactory calibration of the BRS was confirmed in the isolated CABG subgroup. The modified BRS showed improved discriminatory ability and similar calibration. It showed a time-varying coefficient, and accordingly, we calculated the adjusted survival predictions up to 20 years after isolated and combined CABG with or without BITA grafting. Patients with BITA grafting in the low-risk quartile showed 68.4% and 65.5% predicted survival rates at 20 years in the isolated and combined CABG subgroups, respectively, versus the survival rates of 56.4% and 52.8% observed among patients without BITA grafting. ConclusionThe modified BRS is a useful simplified algorithm for clinicians in choosing treatment intervention for severe isolated or combined coronary artery disease. We clearly demonstrated the superiority of BITA grafting in long-term survival throughout the entire range of the modified BRS.

Is gender a risk factor for bilateral internal thoracic artery grafting? A twenty-year follow-up.

Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique, especially in female patients, due to its greater complexity and potential increased risk of sternal infection. The aim of this study was to compare the outcomes of male and female patients who underwent BITA grafting. We evaluated at the early outcome and late mortality, 551 female versus 2525 male patients who underwent isolated BITA grafting between January 1996 and December 2011. To adjust for differences in demographic and clinical characteristics, a multivariate risk analysis and propensity score matching were performed. Kaplan-Meier analysis was performed for the entire cohort and for the matched cohort. Female patients were older and were more likely than males to have congestive heart failure, unstable angina pectoris, and diabetes. Sternal infection was more frequent in females than males (3.3% vs. 1.8%; p = .04). Differences were not observed in operative mortality (2.9% vs. 1.9%; p = .15) and stroke incidence (3.4% vs. 2.6; p = .30). After multivariate risk analysis and propensity score matching, the female gender was not found to be a predictor of worse outcomes. There was no difference in median survival amongfemale and male patients (14.3 and 14.2 years, respectively; p = .68). Our results support the routine use of BITA grafting in proper selected female patients who undergo myocardial revascularization.

Are two internal thoracic grafts better than one? An analysis of 5301 cases.

Although bilateral internal thoracic artery (BITA) grafting is associated with improved survival, many surgeons are reluctant to use this technique due to its greater complexity and the potentially increased risk of sternal infection. This observational study examined if BITA grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting in patients with multivessel coronary disease. Patients in our institution who underwent BITA grafting during 1996-2011 were compared to those who underwent SITA grafting during the same period. To adjust for differences in demographic and clinical characteristics, patients were matched by propensity score. The Cox model was used to identify predictors of decreased survival and the Kaplan-Meier analysis was performed, both for the entire cohort and for the matched cohort. SITA patients were older than BITA patients, included more females, and were more likely to have chronic obstructive lung disease, an ejection fraction <30%, diabetes, renal insufficiency, peripheral vascular disease and emergency and repeat operations. Three-vessel and left main diseases were more common among BITA patients, and operative mortality was reduced (2.1% vs 3.6% for SITA, P = 0.002). Sternal infection and stroke rates were similar for the groups. Ten-year Kaplan-Meier survival of BITA patients was better (71.2% vs 56.8%, respectively, P < 0.001). BITA grafting was found to be a predictor of better survival in the analysis of the matched cohort (P < 0.001). Our results support the routine use of BITA grafting in patients who undergo myocardial revascularization.

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.

Are two internal thoracic grafts better than one in patients with peripheral vascular disease?

The use of two bilateral internal thoracic artery grafting (BITA) was shown to lead to survival benefit. However, operators are reluctant to use BITA with peripheral vascular disease (PVD) because of concerns of increased rates of sternal wound infection and lack of studies supporting survival benefit compared with single internal thoracic artery (SITA) grafting. The aim of this study is to compare outcome BITA grafting versus of SITA and vein grafts in PVD patients. Six hundred and twenty-one PVD patients who underwent BITA between 1996 and 2011 were compared with 372 patients who underwent SITA. SITA patients were older and more likely more likely to have comorbidities (female, insulin-dependent diabetes, chronic obstructive lung disease, congestive heart failure, previous coronary artery bypass grafting, renal insufficiency, cerebrovascular disease, and emergency operation). Operative mortality (5.1 vs. 4.5%, in the SITA and BITA, respectively, P=0.758), rate of sternal wound infection (5.1 vs. 3.9%, P=0.421), and strokes (4.8 vs. 7.4%, P=0.141) were not significantly different between groups. BITA patients did not have significantly better 10-year survival (52.6 vs. 45.9%, P=0.087) and after propensity score matching (302 well-matched pairs), BITA was not associated with improved survival (hazard ratio: 0.902; 95% confidence interval: 0.742-1.283; P=0.784) (Cox model). The routine use of BITA versus SITA in PVD patients does not improve long-term survival. Selective use of BITA in lower risk patients might unmask the benefits of BITA.

Use Rate and Outcome in Bilateral Internal Thoracic Artery Grafting: Insights From a Systematic Review and Meta-Analysis.

BackgroundThis meta‐analysis was designed to assess whether center experience affects the short‐ and long‐term results and the relative benefits of bilateral internal thoracic artery grafting (BITA) for coronary artery bypass grafting.Methods and ResultsMEDLINE and EMBASE were searched to identify all articles reporting the outcome of BITA in patients undergoing coronary artery bypass grafting. The BITA center experience was gauged according to the percentage use of BITA in the institutional overall coronary artery bypass grafting population (%BITA). The primary outcome was long‐term all‐cause mortality. Secondary outcomes were operative mortality, perioperative myocardial infarction, perioperative stroke, deep sternal wound infections (DSWIs), and major postoperative adverse event. The rates of the primary and secondary outcomes were calculated after adjusting for %BITA. Primary and secondary outcomes were also compared between the BITA and the single internal thoracic artery arms in the adjusted studies. Meta‐regression was used to evaluate the effect of %BITA on the primary and secondary outcomes. Thirty‐four studies (27 894 patients undergoing BITA) were included. In the pooled analysis, the incidence rate for long‐term mortality was 2.83% (95% confidence interval, 2.21%–3.61%). %BITA was significantly and inversely associated with long‐term mortality and the rate of DSWI. In the pairwise comparison, %BITA was significantly and inversely associated with the risk of long‐term mortality and DSWI in the group undergoing BITA.ConclusionsBITA series with higher %BITA report significantly lower long‐term mortality and DSWI rate as well as higher long‐term survival advantage and lower relative risk of DSWI in their BITA cohort. These findings suggest that a specific volume‐outcome relationship exists for BITA grafting.

Is bilateral internal thoracic artery grafting a safe option for chronic dialysis patients?

The use of bilateral internal thoracic artery (BITA) grafting has been proposed for dialysis patients with multivessel coronary artery disease, primarily because of hypothetical long-term survival benefits. To investigate the outcome of BITA grafting in dialysis patients. This was a retrospective analysis of the use of BITA grafting in 105consecutive patients with end-stage renal failure on chronic dialysis in three European centres with extensive experience in BITA. Baseline patient characteristics, operative data, early postoperative complications and late survival were reviewed. Outcomes of patients from one of the three centres who underwent either BITA (n=40) or single internal thoracic artery (SITA) grafting (n=19) were also analysed; a one-to-one propensity score (PS)-matched analysis was performed. There were 19 (18.1%) hospital deaths. Despite differences in preoperative patient characteristics and surgical features, in each centre, hospital mortality was greater than the 75th percentile of expected operative risk (EuroSCORE II). Diseased ascending aorta and extracardiac arteriopathy were found to be predictors of hospital death (odds ratio 9.7; P=0.006) and complicated hospital course (odds ratio 2.54; P=0.035), respectively. The 7-year non-parametric estimates of freedom from all-cause death and cardiac or cerebrovascular death were 59% (95% confidence interval: 52.3-65.7%) and 75.6% (95% confidence interval: 71.2-80%), respectively. There were no significant differences in early and late outcomes between BITA and SITA PS-matched groups. BITA grafting remains a risky operation for chronic dialysis patients, even when performed routinely. No long-term survival benefits for the use of BITA versus SITA were proven.

Abstract 331: Are Two Internal Thoracic Grafts Better Than One in Patients With Peripheral Vascular Disease?: Analysis of 858 Cases Between 1996- 2011

Objectives: Bilateral internal thoracic artery( ITA) grafting is associated with improved survival. However, potential survival benefit of using two ITA`s in patients with peripheral vascular disease(PVD) is questionable due to their short life expectancy and the increased risk of sternal wound infection(SWI) compare to operations incorporating single ITA (SITA). The purpose of this study is to compare early and long-term outcome of bilateral ITA grafting(BITA) to that of SITA and vein grafts in PVD patients with multi-vessels coronary disease. Methods: Five hundred and thirty three PVD patients who underwent BITA between 1996 and 2011 were compared with 319 who underwent SITA . Results: SITA patients were more often female, more likely to have Diabetes, chronic obstructive lung disease, unstable angina, previous CABG, renal insufficiency, Cerebro- vascular disease and emergency operation .On the other hand congestive heart failure and triple vessel coronary disease were more prevalent among BITA patients. Operative mortality(3.5% vs. 4.1%, in the SITA and BITA respectively) and occurrences of SWI (6.6% vs 3.9%) and strokes(4.1% vs 6.8%) were not significantly different between groups . BITA patients did not have better Kaplan- Meier 10 year survival ( 52.1% vs.47.1%, p=0.145) and after propensity score matching(243 well matched pairs) BITA was not associated with better adjusted survival ( HR 1.108[95%CI 0.810-1.516] p=0.521)(cox model) Conclusion: This study does not support routine use of BITA in PVD patients .Earlier mortality from non-cardiac causes, reduces contribution of BITA and increases the influence of PVD and other co-morbidities on survival. Selective use of BITA in lower risk patients might un-mask the benefits of BITA

Bilateral Internal Thoracic Artery Grafting: Is It Reasonable in Octogenarians?

The feasibility of using bilateral internal thoracic artery (BITA) grafts for coronary artery bypass grafting (CABG) in octogenarians is not clear. This study aimed to compare outcomes between use of BITA and single internal thoracic artery (SITA) grafts in octogenarians undergoing isolated CABG. Isolated CABG was performed in 1,566 patients at the Sakakibara Heart Institute between September 2004 and December 2012. Of these, 125 consecutive octogenarians were included and divided into two groups, according to the use of BITA grafts (101 subjects) or SITA grafts (24 subjects). Early and late outcomes were compared between groups. The preoperative patient characteristics were similar between the two groups. Early outcomes were similar, including hospital death or deep sternal infection. The estimated 5-year survival rate was similar in the BITA and SITA groups (78% vs 62%, p = 0.269). Freedom from major adverse cardiac or cerebrovascular events was significantly higher in the BITA group than in the SITA group after 5 years (90% vs 75%, p = 0.032). Our results suggest that use of BITA grafts for CABG is feasible and beneficial in octogenarians, resulting in improved late outcomes without increased operative risk.

Bilateral internal thoracic artery grafting increases long-term survival in elderly patients.

Bilateral internal thoracic artery (BITA) grafting is extensively underused in coronary artery bypass graft surgery and it is mostly preserved for patients under the age of 70. The purpose of the present study was to compare outcomes in propensity score-matched patients aged 70 years or greater using a BITA, with patients using a single internal thoracic artery (SITA) graft. Among 18 761 patients operated on in our unit until December 2006, we selected 3496 patients aged 70 years or greater; of these, 1328 received a BITA (BITA group) and 2168 received a SITA (SITA group). Propensity score matching was used to reduce the preoperative patient variability. The 3-month and 10-year survival, stroke, myocardial infarction and sternal wound complication rate (defined as sternal instability or need for refixation) were compared between the two groups. After the correction, 892 patients per group were selected. Survival at 3 months was 90.6% in the SITA group and 91.6% in the BITA group (P = 0.34) and at 10 years was 38.9 and 57.5% (P = 0.02), respectively. The rates of stroke (1.01 vs 1.12%, P = 1), myocardial infarction (1.91 vs 2.13%, P = 0.86) and sternal wound complications (3.30 vs 5.42%, P = 0.17) were all similar between the SITA and BITA groups, respectively. The use of BITA grafting in elderly patients improves the 10-year survival rate, with similar postoperative morbidity. Thus, using adequate selection criteria, this technique should be routinely extended also to patients older than 70 years.

Off-pump bilateral internal thoracic artery grafting.

We read with interest the article by Dr. Lytle on bilateral internal thoracic artery (BITA) grafting (1). We congratulate him for an excellent review on the subject. We would like to take this opportunity to humbly express our opinion regarding off-pump use of BITA grafting. Our limited experience contradicts his opinion that off-pump CABG (OPCAB) may have negatively influenced the use of BITA and sequential ITA grafting (1). We have reported a simple technique to use BITA with aortic no touch (2) that can be performed off-pump by surgeons even with limited OPCAB experience. Sequential grafting using LITA-RITA y graft technique off-pump has been in practice for a while. Intra-myocardial blood vessels had been successfully grafted during OPCAB (3). We feel that in the absence of the stress of increasing clamp or bypass time, a perfect anastomosis can be performed even in severely diseased arteries. Moreover, the absence of cardiopulmonary bypass-induced inflammatory response may have a favorable impact on the vulnerability of deep mediastinal infection after BITA use. OPCAB is associated with less use of blood and blood product which is known to reduce immunity. We would argue that immunity may be better preserved after OPCAB because of the absence of inflammatory response and less use of blood and blood product. In addition to routine use of skeletonised ITA, these factors may explain the very low incidence of major infection in our OPCAB patients with BITA grafting. Stroke after CABG is probably the major drawback in all the recent trials comparing CABG with percutanous coronary intervention (PCI). Even with the improvement in technology, it would be difficult to reduce the incidence of stroke to less than 2% after on-pump CABG. Even OPCAB (where aortic side clamp had been used) can be complicated by postoperative incidence of stroke. Stroke after CABG is probably the worst complication. OPCAB with aortic-no-touch can reduce the incidence of stroke to the minimum (4). OPCAB with aortic-no-touch which has the lowest incidence of stroke compares favorably with PCI. We have successfully adopted OPCAB use of BITA grafting in more than 90% of unselected consecutive cases of isolated CABG (5). It is well known that coronary artery disease in the Asian population has a very aggressive pattern affecting the younger generation. Moreover, while PCI is preferred for younger patients with low syntax score, our surgical patients have become more complex with higher syntax scores. By using OPCAB with aortic-no-touch and BITA grafting, we have been able to provide an alternative to PCI which has not only better graft patency rates, and provides complete revascularization but also the incidence stroke is comparable or lower than PCI (even passing coronary angioplasty catheters through diseased aorta can produce stroke). Our limited experience has proved that BITA grafting can be successfully used during OPCAB (5). I congratulate Dr. Lytle for highlighting the superiority of BITA grafting in improving long-term patient outcomes. It will require a change in mindset toward BITA grafting to successfully provide a better alternative to PCI in patients with coronary artery disease.

Does the use of bilateral mammary artery grafts compared with the use of a single mammary artery graft offer a long-term survival benefit in patients undergoing coronary artery bypass surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'Does the use of bilateral mammary artery grafts compared with the use of a single mammary artery graft offer a long-term survival benefit in patients undergoing coronary artery bypass surgery?' Altogether 214 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All the included studies were follow-up studies; eight studies used prospective data collection, and five studies collected the study data retrospectively. No randomized controlled trials were found. Nine of the 13 included papers used a propensity-score-matched comparison of the survival of bilateral mammary artery graft [or, bilateral internal thoracic artery (BITA) graft] patients vs single mammary artery graft [or, single internal thoracic artery (SITA) graft] patients. These studies consistently showed an enhanced survival of BITA patients compared with propensity-score-matched SITA patients. Three of the 13 included papers used Cox proportional hazards regression analysis to compare survival of BITA vs SITA patients; one larger study showed better crude survival of BITA patients, but did not identify BITA grafts as independent predictor of enhanced survival. The remaining two studies also did not identify BITA grafts as independent predictor of enhanced survival. One study only presented crude survival estimates of BITA vs SITA patients and therefore was of limited informative value. We conclude that the use of BITA grafts seems to offer a long-term survival benefit compared with a SITA graft for patients undergoing coronary artery bypass grafting surgery. Although randomized evidence is lacking, observational evidence supporting this hypothesis is mounting.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: A propensity-matched study with 30-year follow-up

Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied. Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm. There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001). Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.

Thirty‐Year Experience with Bilateral Internal Thoracic Artery Grafting: Where Have We Been and Where Are We Going?

As a profession, surgery is well into its fourth decade of experience with bilateral internal thoracic artery (BITA) grafting for the treatment of ischemic cardiovascular disease. Numerous compelling retrospective analyses appear to have documented a clear benefit for BITA grafting over the use of a single internal thoracic artery (SITA) graft in reducing the long-term risk of mortality, cardiac mortality, and cardiac events. Despite this wealth of literature and scientific as well as clinical investigation, the chilling fact remains that the STS database reports that less than 4% of coronary bypass (CABG) operations involve the use of BITA grafting. The historic, physiologic, and clinical aspects of BITA grafting are reviewed. Clinical challenges and technical advances are addressed. The future of BITA grafting is explored, both from a research perspective and from a clinical point of view.

Cirurgia de revascularização miocárdica: uso de enxerto bilateral de artéria torácica interna sem circulação extracorpórea

Advances in surgical myocardial revascularization (MR) have introduced additional benefits with the off-pump (OP) technique and the use of bilateral internal thoracic artery (ITA) grafting. Off-pump surgical MR has been associated with improved immediate outcomes and reduced incidence of perioperative complications, and the use of bilateral ITA grafts provides increased survival and decreased cardiovascular events in the long term. To present the initial experience with the combined use of these advances in surgical MR. A total of 35 consecutive patients undergoing off-pump MR with bilateral ITA grafting were studied; the left ITA was directed toward the anterior descending artery and the right ITA was anastomosed to the circumflex artery branches. The predominant comorbidities were previous myocardial infarction in 71.4% of the patients, diabetes mellitus in 34.2%, and renal failure in 14.2%. RESULTS No patients presented electrocardiographic changes or enzyme elevation in the postoperative period. The number of bypasses per patient ranged from two to four (median of three bypasses/patient). Postoperative hospital stay ranged from three to 12 days (mean of 4.7 + 1.7 days). No cases of sternal dehiscence or infection were observed, but one patient suffered a stroke on the fourth postoperative day and died. Late follow-up lasted from four to 48 months. No late deaths occurred, 31 patients are asymptomatic, and three have residual angina. The combination of these technical advances in surgical myocardial revascularization proved efficient and able to contribute to improved benefits in the long term.

Long-Term Results of Bilateral Internal Thoracic Artery Grafting in Dialysis Patients

We evaluated the perioperative and long-term results of bilateral internal thoracic artery grafting in dialysis patients. One hundred one consecutive patients on chronic dialysis who underwent isolated coronary artery bypass grafting were retrospectively compared according to the surgical technique, bilateral internal thoracic artery (BITA) grafting (n = 76) or single internal thoracic artery (SITA) grafting (n = 25). Hospital mortality was 5.3% in the BITA group and 8.0% in the SITA group (p = not significant). The incidence of mediastinitis was not different (7.9% in the BITA group and 8.0% in the SITA group). The median duration of follow-up was 3.1 years (range, 0.1 to 10.9). Survival and freedom from cardiac mortality were not different between the two groups, but the BITA group had a trend toward better results. Freedom from cardiac events (including cardiac-related death, myocardial infarction, percutaneous coronary intervention, redo coronary artery bypass grafting, and congestive heart failure) was superior in the BITA group (p = 0.03). Calcification of the ascending aorta, peripheral vascular disease, insulin-dependent diabetes mellitis, and age were the independent risk factors of late death. Perioperative results of BITA grafting in dialysis patients were not different from the results of SITA grafting. However, the long-term results of BITA grafting in dialysis patients were better than the results of SITA grafting. Overall, our results support the continued use of BITA grafting in dialysis patients.

Myocardial revascularization with bilateral internal thoracic artery in patients with left main disease: an incremental risk?

Although the long-term patency of the internal thoracic artery (ITA) has been well proved, there is still some concern about its preoperative performance. We considered 80 patients with left main disease (mean age 60.2 years) who underwent coronary artery bypass grafting in our institute from March 1988 to September 1992. Patients with left main disease were divided into 2 groups: group I-38 patients receiving only ITA grafts on the left coronary system and group II-42 patients having a single ITA graft together with saphenous vein grafts on the left coronary system. No patients in group I received a saphenous graft on the left coronary system and three patients with right coronary artery involvement received total arterial myocardial revascularization with the use of the inferior epigastric artery. Perioperative complications in group I and group II patients were, respectively: myocardial necrosis in 2 (6.9%) and 3 (8.8%), use of intraaortic balloon pump in 2 (6.9%) and 2 (5.9%). No death occurred in either group. In our experience, the use of bilateral ITA grafts in patients with left main stenosis was not related to an incremental risk. We conclude that left main disease should not be considered as counterindication to the extensive use of arterial conduits.

Mid-term results of bilateral internal thoracic artery grafting.

Forty patients underwent coronary revascularization using bilateral internal thoracic artery (ITA) grafts between 1988 and 1992. A total of 111 coronary grafts were performed, or an average of 2.8 grafts per patient. Each patient received bilateral ITA grafts, and in 20 patients an additional 29 grafts were constructed with 18 autologous veins and 11 gastroepiploic arteries. The right ITA was grafted as a free graft in 20 patients. The ITA graft patency rate was 96 per cent (67/70) at the time of hospital discharge. The operative morbidity included 3 reoperations for bleeding, 1 perioperative myocardial infarction, 1 renal failure, 2 postcardiotomy shock, and 1 colon perforation. Two hospital deaths occurred; one due to colon perforation and the other due to postcardiotomy cardiogenic shock. One patient died of cerebral infarction 6 month after the operation. Thirty-four patients were in New York Heart Association functional class I, 2 were in class II and 1 was in class III. Cardiac function evaluated by echocardiography and scintigraphy showed significant improvement postoperatively. These data suggest that the use of bilateral ITA grafts is associated with an acceptable mortality and increases the versatility of arterial grafting.