Use Of Internal Thoracic Artery Research Articles

Randomized Trial of Bilateral versus Single Internal-Thoracic-Artery Grafts

BackgroundThe use of bilateral internal thoracic (mammary) arteries for coronary-artery bypass grafting (CABG) may improve long-term outcomes as compared with the use of a single internal-thoracic-artery plus vein grafts.MethodsWe randomly assigned patients scheduled for CABG to undergo single or bilateral internal-thoracic-artery grafting in 28 cardiac surgical centers in seven countries. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. Interim analyses were prespecified at 5 years of follow-up.ResultsA total of 3102 patients were enrolled; 1554 were randomly assigned to undergo single internal-thoracic-artery grafting (the single-graft group) and 1548 to undergo bilateral internal-thoracic-artery grafting (the bilateral-graft group). At 5 years of follow-up, the rate of death was 8.7% in the bilateral-graft group and 8.4% in the single-graft group (hazard ratio, 1.04; 95% confidence interval [CI], 0.81 to 1.32; P=0.77), and the rate of the composite of death from any cause, myocardial infarction, or stroke was 12.2% and 12.7%, respectively (hazard ratio, 0.96; 95% CI, 0.79 to 1.17; P=0.69). The rate of sternal wound complication was 3.5% in the bilateral-graft group versus 1.9% in the single-graft group (P=0.005), and the rate of sternal reconstruction was 1.9% versus 0.6% (P=0.002).ConclusionsAmong patients undergoing CABG, there was no significant difference between those receiving single internal-thoracic-artery grafts and those receiving bilateral internal-thoracic-artery grafts with regard to mortality or the rates of cardiovascular events at 5 years of follow-up. There were more sternal wound complications with bilateral internal-thoracic-artery grafting than with single internal-thoracic-artery grafting. Ten-year follow-up is ongoing. (Funded by the British Heart Foundation and others; ART Current Controlled Trials number, ISRCTN46552265.)

The Fate of a Composite Arterial Graft in a 58-Year-Old Man with Strong Comorbidities and Atherosclerotic Burden

For some difficult subsets of coronary patients having specific comorbidities, such as insulin-dependent diabetes and chronic renal failure, arterial myocardial revascularization could be a satisfactory option. The key question is which arteries should be used. A 58-year-old insulin-dependent diabetic patient with severe renal failure, despite previous kidney transplantation, underwent treatment of his severe and diffuse coronary disease using a composite arterial Y-graft and saphenous vein. Both internal thoracic arteries were harvested as skeletonized conduits. The patient's hospital course was totally uneventful. Fifty-six months later, the patient underwent hospital readmission due to a new (inferior) myocardial infarction. Coronary angiography showed both the progression of disease into the native vessels and occlusion of the venous graft. The Y-graft was patent and well functioning despite the presence of a preoperative left upper limb dialysis fistula. This case report emphasizes the concept that both internal thoracic arteries seem to be refractory to most aggressive forms of atherosclerosis, and that a more liberal use even for high-risk candidates could be a rational practice. However, many surgeons consider the use of both internal thoracic arteries for myocardial revascularization as a too risky strategy that has to be adopted only for young and low-risk patients.

14-Year Results of Bilateral versus Single Internal Thoracic Artery Grafts for Left-Sided Myocardial Revascularization in Young Diabetic Patients.

Objectives Despite encouraging late outcomes, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization in diabetic patients remains controversial because of an increased risk of sternal wound complications. In the present study, early- and long-term outcomes of the use of left-sided BITA versus single internal thoracic artery (SITA) grafting in young (< 65 years of age) diabetic patients were reviewed retrospectively. Methods A total of 250 propensity score pair-matched diabetic patients, operated on between February 2000 and December 2011, receiving either BITA (n = 125) or SITA (n = 125) grafting were analyzed retrospectively. In each group, 104 patients were males, and mean age was 60.1 ± 5.3 years. Follow-up was 2.1 to 14.8 years (mean, 9.3 ± 3.5 years) and complete for 100%. Results Incidence of deep sternal wound infection was 2.4 versus 3.2% (p = 0.722). Rethoracotomy due to bleeding occurred in 4.8 versus 3.2% (p = 0.608). The 5-, 10-, and 14-year estimates of survival were 93.4, 76.6, and 67.5% (BITA) versus 89.5, 81.5, and 32.8% (SITA); p = 0.288. Freedom from reangiography/intervention (60.5 vs. 63.9%) during follow-up was comparable (p = 0.507) as well as infarction rate (93.8 vs. 95.1%, p = 0.833) and redoes (p = 0.672, exclusively valve surgery) were comparable. Freedom from thromboembolic or cerebrovascular events did not show any significant differences (94.0 vs. 94.0%, p = 0.78). Multivariate analysis identified poor ejection fraction as predictor for decreased long-term survival. Neither age nor gender or urgency had an influence on long-term mortality. Conclusion Left-sided BITA grafting may be performed routinely even in diabetic patients without increased incidence of postoperative wound-healing complications. Survival rates after 5, 10, and 14 years were comparable for BITA and SITA grafting.

Bilateral internal thoracic artery graft configuration and coronary artery bypass grafting conduits.

Bilateral internal thoracic arteries (BITAs) have demonstrated their superiority over all other types of graft in terms of patency and survival benefit. BITA implementation requires the surgeon's evaluation of the patient's coronary anatomy and demographics. There is no single ideal approach to BITA utilization, but instead a variety of configurations that can be implemented based on the patient characteristics. This article details the advantages and disadvantages of several BITA configurations in the setting of left-sided myocardial revascularization and right-sided myocardial revascularization. Different BITA configurations will be described and will ultimately serve as a guide to avoiding technical difficulties and helping surgeons construct decision-making trees to direct the implementation of BITA grafts. BITA grafting provides long-term clinical benefit over conventional grafting. Efforts should be directed toward a more efficient use of internal thoracic arteries, reducing the need for a third complementary graft, and toward identification of the best alternative to the saphenous vein graft as the third graft material for complete revascularization. Surgeons should ask their cardiologists to be as accurate as possible regarding the severity of the coronary lesion. If the severity of the lesion is not obvious upon an informal qualitative assessment, a functional flow reserve of the lesion should be performed, in order to identify the optimal graft.

Bilateral Internal Thoracic Artery Grafting Increases Mediastinitis: Myth or Fact?

There is controversy about the risk of mediastinitis associated with the use of both internal thoracic arteries (ITA). We performed a case-control study of patients operated on at a single institution from January 2003 to December 2014. A total of 3,118 consecutive patients undergoing isolated coronary artery bypass graft surgery were included; 81.3% (n= 2,533) underwent bilateral ITA (BITA) grafts exclusively and constitute the BITA group, and 18.7% (n= 585) constitute the single ITA (SITA) group. Mediastinitis was defined as deep tissue mediastinal infection, with clinical or microbiologic evidence. Continuous variables were expressed as mean ± SD, and categoric variables as percentage (range). Student's t test and Fisher's exact test were used, as appropriate. Propensity score matching analysis was performed according to the nearest neighbor estimation method (n= 1,040). The incidence of diabetes mellitus was similar in both groups (29%, p= 0.9). The BITA patients were more like to be younger (p < 0.001), men (p < 0.001), had a higher prevalence of hypertension (p < 0.01), higher body mass index (p < 0.001), lower prevalence of left ventricular dysfunction (p < 0.001) and of previous myocardial infarction (p < 0.01), and greater use of off-pump coronary artery bypass graft surgery (p < 0.01). The BITA patients had lower unadjusted hospital mortality (1.6%, versus 5.3% for SITA, p < 0.0001). The total incidence of mediastinitis was 1.8% (BITA 1.9% versus SITA 1.5%, p= 0.6). Diabetes (p < 0.01) and nonelective surgery (p= 0.004) were the only predictors of mediastinitis in the entire population. Propensity score matching showed no differences in mediastinitis: BITA 2.5% versus SITA 1.3% (p= 0.17). In this series of patients, BITA did not increase the risk of mediastinitis in the total population or in the propensity score matched subgroups.

Right internal thoracic artery or radial artery? A propensity-matched comparison on the second-best arterial conduit

ObjectivesWe conducted propensity score matching to determine whether the use of the right internal thoracic artery (RITA) confers a survival advantage when compared with the radial artery (RA) as second arterial conduit in coronary artery bypass grafting. MethodsThe study population included a highly selected low-risk group of patients who received the RITA (n = 764) or the RA (n = 1990) as second arterial conduit. We obtained 764 matched pairs that were comparable for all pretreatment variables. A time-segmented Cox regression model that stratified on the matched pairs was used to investigate the effect of treatment on late mortality. ResultsAfter a mean follow-up of 10.2 ± 4.5 years (maximum 17.3 years), survival probabilities at 5, 10, and 15 years were 96.4% ± 0.7% versus 95.4% ± 0.7%, 91.0% ± 1.1% versus 89.1% ± 1.2%, and 82.4% ± 1.9% versus 77.2% ± 2.5% in the RITA and RA groups, respectively. During the first 4 years, RITA and RA were comparable in terms of mortality (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.56-1.78; P = .98). However, after 4 years RITA was associated with a significant reduction in late mortality (HR, 0.67; 95% CI, 0.48-0.95; P = .02). RITA was superior to RA when the experimental conduit was used to graft the left coronary system (HR, 0.69; 95% CI, 0.47-0.99; P = .04) but not the right coronary system (HR, 0.98; 95% CI, 0.59-1.62; P = .93). ConclusionsIn a highly selected low-risk group of patients, the use of the RITA as second arterial conduit instead of the RA was associated with better survival when used to graft the left but not the right coronary artery.

Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes.

Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting in women. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender. Of 786 consecutive women with multivessel coronary disease who underwent isolated coronary bypass surgery at the authors' institution from 1999 throughout 2014, 477 (60.7%; mean age: 70±7.7years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models. There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2±6.1%); glomerular filtration rate<50ml/min was an independent risk factor (p=0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index >35kg/m2 (p=0.0094), diabetes (p=0.005), non-elective surgical priority (p=0.0087) and multiple blood transfusions (p=0.016). The mean follow-up was 6.8±4.5years. The non-parametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1-79.1], 59.5 (95% CI: 55.9-63.1) and 91.9% (95% CI: 90.1-93.7), respectively. Preoperative congestive heart failure (p=0.04) and left main coronary artery disease (p=0.0095) were predictors of major adverse cardiac and cerebrovascular events. BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes.

Dilated right internal thoracic artery as a systemic pulmonary shunt

We report the use of a dilated right internal thoracic artery as a systemic-pulmonary shunt in a patient with a single ventricle who developed a systemic-pulmonary shunt stenosis following a modified Norwood's procedure. The systemic-to-pulmonary artery shunt was performed at 13 months of age, and the patient has stable oxygen saturations five years after the surgery.

Is the Risk of Wound Infection Related to Bilateral Internal Thoracic Artery Graft Potentiated by Age?

Older age and the use of bilateral internal thoracic artery (ITA) grafting are both considered risk factors for surgical wound infection (SWI) after coronary artery bypass grafting (CABG). The 2014 European Guidelines recommend that bilateral ITA grafting should be considered in patients aged younger than 70 years. Our aim was to investigate interaction between age and the number of ITA grafts. All patients aged 18 years and older who had undergone CABG with at least 1 ITA at Rouen University Hospital between 2001 and 2012 were selected. Data regarding surgical procedure (single/bilateral ITA grafting) were extracted from the medical information system. SWI was identified from prospective surveillance of patients according to Centers for Disease Control and Prevention criteria. Independent factors associated with SWI were assessed by logistic regression, and an interaction test between age (≤69 or ≥70 years) and the number of ITA grafts was performed. SWI occurred in 71 of 2,726 patients (2.6%). Bilateral ITA grafting was associated with SWI (adjusted odds ratio [aOR], 2.55; 95% confidence interval, 1.51 to 4.30). After fitting an interaction term between age and number of ITA grafts, the aORs for SWI after bilateral ITA grafting substantially differed between patients aged 69 years and younger (aOR, 1.88; 95% confidence interval, 0.94 to 3.75) and 70 years and older (aOR, 3.52; 95% confidence interval, 1.69 to 7.33). However, this interaction failed to reach statistical significance (p= 0.2213), possibly because of insufficient statistical power (23.5%) despite the large sample size. Age 70 years and older compared with age 69 years and younger was associated with higher occurrence of SWI after bilateral ITA grafting, but this interaction was not statistically significant. Larger studies are needed to test this interaction.

The Impact of Diabetes on Early Outcomes after Routine Bilateral Internal Thoracic Artery Grafting

Increased risk of postoperative complications limits use of bilateral internal thoracic artery (BITA) grafting in diabetic patients. The authors' experience in routine BITA grafting was reviewed to investigate the impact of diabetes on early outcomes. Among the 4508 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery from January 1999 throughout August 2015, skeletonised BITA grafts were used in 3228 (71.6%) patients, 972 diabetic and 2256 non-diabetic. After one-to-one propensity score (PS)-matched analysis, 819 pairs of diabetic/non-diabetic patients were compared for postoperative outcomes. The operative risk was calculated for each patient according to the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II). Although diabetic had higher risk profiles than non-diabetic patients both in unmatched (EuroSCORE II: 5.3±7.3% vs. 3±4.2%, p<0.0001) and PS-matched series (EuroSCORE II: 5.1±7.1% vs. 3.6±4.3%, p<0.0001), there were no differences in hospital mortality (2.2% vs. 1.8%, p=0.52 and 2.1% vs. 2.3%, p=0.74, respectively). In PS-matched pairs, the use of adrenergic agonists (p=0.03), postoperative bleeding (p=0.0055) and deep incisional sternal wound infection (p=0.0018) were more frequent in diabetic patients who had a mean of longer hospital stays (p=0.023). Bilateral internal thoracic artery grafting may be routinely performed even in diabetic patients despite higher risk profiles. Increased postoperative complications prolong hospital stay but do not impact on early mortality.

The Effect of Bilateral versus Single Internal Thoracic Artery Harvesting on Superficial and Deep Sternal Wound Infection

Objectives: Many studies have shown that the use of both internal thoracic arteries (BITA) increases long-term survival relative to the use of the single internal thoracic artery (SITA) and saphenous vein grafts (SVG). But on the other side the use of BITA potentially increases the incidence of sternal wound infections.

Coronary artery bypass grafting with use of autograft internal thoracic artery

Coronary artery bypass grafting with use of autograft internal thoracic artery

Bilateral Internal Thoracic Artery Composite Y Grafts: Analysis of 464 Angiograms in 296 Patients

The use of bilateral internal thoracic arteries (BITA) in coronary artery bypass graft surgery improves patient survival. The optimum BITA graft configuration is unknown. This study evaluates outcomes after the use of bilateral internal mammary Y grafting as the primary grafting strategy. Patients who underwent BITA composite Y grafting (n = 1,011) between October 1994 and March 2009 were identified from a cardiac surgical database. Follow-up (mean 12 years) was obtained by cross-reference with the state death registry and local cardiology databases. Perioperative mortality was 1.6%. Kaplan-Meier 10-year survival was 87.2%. There were 464 episodes of postdischarge angiography in 296 patients, at an average of 5.5 years to first angiography. Graft failure occurred in 151 patients, predominately affecting the right ITA limb (n = 139). Degree of native vessel stenosis (odds ratio [OR] 0.66 per 10% increase), anatomic territory grafted (circumflex OR 2.64, right coronary OR 6.73 versus anterior), and end-to-side free wall anastomoses (OR 1.98) predicted anastomotic occlusion. The left anterior descending artery graft patency was unaffected by sequential grafting. Progression to graft failure after the first angiogram was rarely seen in the 111 patients who had serial angiography. Outcomes of BITA Y grafting are similar to those for other BITA configurations. The rate of presentation with arterial graft dysfunction decreases over time. Although competitive flow affects anastomotic patency, there is no threshold at which risk of occlusion substantially increases.

Long-term survival after use of internal thoracic artery in octogenarians is gender related

ObjectiveThe goal of this study is to assess the benefits of a left internal thoracic artery as a bypass conduit in octogenarians undergoing elective coronary artery bypass grafting. We hypothesize that there is no survival advantage and that outcome may be gender related. MethodsIn a retrospective analysis of 1141 octogenarians (aged >80 years) undergoing isolated coronary artery bypass grafting from 1996 to 2012, patients were divided into 2 groups: Group I (coronary artery bypass grafting–left internal thoracic artery) included 870 patients (339 female/531 male), and group II (coronary artery bypass grafting–saphenous vein graft) included 271 patients (131 female/140 male). ResultsThe overall 30-day mortality was 5.7%: 4.3% in group I and 7.0% in group II (P = .1). Group II had a lower trend of any postoperative complication (P = .05) and pneumonia (P = .05). When analyzed by gender, there were no discernable differences in long-term survival for male patients in group I (65% at 5 years and 29% at 10 years) versus male patients in group II (65% at 5 years and 31% at 10 years) (P = .2). However, survival was significantly greater for female patients in group I (70% at 5 years and 35% at 10 years) versus female patients in group II (63% at 5 years and 21% at 19 years) (P = .01). Multiple logistic and Cox regression analysis showed that left internal thoracic artery use is associated with improved survival in female patients (hazard ratio [HR], 0.72; confidence interval [CI], 0.56-0.93) but not in male patients (HR, 1.14; CI, 0.9-1.4). Advanced age was associated with an increased risk of mortality (HR, 1.08 per year; CI, 1.05-1.1). Both patient age (P = .01) and Society of Thoracic Surgeons–predicted 30-day mortality (P = .03) remain in the final model for 30-day mortality. The benefit of the left internal thoracic artery after coronary artery bypass grafting in octogenarians may be gender related. ConclusionsThis study shows that the benefit of the left internal thoracic artery in the octogenarian population undergoing coronary artery bypass grafting may be gender related. For elderly female patients, the use of the left internal thoracic artery as a bypass conduit was associated with better long-term survival, whereas no significant difference was found among the male population. The use of the left internal thoracic artery was associated with a greater postoperative pulmonary morbidity for the study population as a whole. The present study does not refute the benefit of the left internal thoracic artery–left anterior descending graft, but instead distinguishes a subset who might benefit more.

Are all forms of total arterial revascularization equal? A comparison of single versus bilateral internal thoracic artery grafting strategies

ObjectiveTotal arterial revascularization (TAR) with internal thoracic arteries (ITAs) and radial arteries (RA) is associated with greater long-term survival compared with the use of a single internal thoracic artery supplemented by veins. The optimal conduit choice and configuration in achieving TAR remains controversial, with uncertainty regarding the individual prognostic impact of ITAs and RAs. As such, among patients solely undergoing TAR, we compared long-term survival between patients receiving single thoracic arteries and those receiving bilateral ITAs. MethodsFrom 1995 to 2010, 2821 patients with 3-vessel coronary artery disease at 8 centers underwent primary isolated coronary artery bypass with TAR using ITAs and RAs. Bilateral ITAs were used in 912 patients. In 380 cases, bilateral in situ ITAs were grafted to the left coronary system. RAs were used in 848 patients (93%) receiving bilateral ITAs and 1906 patients (99.8%) receiving single ITAs. Survival data were obtained using the National Death Index. Separate 1:1 propensity score–matched analyses were performed for (1) bilateral ITA versus single ITA and (2) bilateral ITA incorporating a free right ITA versus single ITA and RAs. Among the 912 patients with bilateral ITAs, those receiving an in situ right ITA to the left coronary system were compared with those receiving a free right ITA. ResultsIn the propensity score–matched analysis comparing bilateral versus single ITAs (591 matched pairs), there were similar rates of 30-day mortality and deep sternal wound infection. Bilateral ITA use was associated with greater 15-year survival (79% ± 3.9% vs 67% ± 4.7%, P < .001). In the analysis between bilateral ITA incorporating a free right ITA versus single ITA + RAs (380 matched pairs), bilateral ITA use demonstrated comparable survival at 15 years (79% ± 4.7% vs 67% ± 5.7%, P = .09). Among patients receiving bilateral ITAs, comparison between in situ right ITA versus free right ITA recipients (206 matched pairs) revealed comparable 15-year survival (84% ± 6.1% vs 79% ± 6.7%, P = .13). Multivariable Cox regression found bilateral ITA use to be protective from mortality (hazard ratio, 0.73; 95% confidence interval, 0.59-0.90, P = .004). ConclusionsThe use of bilateral ITAs as an in situ or free conduit is associated with greater survival and seems to offer a prognostic advantage over the use of only a single ITA supplemented by RAs. Therefore, all configurations of TAR are not equivalent.

A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting.

Despite long-term survival benefits, the increased risk of sternal complications limits the use of bilateral internal thoracic artery (BITA) grafts for myocardial revascularization. The aim of the present study was both to analyse the risk factors for deep sternal wound infection (DSWI), which complicates routine BITA grafting and to create a DSWI risk score based on the results of this analysis. BITA grafts were used as skeletonized conduits in 2936 (70.6%) of 4160 consecutive patients with multivessel coronary artery disease who underwent isolated coronary bypass surgery at the authors' institution from 1 January 1999 to 2013. The outcomes of these BITA patients were reviewed retrospectively and a risk factor analysis for DSWI was performed. A total of 129 (4.4%) patients suffered from DSWI. Two multivariable analysis models were created to examine preoperative factors either alone or combined with intraoperative and postoperative factors. Female gender, obesity, diabetes, poor glycaemic control, chronic lung disease and urgent surgical priority were the predictors of DSWI common to both models. Two (preoperative and combined) models of a new scoring system were devised to predict DSWI after BITA grafting. The preoperative model performed better than five of six scoring systems for sternal wound infection that were considered; the combined model performed better than three considered scoring systems. A weighted scoring system based on risk factors for DSWI was specifically created to predict DSWI risk after BITA grafting. This scoring system outperformed the existing scoring systems for sternal wound infection after coronary bypass surgery. Prospective studies are needed for validation.

Bilateral internal thoracic artery grafting in octogenarians: where are the benefits?

The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization is usually discouraged in the very elderly because of increased risk of perioperative complications. The aim of the study was to analyze early and late outcomes of BITA grafting in octogenarians. From January 1999 throughout February 2014, 236 consecutive octogenarians with multivessel coronary artery disease underwent primary isolated coronary bypass surgery at the authors' institution. Six of these patients underwent emergency surgery and were excluded from this retrospective study; consequently, 135 BITA patients were compared with 95 single internal thoracic artery (SITA) patients according to early and late outcomes. Between BITA and SITA patients, there was no significant difference in the operative risk (EuroSCORE II: 8±7.7 vs. 7.6±6.1%, p=0.65). There was a lower aortic manipulation in BITA patients. Hospital mortality (3 vs. 4.2%, p=0.44) and perioperative complications were similar except that only BITA patients experienced sternal wound infection (5.2%, p=0.022). The mean follow-up was 4.7±3.3years. There were no differences between the two groups in overall survival (p=0.79), freedom from cardiac and cerebrovascular deaths (p=0.73), major adverse cardiac and cerebrovascular events (p=0.63) and heart failure hospital readmission (p=0.64). Predictors of decreased late survival were diabetes (p=0.0062) and congestive heart failure (p=0.0004). BITA grafting can be routinely used in octogenarians with atherosclerotic ascending aorta without an increase in hospital mortality or major adverse cardiac and cerebrovascular complications. However, there is an increased risk of sternal wound infection without a demonstrable long-term benefit.

"Blame it on the Comorbidities": A 5-Year Follow-Up of 53 Chronic Dialysis-Dependent Patients Who Underwent Cardiac Surgery.

Objectives This study evaluates midterm survival rates and risk factors for mortality of chronic dialysis-dependent patients undergoing cardiac surgery. Methods Fifty-three dialysis-dependent patients (34 males, aged 67 ± 12 years) with end-stage renal disease operated within March 2007 and May 2012 were analyzed retrospectively. Survival rates were calculated using Kaplan-Meier methods. Predictors of midterm survival were identified with multivariate Cox-regression analysis. Results Twenty-three patients received isolated coronary artery bypass graft surgery, 17 received isolated valve replacement, and 13 received combined procedures. Thirty-day mortality was 24.5% (n = 13). Follow-up was complete for 94.3% (n = 50). Survival rates at 1, 3, and 5 years were: 82, 50, and 17%, respectively. Neither age, gender, poor ejection fraction, emergency, ECC/X-clamp (cross-clamp) time, nor use of left internal thoracic artery or right internal thoracic artery had any influence on midterm survival. Causes of death within midterm follow-up period were related to cardiac events in 16% and neurological events in 16%. In the majority (47%), cause of death was associated with peripheral arterial disease (PAD).The only comorbidity, which could be identified as a significant risk factor, was PAD (p = 0.035). Five patients underwent successful renal transplantation within the follow-up period. Conclusion Although 30-day mortality in this high-risk patient population was increased, midterm survival rates were comparable to the results described in the literature. Cause of death within midterm follow-up period was mostly noncardiac related. Given the limited number of patients, predictors for enhanced 30-day mortality, such as preoperative myocardial infarction, prolonged extracorporeal circulation, operation time, and diabetes mellitus, did not have an influence on midterm survival.

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.

The Use of Vacuum-Assisted Closure in Purulent Complications and Difficult-To-Heal Wounds in Cardiac Surgery.

Sternal wound infections are aserious and potentially fatal complication of cardiac surgery. The aim of the study was to analyze the results of using the vacuum-assisted closure (VAC) system over a4-year period. Quantitative VAC performance data from aretrospective review of aconsecutive cohort of 47patients treated with VAC for post-cardiac surgery wound complications were collected and statistically analyzed. In the study group35patients developed infections of the post-operative chest wound. In 12 other patients wound dehiscence was observed, but repeated cultures did not reveal the presence of any bacteria. The statistical analysis identified the following as significant risk factors: age, female sex, being overweight, ahigh total logistic EuroScore, the use of both internal thoracic arteries for bypass grafting, and diabetes. In the wound negative culture group the total length of hospital stay was significantly shorter than in the wound positive culture group. Mortality in this group was 0.0% vs. 5.7% in the wound positive culture group. In the study material, Gram-negative bacteria were responsible for 77% of the post-operative wound infections, with only 14% Gram-positive wound cultures. No complications were related to VAC use. The use of negative-pressure wound therapy with other concomitant surgical procedures is agood method of treating infected wounds as well as non-contaminated dehiscence of the wound and sternum. Considering that most of the infections within the authors' department are caused by Gram-negative bacteria, it would be beneficial to consider modifying the model of preventive antibiotic treatment to cover the Gram-negative spectrum in addition to the Gram-positive bacteria currently targeted.