Propensity-Score Analysis of Early Outcomes after Bilateral versus Single Internal Thoracic Artery Grafting

Pusca, Sorin V.; Kilgo, Patrick D.; Vega, J. David; Cooper, William A.; Vassiliades, Thomas A.; Chen, Edward P.; Lattouf, Omar M.; Guyton, Robert A.; Puskas, John D.

doi:10.1177/155698450800300105

Cited by 4 publications

(8 citation statements)

References 18 publications

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“…This was not an entirely unexpected result. Although many published series [21,[24][25][26][27][28] and a randomized controlled trial as well [29] have shown no significant differences in the early mortality between bilateral and single ITA grafting, in many out of these studies, however, hospital (or 30-day) mortality was lower (albeit not significantly) in bilateral than in single ITA grafting. Moreover, almost none of these studies discriminate between patients with and without LV dysfunction.…”

Section: Discussionmentioning

confidence: 87%

Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction

et al. 2015

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Despite encouraging improvements, outcomes of coronary artery bypass grafting (CABG) in the presence of left ventricular (LV) dysfunction remain poor. In the present study, the authors' experience on this subject was reviewed to establish the predictors of immediate and long-term results of surgery. Out of 4383 consecutive patients with multivessel coronary artery disease who underwent primary isolated CABG at the authors' institution from January 1999 throughout September 2014, 300 patients (mean age 66.1 ± 9.6 years) suffered preoperatively from LV dysfunction (defined as LV ejection fraction ≤35 %). The mean expected operative risk (EuroSCORE II) was 10.3 ± 13 %. Hospital deaths and perioperative complications were analyzed retrospectively. Outcomes were evaluated during a mean follow-up of 6.2 ± 4 years. None, one or both internal thoracic arteries (ITAs) were used in 6.3, 29 and 64.7 % of cases, respectively. There were 16 (5.3 %) hospital deaths. Prolonged invasive ventilation (17.7 %), acute kidney injury (14.7 %) and multiple blood transfusion (21.3 %) were the most frequent major postoperative complications. The 10-year non-parametric estimates of freedom from all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were 47.8 [95 % confidence interval (CI) 44.1-51.5], 65.3 (95 % CI 61.4-69.2), and 42.3 % (95 % CI 38.3-46.3), respectively. Shared predictors of decreased late survival and MACCEs were old age (P < 0.04), chronic lung disease (P < 0.01), chronic dialysis (P < 0.0001) and extracardiac arteriopathy (P < 0.045). After adjustment for corresponding risk factors, freedom from cardiac death was higher when both ITAs were used but only for patients with significant increase of LV ejection fraction early after surgery (P = 0.04). In patients with LV dysfunction, CABG may be performed with acceptable hospital mortality and long-term survival. Late outcomes depend mainly on preoperative characteristics of the patients. The use of both ITAs for myocardial revascularization may give long-term survival benefits but only for patients whose LV function improves significantly early after surgery.

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Section: Discussionmentioning

confidence: 87%

Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction

et al. 2015

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“…BITA grafting has been previously reported to be used in only 5.3% of obese patients undergoing CABG. 14 This report is likely to be among the very few that have focused on the impact of the use of BITA in obese patients. We found that, compared with SITA grafting, BITA grafting was associated with a 65% absolute risk reduction for late death and a 55% absolute risk reduction for the need for repeat revascularization.…”

Section: Discussionmentioning

confidence: 98%

“…9,10 The main reason for the long-term benefit from the use of a second internal thoracic artery has been attributed to its better patency rate, 11 secondary to the reduced susceptibility to atherosclerosis compared with SVG. 12 Although such a benefit is expected to be enhanced in patients with higher BMI, 11,13 surgeons continue to be reluctant to perform bilateral internal thoracic artery (BITA) grafting in obese patients, 14 because of the lack of evidence of a longterm benefit in such a high-risk group. Furthermore, concerns still exist regarding the detrimental effect of this strategy on operative outcomes, including the potential vulnerability for sternal wound complications in such a high-risk group.…”

mentioning

confidence: 99%

“…Furthermore, concerns still exist regarding the detrimental effect of this strategy on operative outcomes, including the potential vulnerability for sternal wound complications in such a high-risk group. 5,[14][15][16] Therefore, there is an urgent need to validate the safety and efficacy of BITA grafting for obese patients requiring CABG. We undertook a single-center propensity matched outcomes analysis to evaluate the impact of BITA compared with single internal thoracic artery (SITA) on short-and long-term outcomes in obese patients.…”

mentioning

confidence: 99%

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Impact of the second internal thoracic artery on short- and long-term outcomes in obese patients: A propensity score matched analysis

Benedetto

Montecalvo

Kattach

et al. 2015

The Journal of Thoracic and Cardiovascular Surgery

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“…This increase in sternal mediastinitis may be secondary to a diminution of sternal blood supply after pedicled BITA [24,[46][47][48]. Although several investigators have reported an increased risk of sternal wound infections with BITA harvesting [49,50], others have reported no significant difference in sternal wound complications, particularly after adjustment for other potentially confounding risk factors (such as sex, obesity, COPD and smoking) [51].…”

Section: Bilateral Itamentioning

confidence: 99%

The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting

Aldea

Bakaeen²,

Pal

et al. 2016

The Annals of Thoracic Surgery

317

220

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Internal thoracic arteries (ITAs) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated (class of recommendation [COR] I, level of evidence [LOE] B). As an adjunct to left internal thoracic artery (LITA), a second arterial graft (right ITA or radial artery [RA]) should be considered in appropriate patients (COR IIa, LOE B). Use of bilateral ITAs (BITAs) should be considered in patients who do not have an excessive risk of sternal complications (COR IIa, LOE B). To reduce the risk of sternal infection with BITA, skeletonized grafts should be considered (COR IIa, LOE B), smoking cessation is recommended (COR I, LOE C), glycemic control should be considered (COR IIa, LOE B), and enhanced sternal stabilization may be considered (COR IIb, LOE C). As an adjunct to LITA to LAD (or in patients with inadequate LITA grafts), use of a RA graft is reasonable when grafting coronary targets with severe stenoses (COR IIa, LOE: B). When RA grafts are used, it is reasonable to use pharmacologic agents to reduce acute intraoperative and perioperative spasm (COR IIa, LOE C). The right gastroepiploic artery may be considered in patients with poor conduit options or as an adjunct to more complete arterial revascularization (COR IIb, LOE B). Use of arterial grafts (specific targets, number, and type) should be a part of the discussion of the heart team in determining the optimal approach for each patient (COR I, LOE C).

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Propensity-Score Analysis of Early Outcomes after Bilateral versus Single Internal Thoracic Artery Grafting

Cited by 4 publications

References 18 publications

Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction

Predictors of immediate and long-term outcomes of coronary bypass surgery in patients with left ventricular dysfunction

Impact of the second internal thoracic artery on short- and long-term outcomes in obese patients: A propensity score matched analysis

The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting

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