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Background: Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery. While thyroid dysfunction can predict POAF, the association between preoperative serum free triiodothyronine (FT3) levels and POAF in patients undergoing off-pump coronary artery bypass (OPCAB) grafting remains unclear. This study aimed to investigate the relationship between preoperative FT3 levels and POAF in OPCAB patients., Methods: This prospective observational study included patients with sinus rhythm and no history of atrial fibrillation or thyroid disease who underwent OPCAB and FT3 testing at the Tianjin Chest Hospital from June 2021 to March 2023. The relationship between FT3 level and POAF was evaluated using restricted cubic spline. Cox proportional hazards regression models were used to analyze the associations between FT3 concentration categories [low T3 syndrome (LT3S) (FT3 below the normal range), low normal FT3 (3.10-4.59 pmol/L), high normal FT3 (4.60-6.80 pmol/L)] and POAF, adjusting for potential confounders. Stratified analyses were performed to assess effect modification by gender and age (<60 vs. ≥60 years old)., Results: Among 875 patients, 259 (29.6%) developed POAF within 2 days after surgery. Restricted cubic spline analysis showed an S-shaped association between FT3 concentration and POAF risk. Compared to the low normal FT3 group, LT3S was associated with an increased risk of POAF [hazard ratio (HR), 1.41; 95% confidence interval (CI): 1.90-2.19], while high normal FT3 was associated with a decreased risk (HR, 0.72; 95% CI: 0.51-0.99). The association between FT3 and increased POAF risk was more pronounced in patients aged ≥60 years (HR, 1.41; 95% CI: 1.89-2.22)., Conclusions: Preoperative FT3 levels most likely could predict POAF risk after OPCAB, especially in patients aged 60 years and older. Measuring FT3 preoperatively may identify high-risk patients benefiting from close monitoring and prophylactic treatment. Further investigation of thyroid hormone replacement therapy for LT3S is warranted., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-655/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Objectives: Female gender and advanced age are regarded as independent risk factors for adverse outcomes after isolated coronary artery bypass grafting (CABG). There is paucity of evidence comparing outcomes of CABG between male and female octogenarians. We aimed to analyse in-hospital outcomes of isolated CABG in this cohort., Methods: All octogenarians that underwent isolated CABG, from January 2000 to October 2017, were included. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. A propensity score was generated for each patient from a multivariable logistic regression model based on 25 pre-treatment covariates. A total of 156 matching pairs were derived., Results: Five hundred and sixty-seven octogenarians underwent isolated CABG. This included 156 females (mean age 82.1 [SD: 0.9]) and 411 males (mean age 82.4 [SD: 2.1 years]). More males were current smokers (P = 0.002) with renal impairment (P = 0.041), chronic obstructive pulmonary disease (P = 0.048), history of cerebrovascular accident (P = 0.039) and peripheral vascular disease (P = 0.027) while more females had New York Heart Association class 4 (P = 0.02), left ventricular ejection fraction 30-49% (P = 0.038) and left ventricular ejection fraction <30% (P = 0.049). On-pump, CABG was performed in 140 males and 52 females (P = 0.921). There was no difference in in-hospital mortality (5.4% vs 6.4%; P = 0.840), stroke (0.9% vs 1.3%; P = 0.689), need for renal replacement therapy (17.0% vs 13.5%; P = 0.732), pulmonary complications (9.5% vs 8.3%; P = 0.746) and sternal wound infection (2.7% vs 2.6%; P = 0.882). The outcomes were comparable for the propensity-matched cohorts., Conclusions: No gender difference in outcomes was seen in octogenarians undergoing isolated CABG., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: The aim of this study was to systematically review the simulators that are currently available for coronary artery bypass graft and valve surgery and, in addition, to review the validation evidence supporting them and to recommend several simulators for training based on the analysis of results., Methods: A systematic literature search of the MEDLINE® (1946 to May 2021) and EMBASE® (1947 to May 2021) databases was performed to identify simulators for coronary artery and valvular procedures in cardiothoracic surgery. A selection of keywords and MeSH terms was used to execute the literature search. After identification of relevant articles, data were extracted and analysed., Results: Thirty-seven simulators were found in 31 articles. Simulators were found for coronary artery bypass graft (n = 24) and valve surgery (n = 13). The majority of models were either benchtop (n = 28) or hybrid (n = 8) modalities. Evidence of validity was demonstrated in 15 (40.5%) simulators. Twenty-two (59.5%) simulators had no validation evidence, and 1 (2.7%) simulator had 3 or more elements of validity established., Conclusions: Two simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills' development whereas high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilized in early training, at which point the learning curve of trainees is steepest., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines., Methods: A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise., Results: 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items., Conclusion: We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Valve disease carries a huge burden globally and the number of heart valve procedures are projected to increase from the current 300 000 to 800 000 annually by 2050. Since its genesis 50 years ago, pericardial heart valve has moved leaps and bounds to ever more ingenious designs and manufacturing methods with parallel developments in cardiology and cardiovascular surgical treatments. This feat has only been possible through close collaboration of many scientific disciplines in the fields of engineering, material sciences, basic tissue biology, medicine and surgery. As the pace of change continues to accelerate, we ask the readers to go back with us in time to understand developments in design and function of pericardial heart valves. This descriptive review seeks to focus on the qualities of pericardial heart valves, the advantages, successes and failures encapsulating the evolution of surgically implanted pericardial heart valves over the past five decades. We present the data on comparison of the pericardial heart valves to porcine valves, discuss structural valve deterioration and the future of heart valve treatments., (Copyright © 2021 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Utilisation of the Endoscopic Vein Harvesting (EVH) technique has been increasing for coronary artery bypass grafting (CABG) for the last two decades. Some surgeons remain concerned about the long-term patency of the long saphenous vein harvested endoscopically compared to traditional Open Vein Harvesting (OVH). The aim of this study was to perform a retrospective analysis of the outcomes between EVH and OVH from three UK centres with 10 years follow-up., Methods: 27,024 patients underwent CABG with long saphenous vein harvested by EVH (n=13,794) or OVH (n=13,230) in three UK centres between 2007 and 2019. Propensity modelling was used to calculate the Inverse Probability of Treatment Weights (IPTW). The primary endpoint was mortality from all causes and secondary endpoints were length of hospital stay, postoperative complications, and incidence of repeat coronary re-vascularisation for symptomatic patients. IPTW was used to balance the two intervention groups for baseline and preoperative co-morbidities., Results: Median follow-up time was 4.54 years for EVH and 6.00 years for OVH. Death from any cause occurred in 13.8% of the EVH group versus 20.8% in the OVH group over the follow-up period. The hazard ratio of death (EVH to OVH) was 0.823 (95% CI: 0.767, 0.884). Length of hospital stay was similar between the groups (p=0.86). Post-operative pulmonary complications were more common in EVH vs OVH (14.7% vs. 12.8%, p<0.001), but repeat coronary re-vascularisation was similar between the groups., Conclusions: This large retrospective multicentre analysis indicates that EVH has a lower risk of mortality compared with OVH during the follow-up period of the study. The observed benefits of EVH may outweigh the risks but should be considered on a case-by-case basis. We hope this review gives confidence to other cardiac centres that offering an EVH approach to conduit harvesting does not affect long term patient outcomes., Competing Interests: No competing interests were disclosed., (Copyright: © 2021 Krishnamoorthy B et al.)

Importance: Randomized clinical trials (RCTs) provide the highest level of evidence to evaluate 2 or more surgical interventions. Surgical RCTs, however, face unique challenges in design and implementation., Objective: To evaluate the design, conduct, and reporting of contemporary surgical RCTs., Evidence Review: A literature search performed in the 2 journals with the highest impact factor in general medicine as well as 6 key surgical specialties was conducted to identify RCTs published between 2008 and 2020. All RCTs describing a surgical intervention in both experimental and control arms were included. The quality of included data was assessed by establishing an a priori protocol containing all the details to extract. Trial characteristics, fragility index, risk of bias (Cochrane Risk of Bias 2 Tool), pragmatism (Pragmatic Explanatory Continuum Indicator Summary 2 [PRECIS-2]), and reporting bias were assessed., Findings: A total of 388 trials were identified. Of them, 242 (62.4%) were registered; discrepancies with the published protocol were identified in 81 (33.5%). Most trials used superiority design (329 [84.8%]), and intention-to-treat as primary analysis (221 [56.9%]) and were designed to detect a large treatment effect (50.0%; interquartile range [IQR], 24.7%-63.3%). Only 123 trials (31.7%) used major clinical events as the primary outcome. Most trials (303 [78.1%]) did not control for surgeon experience; only 17 trials (4.4%) assessed the quality of the intervention. The median sample size was 122 patients (IQR, 70-245 patients). The median follow-up was 24 months (IQR, 12.0-32.0 months). Most trials (211 [54.4%]) had some concern of bias and 91 (23.5%) had high risk of bias. The mean (SD) PRECIS-2 score was 3.52 (0.65) and increased significantly over the study period. Most trials (212 [54.6%]) reported a neutral result; reporting bias was identified in 109 of 211 (51.7%). The median fragility index was 3.0 (IQR, 1.0-6.0). Multiplicity was detected in 175 trials (45.1%), and only 35 (20.0%) adjusted for multiple comparisons., Conclusions and Relevance: In this systematic review, the size of contemporary surgical trials was small and the focus was on minor clinical events. Trial registration remained suboptimal and discrepancies with the published protocol and reporting bias were frequent. Few trials controlled for surgeon experience or assessed the quality of the intervention.

Objective: Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] < 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients., Methods: We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI., Results: 214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p < 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p < 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p < 0.001)., Conclusion: Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken., Competing Interests: Declaration of competing interest None., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: The complexities and risks inherent to the field of surgery and surgical interventions present unique challenges to the design and analysis of surgical randomized controlled trials (RCT). Prior studies have investigated the practical and methodologic challenges posed by surgical RCTs. To date, however, a comprehensive analysis of the contemporary literature across multiple surgical subspecialties does not exist. In this descriptive analysis, we set out to characterize surgical RCTs over the past 10 years across six major surgical specialties., Methods and Analysis: A literature search by a medical librarian will be performed to identify all surgical randomized clinical trials published between January 2009 and December 2019 in the two journals with the highest impact factor for six surgical specialties as well as two large general medicine journals. Two reviewers will independently screen the citations retrieved from the literature search and extract data according to a previously described protocol via a pre-defined data collection form. Categorical variables will be reported as counts and percentages. Following assessment of normality, continuous variables will be reported as mean (standard deviation) or median (inter-quartile range). Based on normality of data, independent t-test or the Mann-Whitney U test will be used to compare continuous variables and chi-square and Fisher's exact tests to compare categorical variables. Comparisons across multiple sets will be performed using ANOVA or Kruskak-Wallis tests. Two-sided significance testing will be used and a p-value <0.05 will be considered significant without adjustment for multiple testing. All analyses will be performed using SPSS version 24 and R within RStudio. PROSPERO (ID number: 162797)., Ethics and Dissemination: There are no ethical concerns directly pertinent to this systematic review. The retrieved data will be made available upon request. The study will be written in English and submitted for publication in a peer-reviewed journal., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2020 The Authors.)

Objectives: Despite evidence from several randomized controlled trials and observational studies validating short-term safety and efficacy of off-pump coronary artery bypass grafting (CABG), concerns persist regarding the impact of off-pump CABG on long-term survival and freedom from reintervention. This persistent scepticism regarding off-pump CABG prompted us to review our practice of CABG over the last 20 years with a view to comparing the impact of off-pump and on-pump CABG on short-term and long-term outcomes in a high-volume off-pump coronary surgery centre., Methods: We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 1996 to September 2017. Over the study period, 5995 off-pump CABG and 4875 on-pump CABG were performed by surgeons with exclusive off-pump and on-pump practices, respectively. Multivariable logistic regression and the Cox model were used to investigate the effect of off-pump versus on-pump procedures on short-term outcomes and long-term survival. Propensity score matching was used to compare the 2 matched groups., Results: Off-pump CABG was associated with a lower risk for 30-day mortality [odds ratio (OR) 0.42, 95% confidence interval (CI) 0.32-0.55; P < 0.001], reintubation/tracheostomy (OR 0.58, 95% CI 0.47-0.72; P < 0.001) and re-exploration for bleeding (OR 0.48, 95% CI 0.37-0.62; P < 0.001). The benefit in terms of operative deaths from off-pump was significant in those with Society of Cardio-Thoracic Surgery logistic EuroSCORE >2 (interaction P = 0.04). When compared with on-pump CABG, off-pump CABG did not significantly reduce the risk of stroke (OR 0.96, 95% CI 0.88-1.12; P = 0.20) and postoperative haemofiltration (OR 0.98, 95% CI 0.86-1.20; P = 0.35). At the median follow-up of 12 years (interquartile range 6-17, max 21), off-pump CABG did not affect late survival [log rank P = 0.24; hazard ratio (HR) 0.95, 95% CI 0.89-1.02] or the need for reintervention (log rank P = 0.12; HR 1.19, 95% CI 0.95-1.48)., Conclusions: This large volume, single-centre study with the longest reported follow-up confirms that off-pump CABG performed by experienced surgeons, who perform only off-pump procedures in a high-volume off-pump coronary surgery centre, is associated with lower risk of operative deaths, fewer postoperative complications and similar 20-year survival and freedom from reintervention rates compared with on-pump CABG., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Competing Interests: Declaration of competing interest None.

Objectives: The intermediate-term all-cause mortality rate of real-world patients with multivessel disease (MVD) treated with percutaneous coronary intervention (PCI) with new-generation drug-eluting stents or coronary artery bypass grafting (CABG) remains unknown. We sought to compare the intermediate-term all-cause mortality rates of real-world patients with MVD including left main stem disease, treated with CABG or PCI., Methods: All consecutive all-comer patients with MVD undergoing CABG or PCI with second/third generation drug-eluting stents from 2007 to 2015 in Harefield Hospital, UK were included in this study. The revascularization modality was based on heart team discussions. Primary outcome was all-cause mortality. Mean follow-up of the study was 3.3 years. Cox regression analysis and propensity matching were used., Results: Of 6383 patients with MVD, 4230 underwent CABG, whereas 2153 had PCI with new-generation stents. In the CABG group, the mean age was 66.4 ± 10 years, whereas in the PCI group it was 65.3 ± 12.1 years (P < 0.001). Fewer female patients with MVD were treated with CABG than were treated with PCI (18.5% vs 20.5%; P = 0.026). There was a higher 5-year estimated survival rate among patients having CABG (88% vs 78.3%; Plog-rank < 0.001). The adjusted hazard ratio (HR) for PCI over CABG was 1.74 [95% confidence interval (CI) 1.41-2.16; P < 0.001]. A total of 653 patients having CABG and 653 having PCI were included in the propensity-matched groups. At mean follow-up, PCI was associated with a higher adjusted HR for all-cause mortality (2.18, 95% CI 1.54-3.1; P < 0.001)., Conclusions: In this contemporary cohort of real-world patients with MVD, CABG was associated with increased intermediate-term survival compared to PCI with new-generation drug-eluting stents., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: Endoscopic vein harvesting (EVH) is growing in popularity and is the method of choice in many centers worldwide as it is associated with lower complication rates compared to the open vein harvesting. The aim of this study was to determine the current use of EVH during coronary artery bypass grafting among cardiac surgeons in United Kingdom and identify the main concerns that limit the use of this technique., Methods: We developed an online survey with 16 questions about the use of EVH. An invitation to participate was sent to all the adult cardiac surgeons currently in practice in United Kingdom., Results: A total of 139 surgeons (52%) of 267 currently in practice across 48 different hospitals completed the survey. Twenty five percent of responding surgeons always use EVH while 44% use it for <10% cases. Forty eight percent of responders regard EVH as an expensive technique and 90% believe that EVH is associated with fewer leg wound issues. Seventy five percent of responding surgeons will use it for their patients due to no leg wound issues while 25% believe that the concerns about patency of EVH are genuine., Conclusion: The majority of UK cardiac surgeons responding to this survey will preferentially consider EVH for obese and diabetic patients and are convinced by its beneficial impact in reducing leg wound complications. However, the reported routine use of EVH is low. Concerns about cost and patency of the endoscopically harvested vein are the possible barriers for universal adoption of EVH in the United Kingdom., (Copyright © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Surgical site infection (SSI) is a costly and devastating complication of surgery. Many cardiac SSIs develop after the patient leaves hospital, but evidence demonstrating the benefit of patient/carer involvement in the process of monitoring and promptly identifying SSI post-discharge is limited. This study estimates the probability of readmission for SSI for coronary artery bypass graft (CABG) patients receiving the Photo at Discharge (PaD)., Methods: Trained personnel undertook continuous, prospective SSI surveillance using Public Health England protocol between January 2013 and December 2016. Baseline covariables were collected for 1747 CABG-only procedures. As a quasi-randomised design, we adjusted for non-random PaD assignment using retrospective propensity score (PS)-matching based on 12 variables of interest, assessed whether the model had been adequately specified and performed an outcomes analysis., Results: A total of 568 patients with PaD were PS-matched with 568 controls. The probabilities of SSI readmission were 0.352 (2/568) and 1.761 (10/568), respectively. The difference in risk of readmission for SSI was significant (relative risk = 0.2, 95% confidence interval = 0.04-0.91; P = 0.04)., Conclusion: Findings from this single-centre observation study suggest the PaD is associated with a reduction in CABG readmission for SSI and a further study is warranted to verify the efficacy of this strategy., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2018.)

Background: Minimally invasive direct coronary artery bypass (MIDCAB) grafting is regarded as an alternative to conventional coronary artery bypass grafting (CABG) through full sternotomy, particularly for patients with isolated proximal left anterior descending (LAD) artery stenosis deemed unsuitable for percutaneous coronary intervention. However, the technically demanding nature of the procedure and lack of long-term published outcomes have precluded its universal adoption. We report the comparative short-term outcomes and long-term survival of MIDCAB and conventional CABG through full sternotomy for grafting of isolated LAD., Methods: From February 1996 to October 2017, a total of 668 patients underwent MIDCAB (n=508) and full sternotomy (n=160) CABG for isolated proximal LAD stenosis. Their data were prospectively entered into the institutional cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Information on patient deaths was obtained from the institutional database and the National General Register Office for all patients., Results: The two groups were comparable with respect to preoperative demographics and risk profile. MIDCAB was associated with longer operative time (177±32 versus 141±12 min; P=0.003). The two groups did not significantly differ with regard to other complications including operative mortality. At a mean follow-up of 12.95±0.47 years, survival was also similar., Conclusions: This large single centre study with longest follow-up validates the status of MIDCAB as an effective strategy for grafting of LAD. However, it fails to show superiority of the minimally invasive approach compared to conventional CABG through full sternotomy., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: In the contemporary era of drug-eluting stents (DES) the issue of optimal revascularization strategy for patients with isolated disease of the left anterior descending (LAD) artery has gained more significance. We aimed to evaluate the current best evidence on the subject by performing a systematic review and meta-analysis of the studies comparing minimally invasive direct coronary artery bypass (MIDCAB) grafting with DES in patients with isolated LAD disease., Methods: A literature search was conducted from 1966 through March 2018 using MEDLINE, EMBASE, and other scientific databases to identify relevant articles. Analyzed outcomes included all-cause mortality, myocardial infarction (MI), major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR). The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I 2 inconsistency test. All P values were 2-sided and a 5% level was considered significant., Results: A total of 7,710 patients from 12 studies were identified. There was no significant difference in mortality rate [pooled odds ratio (OR) =0.92; 95% confidence interval (CI), 0.65 to 1.32; P=0.66], MI rate (pooled OR =1.13, 95% CI, 0.62 to 2.06; P=0.69) or MACCE (pooled OR =1.31; 95% CI, 0.58 to 2.95; P=0.52). However, TVR rate was significantly more for patients having percutaneous intervention with DES (pooled OR =0.27; 95% CI, 0.16 to 0.45; P<0.0001) compared to MIDCAB., Conclusions: MIDCAB offers superior freedom from TVR with similar mortality, MI rate, and MACCE compared to percutaneous intervention with DES for revascularization in patient with isolated proximal LAD stenosis., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Objective: Currently, surgeons are unable to estimate whether the survival benefit from bilateral internal mammary artery (BIMA) grafting outweighs the increased deep sternal infection (DSWI) risk in the individual cases. As a consequence BIMA grafting is still largely underutilized. We aimed to develop and validate a scoring system to predict the individual risk for DSWI and 10 year survival probability to guide surgeons in decision making process for the use of BIMA over single internal mammary artery (SIMA)., Methods: Fast backward elimination on predictors was performed using Lawless and Singhal method. BIMA score was reported as a partial nomogram that can be used to manually obtain predicted individual risk of DSWI and 10 year survival probability from the regression models. Bootstrapping validation of the regression models was performed., Results: The study population consisted of 5234 patients of which a total of 960 (18%) received BIMA and the remaining 4274 (82%) underwent conventional strategy using SIMA. A total of 119 patients experienced DSWI (2.3%). A total of 489 deaths were recorded after a median follow-up time of 5.68 years (interquartile range 2.7-8.8, range 0-12.1). BIMA grafting was found to have effect on both risk of DSWI and 10 year survival probability and was included into partial nomograms. Bootstrapping validation confirmed a good discriminative power of the models., Conclusion: The BIMA score provides an impartial assessment of the decision making process for clinicians to establish the optimum revascularization strategy for individual patients., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Previously, we reported that the Brompton Harefield Infection Score (BHIS) accurately predicts surgical site infection (SSI) after coronary artery bypass grafting (CABG). The BHIS was developed using two-centre data and stratifies SSI risk into three groups based on female gender, diabetes or HbA1c > 7.5%, body mass index ≥ 35, left ventricular ejection fraction < 45% and emergency surgery. The purpose of this study was to prospectively evaluate BHIS internally as well as externally., Methods: Multi-centre prospective evaluation involving three tertiary centres took place between October 2012 and November 2015. SSI was classified using the Public Health England protocol. Receiver operating characteristic (ROC) curves assessed predictive accuracy., Results: Across the four hospital sites, 168 of 4308 (3.9%) CABG patients had a SSI. Categorising the hospitals by BHIS score revealed that 65% of all patients were low risk (BHIS 0-1), 26% were medium risk (BHIS 2-3) and 8% were high risk (BHIS ≥ 4). The area under the ROC curve was in the range of 0.702-0.785. Overall area under the ROC curve was 0.709., Conclusions: BHIS provides a novel, internally and externally evaluated score for a patient's risk of SSI after CABG. It enables clinicians to focus on strategies to prospectively identify high-risk patients and improve outcomes., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Studies comparing coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) have largely been performed in the bare-metal stent (BMS) and first-generation drug eluting stent (F-DES) era. Second-generation DES (S-DES) have shown improved outcomes when compared to F-DES, but data comparing CABG with PCI using S-DES is limited. We compared mortality following CABG versus PCI for patients with multivessel disease and analyzed different stent types., Methods: A total of 6,682 patients underwent multivessel revascularization at Harefield Hospital, UK. We stratified CABG patients into single arterial graft (SAG) or multiple arterial grafts (MAG); and PCI patients into BMS, F-DES or S-DES groups. We analyzed all-cause mortality at 5 years., Results: 4,388 patients had CABG (n[SAG] = 3,358; n[MAG] = 1,030) and 2,294 patients had PCI (n[BMS] = 416; n[F-DES] = 752; n[S-DES] = 1,126). PCI had higher 5-year mortality with BMS (HR = 2.27, 95% CI:1.70-3.05, p<0.001); F-DES (HR = 1.52, 95% CI:1.14-2.01, p = 0.003); and S-DES (HR = 1.84, 95% CI:1.42-2.38, p<0.001). This was confirmed in inverse probability treatment weighted analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI had higher 5-year mortality with BMS (Δ = 15.5, 95% CI:3.6,27.5, p = 0.011) and FDES (Δ = 16.5, 95% CI:6.6,26.4, p<0.001), but had comparable mortality with CABG for PCI with SDES (Δ = 0.9, 95% CI: -9.6,7.9, p = 0.844), and when exclusively compared to CABG patients with SAG (Δ = 0.4, 95% CI: -8.0,8.7, p = 0.931) or MAG (Δ = 4.6, 95% CI: -0.4,9.6, p = 0.931)., Conclusions: In this real-world analysis, when adjusting for measured and unmeasured confounding, PCI with SDES had comparable 5-year mortality when compared to CABG. This warrants evaluation in adequately-powered randomized controlled trials.

Background: Antiseptic skin preparations containing chlorhexidine gluconate and povidone iodine are routinely used to reduce the risk of surgical site infection (SSI). This study assesses the efficacy of two alcohol-based solutions, 2% chlorhexidine-alcohol and 10% povidone iodine-alcohol, on the incidence of cardiac SSI., Methods: A total of 738 consecutive patients undergoing cardiac surgery had skin preparation with 2% chlorhexidine gluconate in 70% isopropanol (ChloraPrep, BD Ltd, UK) were propensity matched to 738 patients with skin prepared with 10% povidone-iodine in 30% industrial methylated spirit (Videne Alcoholic Tincture, Ecolab Ltd, UK). Continuous, prospective SSI surveillance data were collected for all these patients. A retrospective analysis of prospectively collected perioperative data was performed., Results: The overall rate of SSI was similar in the chlorhexidine-alcohol and povidone-iodine-alcohol groups (3.3% versus 3.8%; P = 0.14; relative risk [RR] = 0.98; 95% confidence interval [CI] = 0.52-1.78). Superficial (1.2% versus 1.8%; P = 0.18; RR = 0.97; 95% CI = 0.48-1.80) and deep incisional (1.2% versus 1.6%; P = 0.24) SSI rates were also similar with 10% povidone-iodine-alcohol being marginally more effective against organ-space infections (0.8% versus 0.4%; P = 0.05; RR = 0.38; 95% CI = 0.20-1.01)., Conclusion: Our analysis confirms that alcohol-based skin preparation in cardiac surgery with povidone-iodine reduces the incidence of organ-space infections with no significant superiority in preventing incisional SSI compared with chlorhexidine-alcohol., Competing Interests: Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MR has received a sponsorship from Ecolab Ltd.

Objective: Coronary artery bypass grafting (CABG) is being increasingly offered to octogenarians. Both on- and off-pump CABG are reported as effective surgical revascularization strategies for octogenarians by single institution studies. However, the issue of superiority of one strategy over the other for octogenarians remains unresolved due to limited sample size of these studies. A meta-analysis of studies comparing outcomes of on- and off-pump CABG in octogenarians was undertaken to address the issue., Methods: A literature search was conducted from 1966 through September 2016 using MEDLINE, EMBASE, Scopus and Web of Science to identify relevant articles. Primary outcomes of interest included in-hospital mortality and stroke. Secondary outcomes of interest were atrial fibrillation, acute renal failure, reoperation for bleeding, deep sternal wound infection, myocardial infarction, intensive therapy unit (ITU) stay and hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data to control any heterogeneity between the studies. Heterogeneity amongst the trials was determined by means of the Cochran Q value and quantified using the I 2 inconsistency test. All p-values were 2-sided and a 5% level was considered significant., Results: Sixteen retrospective studies (18,685 on-pump patients and 8938 off-pump patients) were included in the systematic review. In-hospital mortality (pooled OR = 0.64, 95% CI = 0.44 to 0.93; p = 0.02), stroke rate (pooled OR = 0.61, 95% CI = 0.48 to 0.76; p < 0.001) and length of hospital stay (pooled WMD = +0.29, 95% CI = +0.02 to +0.56; p = 0.04) were significantly lower in the off-pump patients. Atrial fibrillation (p = 0.36), acute renal failure (p = 0.47), reoperation for bleeding (p = 0.99), deep sternal wound infection (p = 0.59), myocardial infarction (p = 0.93), and length of ITU stay (p = 0.27) were comparable., Conclusion: Off-pump compared to on-pump CABG offers surgical myocardial revascularization to octogenarians with lower in-hospital mortality, stroke rate and length of hospital stay with similar incidence of other adverse outcomes. Preferentially offering off-pump CABG to octogenarians could translate into reduced economic burden on the healthcare providers., (Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Conflict of Interest: The author has no conflicts of interest to declare.

The morbidity and mortality associated with conventional coronary artery bypass grafting (CABG) attributed to invasiveness of cardiopulmonary bypass (CPB) has been well documented. Recognition of this invasiveness with a focus centered on abolishing, or at least reducing the CPB associated morbidity and mortality led to the resurgence of off-pump coronary artery bypass (OPCAB) surgery nearly two decades ago. At about the same time, OPCAB was adopted at Harefield hospital partly as an institutional drive to promote innovation and partly as a strategy to improve outcomes. What was deemed as a challenging technique initially and practiced by a single surgeon has now become a valid substitute to conventional CABG for achieving complete myocardial revascularization. This strategy now accounts for more than 50% of all coronary artery surgery operations at Harefield hospital and is systematically used to treat all coronary anatomies; achieve complete revascularization by accessing all territories subtended by main coronary arteries; and accomplish equivalent quality grafts without restriction in vascular conduit usage. This review article provides an overview of the evolution of OPCAB surgery at an institution with a well-established OPCAB program confirming that as surgeons' experience matures, OPCAB surgery permits safe and effective total myocardial revascularization in virtually all patients with multivessel coronary artery disease., Competing Interests: The author has no conflicts of interest to declare.

Enhanced life expectancy has confronted cardiac surgery with a rapidly growing population of octogenarians needing coronary artery bypass grafting (CABG). Octogenarians are deemed a high-risk patient population with increased postoperative morbidity and mortality following conventional CABG using cardiopulmonary bypass (CPB). In such patients reducing the invasiveness of the surgical procedure by avoiding CPB may be tried in an attempt to improve outcomes. The increasing performance of off-pump coronary artery bypass (OPCAB) grafting within certain centers reflects surgeon preference to avoid the inherent risks of CPB and cardioplegic arrest including hemodilution, nonpulsatile arterial flow, global myocardial ischemia, atherosclerotic embolization from aortic manipulation, and systemic inflammatory response. Although OPCAB grafting is a well-established surgical myocardial revascularization strategy, its actual benefits in terms of morbidity and mortality remain questionable in the general population. In the higher risk octogenarian patients, however, there is a potential for more tangible clinical benefits when CPB is avoided. This review article provides an overview of the impact of OPCAB grafting on postoperative mortality and morbidity in octogenarians., Competing Interests: The author has no conflicts of interest to declare.

Giant coronary artery aneurysms are rare clinical entities. We report the case of a 49-year-old man who presented with dyspnoea and exertional chest pain. Investigations confirmed an aneurysmal right coronary artery measuring 4 cm with a fistulous communication to the right atrium. Following right atriotomy, the fistula was oversewn and the aneurysmal right coronary artery ligated at its origin and at several points along its course. A saphenous vein graft was anastomosed to the posterior descending artery. Persistent ventricular fibrillation occurred upon chest closure, attributed to ischaemia following ligation of the aneurysmal coronary artery. Emergent resternotomy and internal defibrillation were successfully performed. The sternum was stented open to reduce right ventricular strain and closed the following day. The patient made an unremarkable recovery. We here address the technical challenges associated with surgical repair of right coronary aneurysms and the physiology and management of potential complications., Competing Interests: The authors declare that there are no competing interests regarding the publication of this paper.

Objective: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG., Methods: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes., Results: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46)., Conclusions: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue., (Copyright © 2014 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Coronary artery disease (CAD) is a leading cause of mortality and morbidity in diabetics. Diabetics make up to 20%-35% of all patients undergoing coronary revascularization. Patients with diabetes represent a particularly difficult subset for revascularization due to increased short- and long-term mortality as well as a higher risk of repeat revascularization procedures. Potential factors contributing to the increased risk include co-morbid illnesses, small, diffusely diseased target vessels, progression of native CAD, hyperglycaemic endothelial dysfunction, and systemic inflammation. For diabetic patients with multi-vessel disease, revascularization by coronary artery bypass grafting (CABG) is regarded as the preferred option. There is increasing recognition that the use of arterial conduits for CABG is associated with improved outcomes compared to use of venous conduits. Amongst arterial conduits bilateral internal mammary arteries (BIMA) have emerged as the superior conduits due to better cardiac event-free survival. Consistent with its benefits in non-diabetic patients, BIMA grafting is presumed to offer similar benefits in diabetic patients. However, BIMA grafting remains underutilised in diabetics due to perceived increased risk of sternal wound infection. This review article provides an overview of BIMA grafting in diabetic patients focussing on outcomes, concerns, and controversies associated with BIMA usage in this high-risk group of patients., (Copyright © 2014 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

The internal mammary artery is universally recognised as the preferred conduit for coronary artery bypass grafting. Accumulating evidence in recent years has demonstrated the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery grafting in terms of survival, event-free survival, and freedom from re-intervention. The survival benefit seen with BIMA grafting has been associated particularly to grafting the myocardium supplied by the left coronary artery system. Several surgical strategies have been used to achieve left-sided myocardial revascularisation with BIMA grafting. These include in-situ right internal mammary artery (RIMA) to the left anterior descending and the left internal mammary artery (LIMA) to circumflex marginal branches, directing the RIMA through the transverse sinus in a retroaortic course, and free RIMA graft connected proximally either to the LIMA (composite grafting) or to the ascending aorta. Each one of these surgical strategies for BIMA grafting has its merits and demerits. This review article provides an overview of the various surgical strategies for BIMA grafting focussing on their technical aspects, pros and cons as well as outcomes., (Copyright © 2014 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

Objective: Surgical site infection (SSI) following coronary artery bypass grafting (CABG) is a serious complication associated with significant morbidity and mortality. Despite the substantial impact of SSI there is lack of a specific risk stratification tool to predict this complication after CABG. This study was undertaken to develop a specific prognostic scoring system for the development of SSI that could risk-stratify patients undergoing CABG., Methods: Between January 2009 and June 2012, continuous prospective surveillance data on SSI and a set of 41 variables were collected. Using binary logistic regression analysis we identified independent predictors of SSI. Initially we developed a predictive model in a subset of 769 patients. Dataset was expanded to 4087 cases and a final model and risk score were derived. Calibration of the scores was performed using the Hosmer-Lemeshow test., Results: The model had area under Receiver Operating Characteristic curve of 0.727 (0.827 for preliminary dataset). Baseline risk score incorporated independent predictors of SSI: female gender = 2 (p < 0.0001; RR 2.1), diabetes = 1 (p = 0.0098, RR 1.4) or HbA1c >7.5% = 3 (p < 0.0001; RR 3.4), body mass index ≥35 = 2 (p < 0.0001; RR 2.4), left ventricular ejection fraction < 45% = 1 (p = 0.0255; RR 1.4), and emergency surgery = 2 (p = 0.012; RR 2.4). A risk stratification system, the Brompton & Harefield Infection Score (BHIS) was developed., Conclusion: BHIS effectively predicts SSI risk and may help with risk stratification in relation to public reporting and reimbursement as well as targeted prevention strategies in patients undergoing CABG., (Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: A limited number of patients undergoing coronary artery bypass grafting (CABG) currently receive bilateral internal thoracic arteries (BITA) as a consequence of lack of evidence on survival benefit and concerns about sternal wound complications. This study was undertaken to determine the impact of BITA grafting on short- and long-term outcomes in obese patients., Methods: Propensity score matching for short- and long-term outcomes was conducted for 1522 obese (body mass index ≥ 30 kg/m(2)) patients undergoing CABG using BITA (n = 229, 15.0%) or a single internal thoracic artery (SITA, n = 1293, 85.0%)., Results: Propensity score matching created 229 matching sets. In the matched sample, operative mortality (within 30 days) occurred in 3 (1.3%) and 4 (1.7%) patients in the BITA and SITA groups, respectively (P = 1). Deep sternal wound infection occurred in 6 (2.6%) and 2 (0.9%) patients (P = .2) in the BITA and SITA group, respectively. After a median follow-up of 4.5 ± 3.3 years, the use of BITA was associated with an improved late survival (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.13-0.97; P = .03) and a reduced need for repeat revascularization (HR, 0.45; 95% CI, 0.23-0.85; P = .01)., Conclusions: BITA grafting can be safely offered to obese patients with significant long-term advantages without substantial additional risk of operative complications including deep sternal wound infection., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Controversies exist whether off-pump coronary artery bypass (OPCAB) is superior to miniaturized extracorporeal circulation (MECC) in reducing deleterious effects of cardiopulmonary bypass as only a number of smaller randomized controlled trials (RCT) currently provide a limited evidence base. The main purpose of conducting the present meta-analysis was to overcome the expected low power in RCTs in an attempt to establish whether MECC is comparable to OPCAB., Methods: A MEDLINE/PubMed search was conducted to identify eligible RCTs. A pooled summary effect estimate was calculated by means of Mantel-Haenszel method., Results: The search yielded 7 RCTs included in this meta-analysis enrolling 271 patients in the OPCAB group and 279 in the MECC group. The OPCAB and MECC groups were comparable in terms of incidence of in-hospital mortality (Risk Difference [RD] 0.01; 95%CI -0.02, 0.03; P = 0.55; I(2) = 0%), stroke (RD -0.01; 95%CI -0.05, 0.04; P = 0.69; I(2) = 0%), need for renal replacement therapy (RD 0.00; -0.06, 0.06; P = 1; I(2) = 0%), postoperative atrial fibrillation (RD -0.03; -0.17, 0.10; P = 0.64; I(2) = 0%), re-exploration for bleeding (RD -0.01; 95%CI -0.03, 0.02; P = 0.65; I(2) = 0%), transfusion rate (RD -0.01; 95%CI -0.03, 0.02; P = 0.65; I(2) = 0%) and the amount of blood loss (weighted mean difference -25 mL; 95%CI -71, 21; P = 0.28; I(2) = 0%)., Conclusions: Using a meta-analytic approach, MECC achieves clinical results comparable to OPCAB including postoperative blood loss and blood transfusion requirement. On the basis of our findings, MECC should be considered as a valid alternative to OPCAB in order to reduce surgical morbidity of conventional cardiopulmonary bypass., (Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Whether the survival benefit from coronary artery bypass grafting (CABG), compared with percutaneous coronary intervention (PCI), for multivessel disease extends to the older segment of the population remains unclear. We aimed to investigate whether the effect on survival of PCI compared with CABG is related to the age of the patient., Methods: Propensity score-matching analysis was conducted on 6723 patients (PCI = 1097, CABG = 5626) with multivessel coronary artery disease. In the PCI group, drug-eluting stents were used in 917 (83.5%) patients; bare metal stents were used in only 180 patients (16.5%). Nonparametric, bootstrap, point-wise confidence limits were obtained for PCI:CABG odds and hazard ratios for early (within 12 months) and late hazard phase (beyond 12 months) for a variety of age groups., Results: After a mean follow-up time of 5.5 ± 3.2 years, a total of 301 deaths were recorded in the matched sample (208 in the PCI group and 93 in the CABG group). Overall survival was 95% ± 0.6% versus 95% ± 0.6% at 1 year, 84% ± 1.0% versus 92.4% ± 0.8% at 5 years, and 75% ± 1.6% versus 90% ± 1.0% at 8 years, for the PCI and CABG groups, respectively (log rank P < .001). PCI did not confer any significant benefit compared with CABG during the early hazard phase (within 12 months), but the survival-probability loss from PCI compared with CABG during the late hazard phase was present across all age groups. The hazard ratio declined from 3.8 to 3.4 and was statistically significant (lower limit >1 across all ages, ranging from 1.5 to 2.4)., Conclusions: Compared with PCI, CABG leads to a significant reduction in late-phase mortality across all age groups., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: There is a lack of unequivocal evidence basis for selecting the best second conduit in coronary artery bypass grafting (CABG). We thus aimed to perform head-to-head relative effect estimate on angiographic outcomes for second conduits, including the right internal mammary artery (RIMA), radial artery (RA), right gastroepiploic artery (RGEA) and saphenous vein graft (SVG) by means of network meta-analysis of randomized controlled trials (RCTs)., Methods: Databases were searched for RCTs comparing angiographic outcomes (≥4 weeks) of second conduits in CABG. Odds ratios (95% confidence intervals) were computed with Markov Chain Monte Carlo simulation., Results: A total of nine RCTs were identified, including 2780 patients and 1620 angiographic results available for analysis to compare RIMA (n=145) versus RA (n=871) versus RGEA (n=92) versus SVG (n=845). The mean time to angiographic follow-up ranged from 1 to 7.7 years. An SVG was significantly associated with a 4-fold (1.67-16.00) and 3-fold (0.78-22.20) increased risk of late (≥4 years) functional graft occlusion when compared with the RIMA and RA, respectively. A RIMA was associated with a non-significant 27% absolute risk reduction for functional graft occlusion when compared with the RA., Conclusions: The present network meta-analysis consistently demonstrated an angiographic superiority of RIMA and RA over SVG. The RIMA is expected to achieve a better patency rate than the RA, but further studies are needed., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: We undertook a single-center, 12 years outcomes analysis of the influence of bilateral internal mammary arteries (BIMA) over single internal mammary artery (SIMA) on short-term outcomes and long-term outcomes by means of propensity score matching technique in accordance to current recommendations., Methods: A propensity score was generated for each patient from a multivariable logistic regression model based on 20 pretreatment covariates. The study population consisted of 4195 patients undergoing coronary artery bypass graft procedure using SIMA (n = 3445; 78.3%) or BIMA (n = 750; 21.7%). A total of 750 matching sets were derived., Results: The BIMA group was associated with an increased rate of superficial sternal wound infection (5.6% vs 1.7%; P = .0001) but the incidence of deep sternal wound infection was comparable between the 2 groups, at 2.1% and 1.5% in BIMA and SIMA groups, respectively (P = .43). With regard to other postoperative complications the 2 groups were comparable. Operative mortality rate did not significantly differ between the 2 groups, at 0.7% and 1.2% in the BIMA and SIMA groups, respectively (P = .28). After a mean follow-up time of 4.8 ± 3.2 years, BIMA use was associated with a significantly lower risk for late mortality (hazard ratio, 0.61; 95% confidence interval 0.38-0.97; P = .03) and need for repeat revascularization (hazard ratio, 0.75; 95% confidence interval, 0.53-0.96; P = .03)., Conclusions: When compared with SIMA grafting, BIMA use did not increase operative morbidity and mortality and was associated with a better long-term survival., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)