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Objective: Sternotomy has been the gold standard incision for surgical revascularization but may be associated with chronic pain and sternal malunion. Minimally invasive coronary artery bypass grafting allows for complete surgical revascularization through a small thoracotomy in selected patients. There is a paucity of long-term data, particularly functional outcomes, for patients who underwent minimally invasive coronary artery bypass grafting., Methods: Patients (N = 566) who underwent minimally invasive coronary artery bypass grafting at a single institution over a 17-year period were prospectively followed. The primary outcome was survival. At late follow-up, patients were contacted for a questionnaire on functional outcomes. Multivariable Cox proportional hazard model identified correlates of the primary outcome., Results: Clinical follow-up was complete for 100% of patients (mean 7.0 ± 4.4 years); a follow-up questionnaire was also completed for 83.9% (N = 427) of live patients. Fifty percent of patients (N = 283) had undergone multivessel grafting. At 12 years, survival for the entire cohort was 82.2% ± 2.6%. On late follow-up questionnaire, 12 patients (2.8%) had greater than Canadian Cardiovascular Score Class II angina and 19 patients (4.5%) had greater than New York Heart Association Class II symptoms. More than 98% of patients did not have pain related to the incision site. Cox proportional hazards analysis identified older age, peripheral vascular disease, prior myocardial infarction, left ventricular dysfunction, cancer in the past 5 years, intraoperative transfusion, and hybrid revascularization as correlates of mortality during follow-up., Conclusions: Minimally invasive coronary artery bypass grafting is a safe and durable alternative to sternotomy coronary artery bypass grafting in selected patients, with excellent short- and long-term outcomes, including for multivessel coronary disease. At long-term follow-up, the proportion of patients with significant symptoms and incisional pain was low., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Reimplanting the radial artery in the left internal thoracic artery as a composite graft allows total arterial revascularization (TAR) without aortic manipulation. The limitation of this strategy is the length of the radial artery required to reach distal right coronary artery (RCA) branches. Our analysis focuses on the feasibility of this strategy., Methods: A total of 169 patients underwent TAR using the radial artery in a composite grafting configuration. Length of the radial artery, number of sequential anastomoses, heart size, target location, length of the arm, patient height, body surface area, and flow in the composite graft were prospectively collected., Results: The mean length of the radial artery was 18.02 cm. Patients with a mean length of the radial artery of 15.9 cm needed an extension of the radial artery with another conduit to reach the RCA distal branches. When T-configuration is used, the length of the radial artery should be 0.53 cm per sequential anastomosis to reach the RCA distal branches., Conclusions: Our study shows that an average length of 18.02 cm of radial artery is needed to reach targets on the RCA distal branches in composite grafting. In T-configuration, we need 0.53 cm more length per anastomosis to achieve TAR.

Approximately 95% of patients of any age undergoing contemporary, coronary bypass surgery will receive at least 1 saphenous vein graft (SVG). It is recognized that SVG will develop progressive and accelerated atherosclerosis, resulting in a stenosis, and in occlusion that occurs in 50% by 10 years postoperatively. For arterial conduits, there is little evidence of progressive failure as for SVG. Could avoidance of SVG (total arterial revascularization [TAR]) lead to a different late (>5 year) survival? A literature review of 23 studies (N = 100,314 matched patients) at a mean 8.8 years postoperative found reduced all-cause mortality for TAR (HR: 0.77; 95% CI: 0.71-0.84; P < 0.001). An expanded analysis with a new unpublished data set (N = 63,288 matched patients) was combined with the literature review (N = 127,565). It found reduced all-cause mortality for TAR (HR: 0.78; 95% CI: 0.72-0.85; P < 0.001). Additional Bayesian analysis found a very high probability of a TAR-associated reduction all-cause mortality., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Transit time flow measurement (TTFM) allows quality control in coronary artery bypass grafting but remains largely underused, probably because of limited information and the lack of standardization. We performed a systematic review of the evidence on TTFM and other methods for quality control in coronary artery bypass grafting following PRISMA standards and elaborated expert recommendations by using a structured process. A panel of 19 experts took part in the consensus process using a 3-step modified Delphi method that consisted of 2 rounds of electronic voting and a final face-to-face virtual meeting. Eighty percent agreement was required for acceptance of the statements. A 2-level scale (strong, moderate) was used to grade the statements based on the perceived likelihood of a clinical benefit. The existing evidence supports an association between TTFM readings and graft patency and postoperative clinical outcomes, although there is high methodological heterogeneity among the published series. The evidence is more robust for arterial, rather than venous, grafts and for grafts to the left anterior descending artery. Although TTFM use increases the duration and the cost of surgery, there are no data to quantify this effect. Based on the systematic review, 10 expert statements for TTFM use in clinical practice were formulated. Six were approved at the first round of voting, 3 at the second round, and 1 at the virtual meeting. In conclusion, although TTFM use may increase the costs and duration of the procedure and requires a learning curve, its cost/benefit ratio seems largely favorable, in view of the potential clinical consequences of graft dysfunction. These consensus statements will help to standardize the use of TTFM in clinical practice and provide guidance in clinical decision-making.

Background: The left internal thoracic artery (LITA) to left anterior descending (LAD) artery bypass remains the reference standard for coronary artery bypass graft surgery. With the advent of bilateral internal thoracic artery (BITA) grafting, optimal bypass configuration to the LAD is unclear. The objective of this study was to compare clinical outcomes between LITA-LAD and right internal thoracic artery (RITA)-LAD configurations in BITA grafting., Methods: The primary outcome was the need for percutaneous or surgical reintervention of the LAD. Secondary outcomes included all-cause mortality and cardiac mortality. Cox proportional hazard and competing risk models were used with entropy weighting., Results: Among BITA patients, 1527 had LITA-LAD grafts, and 523 RITA-LAD. Before entropy weighting, RITA-LAD patients were older with more diabetes, peripheral vascular disease, and left ventricular dysfunction, more urgent status (P < .05), and more frequently performed off-pump (P < .001). Need for repeat revascularization of the LAD territory at 10 years was 2.8% in the LITA-LAD group and 1.8% in the RITA-LAD group (subhazard ratio = 0.686; 95% confidence interval [CI], 0.296-1.589; P = .38). Adjusted survival at 10 years was 97.2% in the LITA-LAD group and 98.2% in the RITA-LAD group (hazard ratio = 1.056; 95% CI, 0.677-1.647; P = .81). There was no difference in cardiac mortality (subhazard ratio = 1.063; 95% CI, 0.502-2.251; P = .87)., Conclusions: Use of either LITA or RITA for LAD grafting during BITA revascularization has no effect on long-term all-cause or cardiac mortality or need for repeat revascularization of the LAD. Cardiac surgeons should be confident in using a RITA-LAD bypass during BITA grafting., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Fractional flow reserve (FFR) provides an objective measurement of the severity of ischemia caused by coronary stenoses in downstream myocardial regions. Data from the interventional cardiology realm have suggested benefits of a FFR-guided percutaneous coronary intervention (PCI) strategy. Limited evidence is available on the use of FFR to guide coronary artery bypass grafting (CABG). The most recent data have shown that FFR might simplify CABG procedures and optimize patency of arterial grafts without any clear impact on clinical outcomes. The aim of this review was to summarize the available data on FFR-based CABG and discuss the rationale and potential consequences of a switch toward FFR-based surgical revascularization strategy., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Observational and randomized evidence shows that arterial grafts have better patency rates than saphenous vein grafts (SVGs) in coronary artery bypass grafting. Observational studies suggest that the use of multiple arterial grafts is associated with longer postoperative survival, but this must be interpreted in the context of treatment allocation bias and hidden confounders intrinsic to the study designs. Recently, a pooled analysis of 6 randomized trials comparing the radial artery with the SVG as the second conduit and the largest randomized trial comparing the use of single and bilateral internal thoracic arteries have provided apparently divergent results about a clinical benefit with the use of >1 arterial conduit. However, both analyses have methodological limitations that may have influenced their results. At present, it is unclear whether the well-documented increased patency rate of arterial grafts translates into clinical benefits in the majority of patients undergoing coronary artery bypass grafting. A large randomized trial testing the arterial grafts hypothesis (ROMA [Randomized Comparison of the Clinical Outcome of Single Versus Multiple Arterial Grafts]) is underway and will report the results in a few years.

Aims: Visual estimation is the most commonly used method to evaluate the degree of coronary artery stenosis prior to coronary artery bypass grafting. In interventional cardiology, the use of fractional flow reserve (FFR) to guide revascularization decisions has become routine. We investigated whether the preoperative FFR measurement of coronary lesions is associated with anastomosis function 6 months after surgical revascularization using a multiarterial grafting strategy., Methods and Results: In this prospective double-blind study, 67 patients were enrolled from two institutions in Europe and Canada. From these patients, 199 coronary lesions were assessed visually and with FFR at the time of the preoperative angiogram. All patients received coronary revascularization using multiple arterial grafts. A post-operative 6-month angiogram was performed to assess anastomosis functionality using a described angiographic method. The primary outcome was the association between preoperative FFR values and anastomosis function 6 months after surgery. Preoperative FFR was significantly associated with 6-months anastomotic function for all conduits and for all targets (P  <  0.001). An FFR value of ≤0.78 was associated with an anastomotic occlusion rate of 3%., Conclusion: We found a significant association between the preoperative FFR measurement of the target vessel and the anastomotic functionality at 6 months, with a cut-off of 0.78. Integration of FFR measurement into the preoperative diagnostic workup before multiarterial coronary surgical revascularization leads to improved anastomotic graft function., Clinical Trials. Gov Identifier: NCT02527044., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Rationale: Minimally invasive cardiac surgery has emerged as a safe alternative to standard cardiac surgery. Minimally invasive coronary surgery (MICS CABG) was developed to allow adequate exposure and complete revascularization in CABG from a small thoracotomy incision without cardiopulmonary bypass. Multiple studies have reported significant shorter length of hospital stay and earlier postoperative physical recovery for MICS CABG patients when compared to sternotomy CABG patients. However, there have been no convincing clinical trials that demonstrate improvement in post-operative quality of life for patients who undergo MICS CABG., Study Design: The Minimally Invasive Coronary Surgery compared to Sternotomy Coronary Artery Bypass Grafting (MIST) trial is a multi-centered, prospective randomized controlled trial that compares the quality of life and recovery in the early post-operative period between patients undergoing MICS CABG versus patients undergoing sternotomy CABG. Patients will be randomized either to the MICS CABG group or the sternotomy CABG group, and the target enrollment is 88 patients per group. The primary outcome is quality of life assessment performed by SF-36 questionnaire at 1 month., Conclusion: The MIST trial is the first prospective study that compares the quality of life between MICS CABG and sternotomy CABG patients. The results of this trial may enhance the procedural desirability of MICS CABG by patients and provide an incentive for surgeons and institutions to increase the availability of MICS CABG in suitable patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This article reviews the context and evidence of recent myocardial revascularization trials that compared percutaneous coronary intervention with coronary artery bypass grafting for the treatment of left main and multivessel coronary artery disease. We develop the rationale that some of the knowledge synthesis resulting from these trials, particularly with regard to the claimed noninferiority of percutaneous coronary intervention beyond nondiabetic patients with low anatomic complexity, may have been affected by trial design, patient selection based on suitability for percutaneous coronary intervention, and end point optimization favoring percutaneous coronary intervention over coronary artery bypass grafting. We provide recommendations that include holding a circumspect interpretation of the currently available evidence, as well as suggestions for the collaborative design and conduct of future clinical trials in this and other fields.

Myocardial revascularization can be achieved through 2 different methods: coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Clinical trials comparing PCI and CABG generally use the composite end points of death, stroke, myocardial infarction and target vessel revascularization to determine superiority. Other effects of these interventions, including the preservation of normal coronary physiology, the response of the coronary tree to stressors and the response of the vessel wall to the revascularization intervention, are not routinely considered, but these may have significant implications for patients in the medium and long term. For PCI, relatively small differences in clinical outcomes have been reported between bare metal and drug-eluting stents, and the latter seems to have inconsistent and somewhat unpredictable effects on the vascular biology of the coronary arteries. In coronary bypass, the use of arterial conduits is associated with superior clinical outcomes, better long-term patency and the preservation of essentially normal coronary function after intervention. This review assembles the clinical, physiological, angiographic and pathological literature currently available and attempts to provide a more complete picture of the effects of CABG and PCI on coronary arteries.

Objectives: There is growing interest in the use of bilateral internal thoracic arteries (BITAs) for myocardial revascularization. This study sought to compare the balance between early benefits and long-term outcomes of skeletonized or non-skeletonized conduits and to determine whether differences in outcomes are affected by other patient risk factors., Methods: BITAs were used in 1504 cases with either SK or NSK conduits. Propensity matching was completed using 22 covariates identifying 441 pairs of patients. The primary outcomes are the sternal wound infection in the short term and the composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure. Outcomes were assessed using paired analysis techniques and Cox proportional hazards regression models stratified using the matched pairs., Results: Incidences of in-hospital mortality and perioperative myocardial infarction were similar in both groups. There were fewer sternal wound infections in the SK group (5.4 vs 9.1%, P = 0.033). Homogeneity testing of the relative risk estimates confirmed that there was a protective effect of skeletonization in men that was not demonstrated in women (P = 0.020). SK had a protective effect in diabetics not seen in non-diabetics (P = 0.048). The composite outcome of all-cause mortality, myocardial infarction, revascularization and congestive heart failure at a median of 5.6 years was comparable in both groups (hazard ratio 0.81, 95% confidence interval 0.57-1.15)., Conclusion: Skeletonization results in better perioperative outcomes and comparable cardiac outcomes in patients undergoing BITA with the greatest benefit in men and patients with chronic obstructive pulmonary disease.

Background: We sought to investigate the impact of incomplete revascularization (IR) on long-term survival after isolated coronary artery bypass grafting (CABG). The possible interaction between IR and off-pump surgery was also explored., Methods: A total of 13,701 patients with multivessel disease undergoing CABG were included in the analysis. All patients received left internal thoracic artery (LITA) to the left anterior descending artery (LAD) territory. IR was defined as at least one diseased arterial territory (right coronary artery [RCA] and/or circumflex [CX] artery) incompletely revascularized., Results: Overall, 3107 (22.7%) patients received IR. After propensity score matching, IR did not increase all-cause death in the overall group (HR 1.09; 95%CI 0.96-1.22; P=0.17). However, when both RCA and CX artery were incompletely revascularized, late survival was significantly lower (HR 2.15; 95%CI 1.57-2.93). IR was associated with a higher risk of death after off-pump (HR 1.26; 95%CI 1.05-1.49) regardless the extent of IR. After on-pump, IR significantly affected survival only when both RCA and CX artery only were incompletely revascularized (HR 2.32; 95%CI 1.27-4.22)., Conclusions: The present analysis shows that in patients with LITA-LAD graft the impact of IR on survival is marginal when only one coronary territory is left ungrafted. When both the RCA and CX territory remain unrevascularized the survival rate is significantly reduced. IR after off-pump CABG is associated with significantly lower survival and affects long-term outcome even when only one coronary territory is not revascularized., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Objective: In this 8 years' follow-up study, we evaluated the long-term outcomes of the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting, versus aspirin plus placebo, with respect to survival, major adverse cardiac, or major cerebrovascular events, including revascularization, functional status, graft patency, and native coronary artery disease progression., Methods: In the initial Clopidogrel After Surgery for Coronary Artery Disease trial, 113 patients were randomized to receive either daily clopidogrel (n = 56) or placebo (n = 57), in addition to aspirin, in a double-blind fashion for 1 year after coronary artery bypass grafting. All patients were re-evaluated to collect long-term clinical data. Surviving patients with a glomerular filtration rate > 30 mL/min were asked to undergo a coronary computed tomography angiogram to evaluate the late saphenous vein graft patency and native coronary artery disease progression., Results: At a median follow-up of 7.6 years, survival rate was 85.5% ± 3.8% (P = .23 between the 2 groups). A trend toward enhanced freedom from all-cause death or major adverse cardiac or cerebrovascular events, including revascularization, was observed in the aspirin-clopidogrel group (P = .11). No difference in functional status or freedom from angina was observed between the 2 groups (P > .57). The long-term patency of saphenous vein graft was 89.11% in the aspirin-clopidogrel group versus 91.23% in the aspirin-placebo group (P = .79). A lower incidence of moderate to severe native disease progression was observed in the aspirin-clopidogrel group versus the aspirin-placebo group (7 out of 122 vs 13 out of 78 coronary segments that showed progression, respectively [odds ratio, 0.3 ± 0.2; 95% confidence interval, 0.1-0.8; P = .02])., Conclusions: At 8 years' follow-up, the addition of clopidogrel to aspirin during the first year after coronary artery bypass grafting exhibited a lower incidence of moderate to severe progression of native coronary artery disease and a trend toward higher freedom from major adverse cardiac or cerebrovascular events, including revascularization, or death in the aspirin-clopidogrel group., Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00228423., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There are significant gender differences in arterial revascularization approaches in coronary operations. This study addressed these differences to determine whether discrepancies are related to underlying risk profiles or systematic gender bias., Methods: Changes in gender-specific rates of revascularization approaches were determined in 19,557 patients undergoing isolated coronary artery bypass grafting (CABG). A propensity-balanced group was generated on a subset of 1,254 CABG patients based on 45 pretreatment covariates to assess rates in matched groups (627 patients per group)., Results: In the entire cohort, male gender was associated with increased bilateral internal thoracic artery (BITA) use (odds ratio, 1.667; 95% confidence interval [CI], 1.166 to 2.386; p = 0.005). Multiple-arterial grafting increased yearly in both genders, but the rate of increase in BITA use was greater in men (1.59%/year [95% CI, 1.56 to 1.63] vs 1.37%/year [95% CI, 1.30 to 1.45], p < 0.001) as was the use of 3 arteries (1.16%/year [95% CI, 1.13 to 1.20] vs 0.73%/year [95% CI, 0.67 to 0.80), p < 0.001) and the use of any 2 arteries (2.34%/year (95% CI, 2.32 to 2.35) vs 1.92%/year [95% CI, 1.90 to 1.95], p < 0.001). In the propensity-matched group, there was no difference in BITA use (male: 31.9%, female: 30.1%; p = 0.502), BITA use in low-risk patients (male: 46.4%, female: 38.0%; p = 0.126), or radial artery use (male: 44.5%, female: 44.1%; p = 0.994), but use of 3 arteries was greater in men (10.5% vs 7.3%, p = 0.048)., Conclusions: Women receive less complete multiple arterial coronary revascularization than men. This is likely related to later presentation of coronary artery disease in women with higher comorbidity profiles; however, when matched, bias may still exist limiting the option of grafting with 3 arteries to women., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: The publication of the NOBLE and EXCEL trials, with seemingly conflicting results, brought into question whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is better for low-risk patients with left main coronary artery stenosis (LMCAS). This review appraises the methods and results of NOBLE and EXCEL, contextualizes them within the literature, and determines how they may affect clinical practice., Recent Findings: We appraised the trials and describe differences in methodology and results. NOBLE recruited primarily isolated LMCAS, and found that CABG was superior to PCI. EXCEL's population included patients LMCAS in the context of multivessel CAD, and found PCI and CABG were comparable. Both trials enrolled young patients with few comorbidities, and there was more protocol-mandated consistency in the procedural techniques and medical therapy of patients receiving PCI., Summary: The generalizability of these trials is limited by the use of young, healthy patients at highly skilled centres that rarely reflect typical clinical practice. If these studies are to maintain relevance, trialists must address the lack of protocolization of surgical interventions and inconsistent medical therapies. Unfortunately, the limitations of NOBLE and EXCEL mean that we are no closer to answering the question of what is the optimal treatment for patients with LMCAS.

Graft failure occurs in a sizeable proportion of coronary artery bypass conduits. We herein review relevant current evidence to give an overview of the incidence, pathophysiology, and clinical consequences of this multifactorial phenomenon. Thrombosis, endothelial dysfunction, vasospasm, and oxidative stress are different mechanisms associated with graft failure. Intrinsic morphological and functional features of the bypass conduits play a role in determining failure. Similarly, characteristics of the target coronary vessel, such as the severity of stenosis, the diameter, the extent of atherosclerotic burden, and previous endovascular interventions, are important determinants of graft outcome and must be taken into consideration at the time of surgery. Technical factors, such as the method used to harvest the conduits, the vasodilatory protocol, the storage solution, and the anastomotic technique, also play a major role in determining graft success. Furthermore, systemic atherosclerotic risk factors, such as age, sex, diabetes mellitus, hypertension, and dyslipidemia, have been variably associated with graft failure. The failure of a coronary graft is not always correlated with adverse clinical events, which vary according to the type, location, and reason for failed graft. Intraoperative flow verification and secondary prevention using antiplatelet and lipid-lowering agents can help reducing the incidence of graft failure., (© 2017 American Heart Association, Inc.)

Purpose of Review: Coronary artery bypass grafting (CABG) has been regarded as the mainstream treatment for unprotected left main coronary artery (ULMCA) stenosis. However, the results of the Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, in which percutaneous coronary intervention (PCI) was deemed noninferior to CABG, have raised a question whether the guidelines should be changed. This article provides a critical appraisal of recent randomized control trials (RCTs) on ULMCA stenosis., Recent Findings: In contrast to EXCEL trial, another large RCT named the Nordic-Baltic-British Left Main Revascularization trial showed that PCI is inferior to CABG in patients treated for ULMCA stenosis. The reason for the discrepancy between these two RCTs may be due to differences in study design. In EXCEL trial, the adoption of new periprocedural myocardial infarction definition, the noninclusion of target vessel revascularization as a primary endpoint component, and the timeline of the study may have helped claim that PCI is noninferior to CABG., Summary: The long-term efficacy of PCI for ULMCA stenosis has not yet been demonstrated. Further studies and follow-up data are needed before the indications for PCI are expanded in this scenario.

Objective: Minimally invasive coronary artery bypass grafting (MICS CABG) through a small left thoracotomy is a novel technique for surgical coronary revascularization, which is increasingly being adopted around the world. This study aimed to describe the characteristics and mid-term outcomes of a series of MICS CABG to identify areas for improvement., Methods: A prospective longitudinal study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting used a small left thoracotomy to enable coronary revascularization with a similar configuration to an open sternotomy technique, with left internal thoracic artery harvesting, and hand-sewn proximal radial/saphenous and distal anastomoses, under direct visualization. We compared patients who were operated on during the first and second halves of the series to ascertain the impact of a learning curve on outcomes., Results: The mean ± SD age was 62 ± 9 years, 87% were male, and 23% had three-vessel disease. Off-pump coronary artery bypass was performed in 80%, and the median number of grafts was 2 (range 1-4). Sternotomy conversion occurred in 3.3%, reoperation for bleeding in 2%, and unplanned, emergency CPB conversion in 1%. Superficial thoracotomy infection, atrial fibrillation, and left-sided pleural effusion requiring drainage were encountered in 2%, 4%, and 4%, respectively. There were no perioperative stroke, myocardial infarction, or death. At a mean ± SD follow-up of 2.8 ± 2.5 years, 97.4% of patients were free from major adverse cardiac and cerebrovascular events. Between the first and latter half of the series, there was a decrease in the rate of conversion to sternotomy (5.2%-1.3%, P = 0.05) and in the mid-term need for repeat revascularization (11% vs 2.6%, P = 0.03). Overall repeat revascularization rate was 2.5% per year. The intensive care unit and hospital lengths of stay (1.6 ± 1.5 vs 1.4 ± 0.9, P = 0.2, and 6.1 ± 2.6 vs 5.6 ± 1.8, P = 0.4) were not statistically different., Conclusions: Minimally invasive coronary artery bypass grafting can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization, with excellent mid-term results. Learning phase effects were not observed with regard to overall procedural safety, but rather in terms of improved freedom from conversion to sternotomy and from repeat revascularization.

Purpose of Review: 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., Recent Findings: 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., Summary: 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.

Objectives: Bilateral internal thoracic artery (BITA) bypass provides long-term survival benefits over strategies that use single internal mammary arteries during coronary artery bypass grafting (CABG). However, the rate of adoption of this strategy remains very low. Moreover, optimal BITA configuration and the use of cardiopulmonary bypass still remain a matter of debate. We investigated the long-term results of a coronary revascularization strategy, utilising exclusively BITA-Y composite grafts using off-pump platform and sequential anastomoses., Methods: From March 2000 to November 2010, all isolated CABGs (n = 2057 patients) were performed using an off-pump platform. Of these, 1240 patients had three-vessel coronary disease (60.3%), with severe coronary disease defined as >70% stenosis and three-vessel disease defined as the presence of 3 vessels with >70% stenosis, of which 784 (63.2%) were treated with two internal thoracic artery grafts in a composite fashion with a no-touch technique avoiding any manipulation of the ascending aorta. The primary end-point was the long-term survival and freedom from major adverse cerebral and cardiovascular events (MACCEs). The follow-up was completed using the annual anniversary method., Results: The mean number of anastomoses per patient was 4.0. Hospital mortality occurred in 8 patients (1%). Ninety-day stroke, myocardial infarction and repeat revascularization rates were respectively 0.7, 0.6 and 0.3%. The mean follow-up was 6.6 ± 3.2 years and was obtained for 99% of the patients. The 5- and 10-year survival rates were 93.1 ± 1.6 and 83.8 ± 3.2%, respectively. Freedom from major adverse cardiac and cardiovascular event (MACCE) at 5 and 10 years was: cardiovascular event: 98.7 ± 1.6 and 96.1 ± 1.7%, documented ischaemia: 90.5 ± 2 and 80.2 ± 3.8%, revascularization: 94.0 ± 1.5 and 89.7 ± 2.5%, infarction: 98.1 ± 0.8 and 96.0 ± 1.6%. The patency of left and right internal thoracic artery in a BITA-Y configuration was 91.1 and 88.8% at 5 ± 3 years, respectively., Conclusion: Performance of an exclusive composite BITA off-pump revascularization strategy optimal and sustained long-term protection from MACCE., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Bilateral internal thoracic arteries (BITA) have demonstrated superior patency and improved survival in patients undergoing coronary artery bypass grafting. However, the optimal configuration for BITA utilization and its effect on long-term outcome remains uncertain., Methods and Results: We randomly assigned 304 patients undergoing coronary artery bypass grafting using BITA to either in situ or Y grafting configurations. The primary end point was 3-year angiographic patency. Secondary end points included major adverse cardiac and cerebrovascular events (ie, death from any cause, stroke, myocardial infarction, or repeat revascularization) at 7 years. More coronary targets were able to be revascularized using internal thoracic arteries in patients randomized to Y grafting versus in situ group (3.2±0.8 versus 2.4±0.5 arteries/patient; P<0.01). The primary end point did not show significant differences in graft patency between groups. Secondary end points occurred more frequently in the in situ group (P=0.03), with 7-year rates of 34±10% in the in situ and 25±12% in the Y grafting groups, driven largely by a higher incidence of repeat revascularization in the in situ group (14±4.5% versus 7.4±3.2% at 7 years; P=0.009). There were no significant differences in hospital mortality or morbidity or in late survival, myocardial infarction, or stroke between groups., Conclusions: Three-year systematic angiographic follow-up revealed no significant difference in graft patency between the 2 BITA configurations. However, compared with in situ configuration, the use of BITA in a Y grafting configuration results in lower rates of major adverse cardiovascular and cerebrovascular events at 7 years., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01666366., (© 2016 The Authors.)

Background: This study evaluated the long-term outcome of patients undergoing emergency coronary artery bypass grafting (eCABG) for cardiogenic shock after acute myocardial infarction., Methods: Sixty-seven consecutive patients underwent eCABG for cardiogenic shock at 2 European institutions during an 11-year period. Preoperative, intraoperative, postoperative, and long-term follow-up data of all patients were prospectively collected., Results: Hospital survival was 86% (58 of 67), with all deaths due to cardiac causes. At a mean follow-up of 78 ± 48 months (range, 1 to 153 months), 43 of the 58 patients (74%) discharged from the hospital were alive. Causes of death in 9 of the 15 follow-up deaths (60%) were noncardiac. Overall survival rate at the end of follow-up was 64% (43 of 67). Of the 43 survivors, 41 (95%) were in New York Heart Association Functional Classification I to II, ischemia free, had a Karnofsky performance status exceeding 80, and an excellent quality of life as assessed by the Seattle Angina Questionnaire. The use of cardiopulmonary bypass and the internal thoracic artery were associated with significantly better long-term survival., Conclusions: The long-term survival and quality of life of patients who undergo eCABG for cardiogenic shock after acute myocardial infarction are good, and eCABG should be considered a valuable therapeutic option in this setting. The use of cardiopulmonary bypass and the internal thoracic artery at the time of the operation are strongly advocated., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Coronary artery bypass graft (CABG) surgery has evolved and become much safer since its inception. This article outlines recent strategies in optimizing CABG mortality., Recent Findings: Improving operative mortality around CABG relates to five components. These include the role of relevant quality indicators; improved CABG techniques, such as multiple arterial grafting with less manipulation of the aorta; improvements in cardiopulmonary bypass; refinements in cardiac anaesthesia along with postoperative care; and the development of centres of excellence., Summary: The development of advanced surgical revascularization techniques raises the question as to whether CABG expertise should be considered a sub-specialty of cardiac surgery. An expert CABG surgeon should be able to appropriately utilize several different revascularization techniques to adjust the operation to the patient, rather than the contrary.

Objectives: The spread of drug-eluting stents (DES) has reduced the incidence of early restenosis following percutaneous coronary interventions (PCI). Meanwhile, development of minimally invasive coronary artery bypass surgery (MIDCAB) has offered a valuable alternative to conventional sternotomy with preservation of the benefit of the internal mammary artery use. Therefore, the revascularization of the left anterior descending (LAD) artery is suitable for both techniques. However, few data with long-term comparison of these two techniques exist., Methods: Prospective data were collected for 456 patients undergoing isolated LAD revascularization between 1997 and 2011. Two hundred and sixty patients were treated with MIDCAB and 196 with first-generation DES implantation. A propensity score model was created to adjust for 19 relevant confounding variables. Primary and secondary end-points were, respectively, 5-year survival and freedom from major adverse cerebro-cardiovascular events (MACCE)., Results: Both groups were similar in age, EuroSCORE and mean duration of follow-up. Five-year survival was similar after MIDCAB or DES (hazard ratio (HR): 0.95; P = 0.89). Freedom from MACCE was significantly in favour of the MIDCAB group (HR: 0.32, P < 0.0001), mainly triggered by high subsequent need for revascularization of the targeted vessel in the DES group (HR: 0.17, P < 0.0001)., Conclusions: MIDCAB and DES implantation showed similar rates of survival but despite an expected lower rate of reintervention on the targeted vessel with DES use, a highly significant higher MACCE rate was observed in the PCI group at 5-year follow-up.

Purpose of Review: Competition flow is a common finding in arterial grafting. This phenomenon can lead to graft occlusion., Recent Findings: Internal thoracic arteries are the best equipped arterial conduit to withstand the competition flow thanks to their endothelial function. Radial as well as right gastroepiploic arteries support much less flow competition because of their different anatomy, histology and endothelial function than that of internal thoracic artery, leading to spasm and occlusion. Therefore, these two arterial conduits should be used only in case of critical lesion to avoid graft occlusion. Saphenous vein graft is the only conduit that is not significantly affected by flow competition, mainly because of its nonresistivity and common reimplantation in the aorta. Graft configuration is the second important factor influencing the equation between graft flow and native coronary flow. Therefore, composite grafting should be reserved for the case of severely stenotic coronary target, especially if multiple arterial sequential anastomoses have to be performed on the lateral-inferior wall of the heart. Finally, an accurate tool such as the fractional flow reserve to evaluate the stenosis severity should be the milestone of coronary surgery in order to decrease the rate of flow competition and improve arterial grafting functionality., Conclusion: Competition flow plays a crucial role in arterial grafting functionality. Grafting strategy should address this by appropriate graft choice and configuration in order to avoid graft attrition.

Objectives: The long-term advantages of multiple arterial grafts, particularly a third arterial conduit, for coronary artery bypass (CABG) are not clear. This study was designed to test whether multiple arterial grafts would provide better long-term outcomes when compared with approaches using fewer arterial conduits., Methods: Between 1985 and 1995, prospective data were collected for 588 patients undergoing isolated CABG at our institution. We examined long-term survival and freedom from cardiac death. The primary analysis compared patients receiving bilateral internal thoracic artery (BITA) vs. single ITA (SITA). In a subgroup analysis, BITA patients receiving a right gastroepiploic artery (RGEA) were compared with those receiving a saphenous vein graft (SVG) as a third conduit. Cox proportional hazard modelling was used to adjust for relevant confounders. The Kaplan-Meier method was used to create survival curves over the follow-up period., Results: The mean age was 59 ± 9 years and 49% received BITA. Mean follow-up was 16.1 ± 5.4 years. Multivariable analysis revealed that overall survival [hazard ratio (HR): 0.74, P = 0.017] and cardiac survival (HR: 0.61, P = 0.004) was significantly improved in the presence of BITA compared with SITA. The survival at 10 and 20 years was 90.2 ± 3.4 and 56.9 ± 6.4% for the BITA vs. 82 ± 4.4 and 40.9 ± 6% for the SITA, respectively. In the subgroup of BITA patients, those receiving the RGEA as a third conduit had superior overall survival (HR: 0.41, P = 0.0032) and cardiac survival (HR: 0.18, P = 0.004) compared with those receiving an SVG. The survival at 10 and 20 years was 98.9 ± 2 and 68.9 ± 18% for the BITA/RGEA vs. 87.2 ± 4.6 and 50.3 ± 7% for the BITA/SVG, respectively., Conclusions: In a single-institution experience, the use of multiple arterial grafting is independently associated with superior outcomes. Furthermore, the use of a third arterial conduit (RGEA) targeted to the right coronary artery should be considered to improve long-term survival.

Objective: Preliminary data showed an increase in endogenous erythropoietin (EPO) concentrations after acute normovolemic hemodilution (ANH) in patients undergoing coronary artery bypass graft (CABG) surgery. Numerous studies have shown the organ protective properties of EPO. The aim of this study was to investigate the cardioprotective effects of these increased EPO concentrations that resulted from ANH during cardiac surgery., Design: A prospective, randomized, blind study., Setting: A university hospital., Participants: A total of 93 patients undergoing isolated CABG surgery with or without cardiopulmonary bypass (CPB)., Interventions: Subjects with CPB were randomized into the control (C) or ANH group. Those in the off-pump coronary artery bypass group underwent no treatment. In the ANH group, a precalculated amount of blood was withdrawn and replaced by colloids after the induction of anesthesia., Measurements and Main Results: Hemodynamic parameters were recorded intra- and postoperatively. Troponin concentrations were measured as a routine parameter postoperatively. Upon intensive care unit arrival, the EPO levels were higher in the ANH group than in the C group. There was no significant difference between the troponin values of the C and the ANH groups at 4 hours postoperatively., Conclusions: In patients undergoing CABG surgery on CPB, an increase in endogenous EPO concentrations in the physiologic range has no cardioprotective effects., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: Saphenous vein, in situ right gastroepiploic artery, and right internal thoracic artery grafts are routinely used to revascularize the right coronary artery. Little is known about the predictive value of objective preoperative angiographic parameters on midterm graft patency., Methods: We prospectively enrolled 210 consecutive patients undergoing coronary revascularization. Revascularization of the right coronary artery was randomly performed with the saphenous vein grafts in 81 patients and the right gastroepiploic artery in 92 patients. During the same study period, 37 patients received right coronary artery revascularization with the right internal thoracic artery used in a Y-composite fashion. All patients underwent a protocol-driven coronary angiogram 3 years after surgery. Preoperative angiographic parameters included minimum lumen diameter percent stenosis measured by quantitative angiography. A graft was considered "not functional" with patency scores of 0 to 2 and "functional" with patency scores of 3 or 4., Results: Angiographic follow-up was 100% complete. A significant difference in the distribution of flow patterns was observed in the 3 groups. In multivariate analysis, the use of a saphenous vein graft was associated with superior graft functionality compared with the other conduits (odds ratio, 6.1; 95% confidence interval, 2.4-15). Graft function was negatively influenced by the minimum lumen diameter (odds ratio, 0.11; confidence interval, 0.05-0.25). In the right gastroepiploic artery and right internal thoracic artery groups, the proportion of functional grafts was higher when the minimum lumen diameter was below a threshold value in the third minimum lumen diameter quartile (0.64-1.30 mm)., Conclusions: Preoperative angiography predicts graft patency in the right gastroepiploic artery and right internal thoracic artery, whereas the flow pattern in saphenous vein grafts is significantly less influenced by quantitative angiographic parameters., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Selected patients, presenting for reoperative coronary surgery with patent internal thoracic arteries (ITAs), may benefit from techniques to salvage and reuse these ITA grafts. We have termed this practice the recycling of ITAs. The purpose of this study is to report our short-term and midterm results using various recycling techniques., Methods: Between April 1996 and February 2009, 60 patients underwent ITA recycling at our institution. Information regarding survival and cardiac events was obtained from a prospectively maintained, institutional database. Survival and freedom from major adverse cardiac events were calculated using Kaplan-Meier analysis. Mean follow-up duration was 60 ± 36 months., Results: Mean age was 64 ± 9 years and the mean time to reoperation was 117 ± 68 months. The patent ITA served as an inflow for a composite Y graft in 39 patients and was distally reimplanted on the same coronary vessel in 9 patients. A combination of these two techniques was used in 8 patients. Other techniques were used in the remaining 4 patients. Freedom from cardiac death was 93% ± 7% and 85% ± 9% at 1 and 5 years and freedom from major adverse cardiac events was 93% ± 7% and 81% ± 11% at 1 and 5 years, respectively., Conclusions: Recycling of ITA grafts during reoperative coronary artery bypass grafting is safe and feasible in selected patients. These techniques can be useful in selected young patients to avoid saphenous vein graft or in patients with a lack of graft conduits., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Composite Y-grafts, using the left internal thoracic artery as the inflow, allow a more efficient use of conduits without the need to touch a diseased ascending aorta. Among other conduits, the saphenous vein graft may be an alternative to the radial artery in elderly patients., Patients and Methods: We evaluated the hemodynamic characteristics of 17 composite Y-grafts made with the left internal thoracic artery anastomosed to the left anterior descending coronary artery in all cases and with either the free right internal thoracic artery (RITA group, n = 10) or a saphenous vein graft (SVG group, n = 7) implanted proximally to the left internal thoracic artery and distally to the circumflex territory 6 months after the operation., Results: At baseline, the pressure gradient measured with a 0.014-inch pressure wire was minimal between the aorta and the internal thoracic artery stem (2 +/- 1 mm Hg), the internal thoracic artery and left anterior descending (4 +/- 2 mm Hg), the internal thoracic artery and left circumflex (3 +/- 1 mm Hg), and the saphenous vein graft and left circumflex (2 +/- 2 mm Hg). During hyperemia induced by adenosine, the pressure gradient increased significantly to 6 +/- 2 mm Hg in the internal thoracic artery stem, 9 +/- 4 mm Hg in the internal thoracic artery and left anterior descending artery, 9 +/- 3 mm Hg in the internal thoracic artery and left circumflex, and 7 +/- 4 mm Hg in the saphenous vein graft and left circumflex. Fractional flow reserve was 0.94 +/- 0.02 in internal thoracic artery stem, 0.90 +/- 0.04 mm Hg in the internal thoracic artery and left anterior descending, 0.91 +/- 0.03 mm Hg in the internal thoracic artery and left circumflex, and 0.92 +/- 0.06 mm Hg in the saphenous vein graft and left circumflex. No difference between the two types of composite Y-grafts was observed for pressure gradients or fractional flow reserve measured in internal thoracic artery stem or in distal branches., Conclusions: Composite Y-grafts with saphenous vein or right internal thoracic arteries allow similar and adequate reperfusion of the left system with minimal resistance to maximal flow and an even distribution of flow in both distal branches., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Bilateral internal thoracic arteries (BITA) demonstrated superiority over other grafts to the left coronary system in terms of patency and survival benefit. Several BITA configurations are proposed for left-sided myocardial revascularization, but the ideal BITA assemblage is still unidentified., Methods and Results: From 03/2003 to 08/2006, 1297 consecutive patients underwent isolated bypass surgery in our institution. 481 patients met the inclusion criteria for randomization, and 304 (64%) were randomized. Patients were allocated to BITA in situ grafting (n=147) or Y configuration (n=152) then evaluated for clinical, functional, and angiographic outcome after 6 months and 3 years. Patient telephone interviews were conducted every 3 months and a stress test performed twice yearly under the referring cardiologist's supervision. Angiographic follow-up was performed 6 months after surgery. The primary and secondary end points were, respectively, major adverse cerebrocardiovascular events (MACCE) and the proportion of ITA grafts that were completely occluded at follow-up angiography. More arterial anastomoses were performed in patients randomized to the Y than the in situ configuration (3.2 versus 2.4; P<0.001). No significant difference between the 2 groups in terms of hospital mortality or morbidity was found. At follow-up, there was no significant difference in any MACCE rate between the 2 groups. 450 out of 464 anastomosis (97%) in the BITA Y group and 287 of 295 (97%) in the BITA in situ group were controlled patent (P=0.99)., Conclusions: Excellent patency rates were achieved using both BITA configurations with no significant differences in terms of MACCE up to 19 months postoperatively, but longer-term results remain to be established.

Objective: Despite its theoretic advantage over saphenous vein grafts, the right gastroepiploic artery graft has not been accepted as the ideal conduit to revascularize the right coronary artery. We therefore prospectively randomized these 2 grafts types to compare their clinical, functional, and angiographic evolution at 6 months and 3 years., Methods: From 2003 to 2006, 1397 consecutive patients underwent isolated revascularization at the University of Louvain Medical School. Of this group, 370 patients met the inclusion criteria for randomization and 66% of those were randomized. The right coronary artery was revascularized with saphenous vein grafts in 116 patients and with right gastroepiploic arteries in 122 patients. All patients underwent angiographic control 6 months postoperatively. The end points were major adverse cerebrocardiovascular events and proportion of grafts patent or functional at follow-up angiography., Results: There were no significant differences between the 2 groups in terms of hospital events. At follow-up there was no significant difference in major adverse cerebrocardiovascular events between the 2 groups. At the 6-month angiographic follow-up, 91% of the anastomoses in the right gastroepiploic artery group and 95% of the anastomoses in the saphenous vein graft group were controlled patent (P = .92). In nonoccluded right coronary arteries, the proportion of patent grafts was significantly lower and the proportion of nonfunctioning grafts was significantly higher in the right gastroepiploic artery group than in the saphenous vein graft group., Conclusion: There were no significant patency or major adverse cerebrocardiovascular events rate differences between the 2 groups; however, the number of functional grafts was significantly higher in the saphenous vein graft group. Careful selection of the coronary target is mandatory to obtain good results in gastroepiploic artery grafting.

Objectives: The purpose of this study was to define the pre-operative angiographic variables that could influence graft patency and flow pattern., Background: Saphenous vein grafts (SVG) and pedicled right gastroepiploic artery (RGEA) grafts are routinely used to revascularize the right coronary artery (RCA). Little is known about the predictive value of objective pre-operative angiographic parameters on the 6-month graft patency and on the interest of these parameters to select the optimal graft material in individual cases., Methods: We prospectively enrolled 172 consecutive patient candidates for coronary revascularization. Revascularization of the RCA was randomly performed with SVG in 82 patients or with the RGEA in 90 patients. Both groups were comparable with respect to all pre-operative continuous and discrete variable and risk factors. All patients underwent a systematic angiographic control 6 months after surgery. Pre-operative angiographic parameters included minimal lumen diameter (MLD), percent stenosis and reference diameter of the RCA measured by quantitative angiography (CAAS II system, Pie Medical, Maastricht, the Netherlands), location of the stenosis, run off of the RCA, and regional wall motion of the revascularized territory., Results: A significant difference in the distribution of flow patterns was observed between SVG and RGEA. In multivariate analysis, graft-dependent flow pattern was significantly associated with both MLD and percent stenosis of the RCA in the RGEA group but with percent stenosis only in the SVG group. In the RGEA group, the proportion of patent grafts was higher when MLD was below a threshold value lying in the third MLD quartile (0.77 to 1.40 mm)., Conclusions: Pre-operative angiography predicts graft patency in RGEA, whereas the flow pattern in SVG is significantly less influenced by quantitative angiographic parameters.

Background: Although the internal thoracic artery was proven superior to saphenous vein graft in long-term patency, it is thought to be a more resistive conduit than the vein graft. Moreover, patency studies comparing both left and right internal thoracic arteries have provided results favoring the former. Fractional flow reserve is an established functional index of coronary blood flow., Methods: To compare the fractional flow reserve between both internal thoracic arteries and saphenous vein grafts, 43 bypass grafts were studied 6 months after revascularization. Intra-graft pressures were measured during cardiac catheterization using a pressure-wire advanced to the first distal anastomosis of 12 left internal thoracic arteries (ITAs), 10 right ITAs and of 21 vein grafts. Pressure gradients between the aorta and the graft were measured at baseline and during a maximal hyperemia., Results: At baseline, pressure gradient was recorded in the left ITA (2.9+/-2.2 mmHg), in the right ITA (1.2+/-1.2 mmHg) and in the vein graft (0.4+/-0.7 mmHg). During maximal hyperemia, pressure gradient increased to 9.6+/-3.2 mmHg in left ITA, to 4.5+/-2.0 mmHg in the right ITA (p<0.001 vs left ITA) and to 3.3+/-2.7 mmHg in vein (p<0.001 vs left ITA; NS vs right ITA). Fractional flow reserve was 0.90+/-0.04 in left ITA, 0.95+/-0.03 in right ITA (p<0.01 vs left ITA) and 0.96+/-0.03 in vein (p<0.001 vs left ITA)., Conclusion: Internal thoracic arteries and saphenous vein grafts allow myocardial revascularization with minimal resistance to maximal blood flow. The resistance appears significantly higher in left ITA compared to both the right ITA and venous grafts.

Background: Patients with patent grafted bilateral internal thoracic arteries may require repeat myocardial revascularization because of either progression of disease in a nongrafted native vessel or failure of a saphenous vein graft. In order to avoid extensive dissection and possible damage of the internal thoracic arteries, we elected to proceed with an off-pump minimally invasive direct coronary artery bypass grafting (MIDCABG) approach using the pedicled right gastroepiploic artery. This paper summarizes our midterm angiographic results., Methods: From 1996 to 2003, 15 patients were reoperated on using this approach in our department. Internal thoracic artery grafts always revascularized the anterior and lateral territories and were angiographically patent. Indications for repeated surgery were: (1) coronary disease progression in 8 patients; (2) occlusion of the saphenous vein graft in 6 patients; and (3) anastomotic stenosis of a pedicled right gastroepiploic artery in 1 patient. Off-pump grafting of the pedicled right gastroepiploic artery was targeted at the posterior descending artery in 14 patients, and at the left anterior descending artery in 1 patient., Results: Thirty-day mortality was 6.5% (1 of 15 patients). With a mean follow-up of 56 +/- 20 months, angina-free survival was 79%. At angiographic control (mean, 38 months), the pedicled right gastroepiploic artery was patent in 13 patients. One patient had an occluded right gastroepiploic artery graft at 23 months and another patient showed progression of disease distal to the right gastroepiploic artery anastomosis at 28 months., Conclusions: Off-pump MIDCABG repeat revascularization with a pedicled right gastroepiploic artery is an effective method of revascularization for patients with patent bilateral internal thoracic arteries.

Objectives: Studies have emphasized the importance of normal fibrinogen concentrations in surgical patients. The primary hypothesis of this study was that fibrinogen levels significantly decrease in on-pump coronary artery bypass graft (CABG) surgery versus off-pump coronary artery bypass graft (OPCAB) surgery. The second objective was to show that ROTEM (TEM International, GmbH, Munich, Germany) rapidly detects these abnormalities compared with standard tests. Design: A prospective, nonrandomized study. Setting: A university hospital. Participants: Forty-two and 62 patients in the CABG and OPCAB groups, respectively, undergoing first-time bypass surgery were included. Interventions: CABG versus OPCAB surgery. Measurements and Main Results: Routine coagulation tests and ROTEM values were measured before anesthesia (T0), after the first dose of heparin (T1), after protamine (T2), upon intensive care unit arrival (T3), and 4 hours postoperatively (T4). The outcome measures were followed until 4 hours postoperatively. Fibrinogen concentrations were significantly lower in the CABG versus the OPCAB group at T2 (170 ± 44 v 243 ± 73 mg/dL, p < 0.001) and T3 (179 ± 42 v 232 ± 68 mg/dL, p < 0.001). This was confirmed by significantly lower FIBTEM maximal clot firmness values at T2 (9 ± 4 v 14 ± 5 mm, p < 0.001) and T3 (9 ± 4 v 13 ± 6 mm, p < 0.001). In the CABG group, patients received significantly more transfusions of all blood products except fresh frozen plasma. Conclusions: Fibrinogen concentration significantly decreases after cardiopulmonary bypass. ROTEM helps in its fast detection. [Copyright &y& Elsevier]

Abstract: Objective: The manner in which a blood vessel is for used as a coronary graft may be important in maintaining a viable and functional endothelial lining. Composite internal thoracic arteries (ITAs) in a Y-graft configuration are characterized by the connection of an in situ left ITA with preserved innervation and lymphatics and of a free semi-skeletonized right ITA. Methods: To determine whether endothelial function differs between left and right ITA segments in a Y-graft configuration, 11 patients were studied 3 years after surgery. The endothelium-dependent vasodilator substance P was selectively infused (1.4–22.4pmolmin−1 in doubling dose increments) in the ostium of ITA Y-grafts. A maximal endothelium-independent vasodilatory response was then obtained by intragraft infusion of 2mg isosorbide dinitrate (ISDN). Biplane angiograms obtained at 3-min intervals using an automated contrast injection system with fixed preset volume and pressure parameters were analyzed off-line using a quantitative analysis system (CAAS, Pie Medical). Results: A similar dose-dependent vasodilatory response to substance P was observed in the left and in the right ITA. No difference in maximal endothelium-dependent response to substance P (7.4±4.3% in the left ITA and 8.1±5.3% in the right ITA) or in maximal endothelium-independent response to ISDN (12.2±4.4% in the left ITA and 10.6±8.1% in the right ITA) was observed. Conclusions: The endothelium-dependent and the endothelium-independent vasodilator capacity of the two branches of a Y-graft ITA configuration appear similar 3 years after bypass surgery. This suggests that the preservation of the ITA pedicle does not significantly affect basal vasomotor tone, long-term endothelial function, or vasodilator reserve. [Copyright &y& Elsevier]

Abstract: Objective: Y-graft configuration with left and right ITA (RITA) allows complete arterial revascularisation. We previously compared two types of ITA revascularisation in a prospective randomised trial with a systematic 6-month angiographic follow-up study. The present study is a secondary analysis of these populations to evaluate the angiographic parameters influencing the function of the RITA used in a Y-graft configuration Methods: The functionality of the RITA was based on the TIMI grade flow: in TIMI grade 0 (occluded graft) and in TIMI grade 1 or 2 (balanced flow), the RITA was considered not functional. RITA was considered functional when a complete opacification (TIMI 3) of all anastomoses of the targeted coronary vessels was observed. Results: A total of 25.3% of RITA were not functional. In univariate analysis, the number of anastomoses, the type and size of grafted coronary segments and the severity of the native coronary stenosis influenced ITA function. In multivariate analysis, the function of the RITA was positively influenced by the number of anastomoses (OR=0.5, 95% CI: 0.4–0.7), and a severely narrowed first circumflex (OR=39.1, CI: 8.1–189.2) and negatively by the presence of a grafted intermediate coronary artery (OR=0.01, CI: 0.003–0.06), and of a grafted RCA (OR=0.08, CI: 0.02–0.35). The size of targeted vessel, history of infarction and regional myocardial function did not influence ITA function. Conclusions: In this systematic angiographic study, the function of the RITA used as a Y-graft was significantly improved when used on several branches of the circumflex artery or on a severely narrowed first circumflex. Grafting of the intermediate branch or of a RCA has a negative prognostic influence on graft function. [Copyright &y& Elsevier]

The methods of graft sizing in valve-sparing surgery are criticized for their complexity and subjectivity in application. We propose a simple method for graft sizing in valve-sparing root replacement using the reimplantation technique. Practically, the height of the commissure between the noncoronary cusp and the left coronary cusp give the size of the graft. This new method of graft sizing was successfully applied in the last 27 consecutive patients with good immediate results. Graft sizing with this objective and reproducible simple method results in restoration of normal aortic valve geometry and function. [ABSTRACT FROM AUTHOR]

Background: It remains unclear if graft type impacts native disease progression in the target coronary artery post coronary artery bypass grafting (CABG).Methods: Patients who underwent repeat angiograms at least 6 months post CABG with ≥1 arterial graft were included. Pre/post CABG angiograms were examined by 2 experienced readers. Progression was defined as new stenosis of ≥50% in a previously normal coronary, an increase in previous stenosis of ≥20%, or a new occlusion. Primary outcome was the occurrence of native disease progression in bypassed vessels. Secondary outcomes included complete occlusion, left main (LM) and distal disease progression. Cox-proportional hazard regression models were used for time-to-event outcomes.Results: Study population included 98 patients comprising 263 grafts (143 arterial/120 venous grafts). Median time from surgery to catheterization was 559 days (Interquartile Range 374,910).Ninety-one target vessels showed progression (34.6%) with 75 to complete occlusion (28.5%). Progression was not associated with graft choice (HR 0.74(0.49,1.13) p = 0.163),but was significantly associated with age(p = 0.034),previous PCI(p = 0.002),ACE inhibitor (ACEi) use(p < 0.001),CAD severity (p < 0.001),CCS class III/IV(p = 0.016) and NYHA class III/IV(p < 0.001). Progression to occlusion was significantly associated with SVG (p = 0.019), as well as previous percutaneous coronary intervention (p = 0.007) and ACEi use (p < 0.001). LM disease progression was significantly associated with peripheral vascular disease (HR 5.44(1.92, 15.46), p = 0.001), and not affected by graft type (p = 0.754).Conclusions: Native CAD progression in non-LM coronaries is multifactorial, while SVG use was only associated with occlusion of non-LM coronaries. The implications of this study warrant consideration for increased arterial grafting in CABG patients, while the negative associations of previous PCI and ACEi use carry important clinical implications, which require further investigation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the longterm outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed. METHODS: A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for longterm mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals. RESULTS: Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71–1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75–0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33– 0.98; P=0.04). CONCLUSIONS: The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status. [ABSTRACT FROM AUTHOR]

Introduction: Functional mitral regurgitation (MR) is common and associated with significant morbidity and mortality. Notably, correction of functional MR has not been demonstrated to improve survival. We therefore evaluated outcomes following repair of functional MR utilizing prospective population data. Hypothesis: We hypothesized that correction of functional MR may be associated with a survival benefit in selected patients. Methods: Between 2001 and 2018, 1896 patients underwent complex mitral surgery at our institution, of which 168 underwent repair of functional MR in whom the etiology of MR was due to annular dilation in 37, leaflet tethering in 100 and mixed in 31. Mean patient age was 66.2±9.9 years and 66 (39%) were female. Concomitant coronary artery bypass grafting was performed in 79 (47%) with an average of 2.5 grafts per patient. The mean preoperative left ventricle (LV) ejection fraction was 38.3±11.4% and indexed LV end-systolic dimension, 25.1±5.4 mm/m2. Average clinical and echocardiographic follow up averaged 5.5±3.8 years. Results: Thirty-day mortality was 0.6%. Overall survival for the patients following repair of functional MR was 93.3±2.0% and 75.6±3.8% 1-, and 5-years after surgery. Not surprisingly, sensitivity analysis demonstrated that survival was influenced by age at operation (hazard ratio (HR) 1.05±0.02 per increasing year) and preoperative left ventricle (LV) class (HR 1.32±0.18 per increasing LV grade) (Both p<0.05). For patients <70 years of age and with a preoperative LVEF >35%, 5- year survival was 92.3±7.4%, respectively. This compares to an expected 5- year survival of 99.1%, for age and gender matched Canadians (Figure). For patients <70 and with a preoperative LVEF >35%, 5-year freedom from recurrent MR ≥2+ was 81.3±9.8%. Conclusions: Repair of functional MR is associated with favorable early and intermediate term results in selected patients. Notably, for the subset of functional MR patients <70 and with a LVEF>35%, 5-year survival was comparable to age and gender matched patients from the general population. [ABSTRACT FROM AUTHOR]