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Controversy surrounds the long-term clinical benefit of coronary artery bypass grafting (CABG) using dual arterial grafts (DAGs) compared to single arterial grafts (SAGs). We investigated outcomes of DAG, using single internal thoracic artery and radial artery (DAG-RA) or bilateral internal thoracic artery grafts (DAG-BITA), compared to SAG, using the left internal thoracic artery and saphenous vein grafts, in the U.S. Veterans Health Administration (VA). We conducted a cross-sectional study of U.S. Veterans undergoing isolated on-pump CABG between 2005 and 2015 at 44 VA medical centers. The primary composite outcome was first occurrence of a major adverse cardiac and cerebrovascular event (MACCE), comprised of death from any cause, myocardial infarction, stroke, or repeat revascularization. Among 25,969 Veterans undergoing isolated CABG, 1261 (4.9%) underwent DAG (66.8% DAG-RA and 33.2% DAG-BITA). Over a 5-y follow-up, DAG was associated with lower rates of all-cause death (adjusted hazard ratio [AHR] 0.70, 95% confidence interval [CI] 0.58-0.85), MACCE (AHR 0.80, 95% CI 0.71-0.91), and stroke (AHR 0.74, 95% CI 0.57-0.96) versus SAG. DAG-BITA was associated with lower rates of all-cause death (AHR 0.52, 95% CI 0.35-0.77) and MACCE (AHR 0.66, 95% CI 0.51-0.84) than SAG, while DAG-RA was associated with lower rates of all-cause death (AHR 0.79, 95% CI 0.64-0.99). In the VA, DAG was associated with improved long-term MACCE outcomes compared to SAG. These results suggest that the practice of DAG in the VA benefits Veterans and should be promoted further. [ABSTRACT FROM AUTHOR]

Abstract Background To compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA). Methods Among 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting. Results After adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504–0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499–0.902; p = 0.008). Conclusions Bilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG.

Background: To compare postoperative outcomes in patients with left main coronary artery disease who underwent off-pump isolated coronary artery bypass grafting for multivessel disease using either skeletonized bilateral or single internal thoracic artery (ITA). Methods: Among 1583 patients who underwent isolated coronary artery bypass grafting (CABG) in our hospital between 2002 and 2022, 604 patients with left main coronary artery disease underwent single (n = 169) or bilateral (n = 435) ITA grafting. We compared postoperative outcomes between the two groups after adjusting preoperative characteristics using inverse probability of treatment weighting. Results: After adjustment using inverse probability of treatment weighting method, the sum of weights was 599.74 in BITA group and 621.64 in SITA group. There was no significant difference in postoperative deep sternal wound infection (p = 0.227) and 30-day mortality (p = 0.612). Follow-up was completed in 98.7% (596/604) of the patients, and the mean follow-up duration was 6.7 years. At 10 years, the overall survival following bilateral versus single ITA grafting was 71.2% and 60.6%, respectively (log-rank test, p = 0.040), and freedom from major adverse cardiac and cerebrovascular events (MACCE) was 63.3% and 46.3%, respectively (log-rank test, p = 0.008). In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of all-cause death (hazard ratio [HR]: 0.706, 95% confidence interval [CI]: 0.504–0.987; p = 0.042) and MACCE (HR: 0.671, 95% CI: 0.499–0.902; p = 0.008). Conclusions: Bilateral skeletonized ITA grafting is associated with lower rates of all-cause death and MACCE than single ITA grafting in patients with left main coronary artery disease undergoing off-pump CABG. [ABSTRACT FROM AUTHOR]

Preoperative renal dysfunction is a major determinant of operative and long-term mortality following cardiac surgery. The objective of this study was to assess early and long-term results of CABG in patients with preoperative chronic kidney disease (CKD) using a bilateral internal thoracic artery (BITA) strategy, compared to those without CKD. We retrospectively analyzed data for 2,111 consecutive patients who underwent CABG with BITA between 2000 and 2019. One-to-many propensity score matching was performed to produce a cohort of 132 patients with CKD (defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2), matched to 358 patients with normal renal function (non-CKD). The primary end-point of interest was late freedom from all-cause mortality. Late hospital readmissions were also assessed. Mean eGFR and serum creatinine were: 49.8 versus 84.3 mL/min/m2 and 146.1 versus 83.6 µmol/L (CKD vs non-CKD, P < 0.001). In-hospital outcomes were similar among matched patients, including mortality (CKD 0.8% vs non-CKD 0%, P = 0.31). At a median follow-up of 6.9 years, there was no significant difference in survival between both groups (hazard ratio (HR) 1.37, 95% confidence interval (CI) 0.87-2.16, P = 0.17). Hospital readmission for cardiovascular causes (including repeat coronary revascularization) was comparable between the 2 groups. However, the risk of hospital readmission for renal causes was higher in patients with CKD (6.7%) compared to non-CKD (1.2%). In a propensity score-matched cohort of patients undergoing BITA-CABG, CKD was not associated with increased early or late mortality, nor was there a greater risk of hospital readmission for cardiovascular events. [Display omitted] [ABSTRACT FROM AUTHOR]

Keywords: Coronary artery bypass grafting; Arterial grafting; Radial artery; Internal thoracic artery; Bilateral internal thoracic artery; Meta-analysis EN Coronary artery bypass grafting Arterial grafting Radial artery Internal thoracic artery Bilateral internal thoracic artery Meta-analysis 1 5 5 03/02/23 20230201 NES 230201 We are grateful for the opportunity to reply and comment on the Taggart I et al. i [[1]] and Freemantle I et al. i [[2]] pieces. Taggart I et al. i [[1]] raise the following points in their commentary: The mean age of the left internal thoracic artery (LITA) and radial artery (RA) group was younger than the other groups: this is incorrect. Apparent exclusion of the Radial Artery Patency and Clinical Outcomes (RAPCO) trial: RAPCO patients were excluded from the propensity score-matched analysis due to the high rate of missing baseline data which would have not allowed the application of a non-parsimonious model to calculate the propensity score. However, the RA effect is qualitatively consistent with the 30% mortality reduction with RA versus BITA at 15 years recently reported by the RAPCO trial and, despite all the described limitations, cannot be ignored or dismissed as implausible. [Extracted from the article]

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

Background: It is generally agreed that using a bilateral internal thoracic artery (BITA) composite graft improves long-term survival after coronary artery bypass grafting (CABG). Although the left internal thoracic artery (LITA)-based Y-composite graft is widely adopted, technical or anatomical difficulties necessitate complex configurations. We aimed to in-vestigate whether BITA configuration impacts survival or patency in patients undergoing coronary revascularization.Methods: Between January 2006 and June 2017, 1,161 patients underwent CABG at Seoul National University Bundang Hospital, where the standard technique is a LITA-based Y-composite graft with the right internal thoracic artery (RITA) sequentially anastomosed to non-left anterior descending (LAD) targets. Total of 160 patients underwent CABG using BITA with modifications. Their medical records and imaging data were reviewed retrospec-tively to investigate technical details, clinical outcomes, and graft patency.Results: Modifications of the typical Y-graft (group 1, n=90), LITA-based I-graft (group 2, n=39), and RITA-based composite graft (group 3, n=31) were used due to insufficient RITA length (47%), problems using LITA (28%), and target vessel anatomy (25%). The overall 30-day mortality rate was 1.9%. Among 116 patients who underwent computed tomography or conventional angiography at a mean interval of 29.9±33.1 months postoperatively, the graft patency rates were 98.7%, 95.3%, and 83.6% for the LAD, left circumflex artery, and right coronary artery territories, respectively. Patency rates for the inflow, secondary, and tertiary grafts were 98.2%, 90.5%, and 80.4%, respectively. The RITA-based graft (group 3) had the lowest patency rate of the various configurations (p

Background: This study aimed to verify the external validation of a contemporary nomogram in predicting long-term survival after an isolated coronary artery bypass with bilateral internal thoracic artery grafting (CABG-BITA). Methods: Consecutive patients who underwent CABG-BITA at a single center were included in the study. All the predictors of the original risk score (age, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic renal failure, old myocardial infarction, ejection fraction, intra-aortic balloon pump and peripheral arterial disease) were available for analysis. Results: Among the 2846 consecutive patients, a total of 1176 (41.3%) deaths were recorded during the 31,383 patient years of follow-up. The median EuroSCORE II was 2.35, and the median follow-up was 11.1 years. The risk score showed 72.7% overall discriminatory ability as measured by Harrell’s concordance statistic. It showed satisfactory calibration at 10, 15 and 20 years of follow-up. The risk score showed a time-varying nonlinear effect, and accordingly, adjusted long-term survival predictions were calculated. There were subgroups (scores < 50 points) with favorable 20-year survival rates ranging from 77% to 60%. Higher risk subgroups (scores > 90 points) showed poor 20-year survival rates ranging from 22% to 4%. Conclusions: The validated risk score represents a useful algorithm for the detection of patients who could benefit after CABG-BITA with respect to long-term survival. Although further multi-center studies are required worldwide to reveal the usefulness of this score in the clinical setting, its wide adoption may act as a motivation for cardiac surgeons resulting in higher numbers of CABG-BITA procedures.

Aim: To evaluate efficacy and safety of surgical myocardial revascularization with two internal thoracic arteries in the elderly patients and to identify special aspects and immediate results of the interventions on a working heart and with the use of cardiopulmonary bypass and on a working heart.Materials and methods: This retrospective single center study included patients over 65 years of age with multivessel coronary artery disease who underwent coronary artery bypass grafting with two internal thoracic arteries in a working heart without cardiopulmonary bypass at the Federal Clinical Center of High Medical Technologies of FMBA of Russia from 2015 to 2017 (the study group, n=50) and with cardiopulmonary bypass and cardioplegia (the comparison group, n=51). We analyzed demographic characteristics, preoperative state severity, and special aspects of myocardial damage, operational parameters, rates, and structure of postoperative complications.Results: None of the patients died. Median intraoperative parameters in the study group were better than those in the comparison group: blood loss, 300 vs. 800 mL (p

There is still lack of convincing evidence about the superiority of bilateral internal thoracic artery (BITA) use in coronary artery bypass grafting (CABG) and BITA grafts continue to be underutilized. Arterial Revascularization Trial (ART) did not demonstrate the superiority of BITA versus single ITA grafting after 10 years. We have reviewed the most recent literature, assessed the current status as well as indications of BITA grafting in the post-ART era. We believe that BITA grafting is not appropriate for all patients especially in light of the findings of ART. However, the use of BITA is justified in patients of younger age and those without comorbidities (poorly controlled diabetes, obesity, chronic obstructive pulmonary disease, previous mediastinal irradiation, long-term steroid use, elderly women). Further prospective randomized studies with long-term follow-up are needed to validate the benefits of BITA grafting. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide Observational evidence shows that the use of multiple arterial grafts (MAG) is associated with longer postoperative survival and improved clinical outcomes. The current European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommend the use of MAG in appropriate patients. However, a significant volume-to-outcome relationship exists for MAG, and lack of sufficient experience is associated with increased operative risk. A stepwise approach to building experience with MAG allows successful implementation of this technique into routine coronary surgery practice. [ABSTRACT FROM AUTHOR]

Background: The use of the bilateral internal thoracic arteries (BITAs) during myocardial revascularization reportedly provides a survival benefit over using a single internal thoracic artery (SITA). However, the advantages in chronic hemodialysis patients, who generally have multiple comorbidities, is unclear. Methods: Outcomes of chronic hemodialysis patients who underwent isolated coronary artery bypass grafting (CABG) using a SITA with additional saphenous vein grafts (SVGs) (n = 33) or BITAs (n = 30) for left-side revascularization were retrospectively reviewed. Results: With the exception of the rate of diabetes mellitus (SITA vs. BITA: 84.8% vs. 50.0%; p = 0.003), the two groups showed similar patient characteristics. Using the off-pump technique, revascularization was completed without manipulation of the ascending aorta in 45.7% of patients in the BITA group, whereas all patients in the SITA group required aortic manipulation (p < 0.001). Of note, the incidence of extensive aortic calcification (>50% of ascending aorta circumference) was not uncommon (14.3%). The in-hospital mortality (3.0% vs. 0%, p = 0.336) and complication rates (including deep wound infection, re-exploration and stroke) were similar in both groups. The 5-year estimated survival rates for freedom from overall death in the SITA and BITA groups were 42.4% and. 57.4%, respectively (p = 0.202). Conclusions: BITA grafting was able to achieve revascularization with minimal manipulation of the diseased ascending aorta without increasing the complication rate. The long-term survival benefit of BITA grafting, however, was unclear in dialysis patients, especially because such patients have a relatively short life expectancy. [ABSTRACT FROM AUTHOR]

Objective: Despite the improved survival in patients with multi-vessel coronary disease compared to conventional myocardial revascularization associated with the use of multiple arterial grafting for myocardial revascularization, it has been adopted in the minority of centers. We sought to evaluate the long-term outcome of patients with and without diabetes undergoing total arterial versus conventional myocardial revascularization.Methods: Among 1000 consecutive patients undergoing CABG, we performed a propensity-match analysis to compare patients with multi-vessel disease receiving total arterial (G1 = 618 pts) versus conventional myocardial revascularization (LIMA-LAD plus vein grafts, G2 = 382 pts). The primary end-point was survival free from all-cause and cardiac-related mortality, while the secondary end-point was the occurrence of major cardiac and cerebrovascular accidents.Results: Hospital mortality was similar (G1: 0 pts. vs G2: 1 pts., 0.3%, p = .91). At a median follow-up of 101 months (range 11-185 months), total arterial grafting was associated with significantly improved survival free from overall (G1 = 76.5 ± 3.0% vs G2 = 66.0 ± 3.1%; p < .001) and cardiac mortality (general population: G1 = 90.8 ± 2.1% vs G2 = 84.2 ± 1.9%, p = .043; diabetics:G1 = 84.7 ± 2.1 vs G2: 79.3 ± 3.4; p = .035) as well as occurrence of MACCEs (general population:G1 = 80.1 ± 3.2% vs G2 = 70.8 ± 2.9%; p > .001; diabetics:G1 = 77 ± 6 vs G2 = 53 ± 5.8; p < .001). Cox regression analysis identified diabetes (HR = 1.94, CI 95% = 1.12-2.93; p < .001) and the use of veins (HR = 1.81, CI 95% = 1.32-2.65; p < .001) as independent predictors for all-cause mortality; among diabetics, vein grafts was the strongest predictor of MACCEs (HR = 2.41, CI 95% = 1.27-4.59; p = .007) and cardiac mortality (HR = 3.24, CI 95% = 1.69-6.23; p < .001).Conclusions: Long-term survival following total arterial CABG is remarkably improved compared to conventional grafting with vein grafts especially in diabetic patients. [ABSTRACT FROM AUTHOR]

Objectives: Bilateral internal thoracic artery (BITA) grafting strategy is the current trend in coronary artery bypass grafting for multivessel coronary artery disease. Although better long-term outcomes have been shown, BITA grafting is underutilized as a main strategy for revascularization by most of the surgeons. The survey was conducted to ascertain the current usage and concerns of BITA grafting in India. Methods: Database of 856 Indian cardiac surgeons currently with predominantly adult practice was prepared and a questionnaire was sent about use of single and bilateral ITA grafts and BITA grafting strategy in different clinical scenarios. Results: A total of 112 surgeons (13.08%) from 75 institutions responded and 92 surgeons (10.7%) completed the survey. Single ITA is used by 79% of surgeons in more than 90% of their patients. 31% and 29% of surgeons use BITA grafting in 5–10% and 11–98% of their patients respectively. 53% of surgeons avoided the usage of BITA grafting in patients with smoking, 35% of surgeons in chronic obstructive pulmonary disease, 58% of surgeons in obesity and 62% of surgeons in acute coronary syndrome, 36% of surgeons in patients with left ventricular dysfunction and 61% of surgeons in patients with poor coronary anatomy. The concerns for BITA usage are risk of deep sternal wound infection (DSWI) (40%), increased operative time (27%), unknown superiority (12%) and limited length of right ITA (5%). Conclusions: The usage of BITA grafting is restricted to 10% in India and main concerns are DSWI and increased operative time.

Abstract Background Congenital left main coronary atresia is an extremely rare coronary anomaly. Long-term surgical outcomes and the optimal management strategies for recurrence of ischemia remain uncertain. Herein, we present a case involving successful redo coronary artery bypass grafting for unstable angina 27 years after the initial coronary artery bypass grafting for congenital left main coronary atresia. Case presentation A 33-year-old woman was referred to our department with unstable angina. At the age of 6, she had undergone coronary artery bypass grafting of the second diagonal branch using the left internal thoracic artery and the obtuse marginal branch using saphenous vein grafting for left main coronary atresia. Although a coronary angiogram showed a patent left internal thoracic artery graft to the second diagonal branch and a patent saphenous vein graft to the obtuse marginal branch, the left anterior descending artery was not being perfused by the grafts because of a disruption of blood flow to the left anterior descending artery from the left internal thoracic artery. Therefore, we performed a redo coronary artery bypass grafting using the in situ right internal thoracic artery to the first diagonal branch, which was to be connected to the left anterior descending artery, resulting in amelioration of the ischemia of the left anterior wall. The patient was discharged 10 days after the operation and has been in good health for over 3 years without recurrence of chest symptoms. Conclusions Coronary revascularization using a saphenous vein and left internal thoracic artery grafts is effective in achieving an adequate blood supply to the distal coronary arteries, and this effect can last for decades. However, careful follow-up is necessary because recurrent myocardial ischemia due to the development of a coronary artery occlusion may occur in adulthood.

Background and Aim Of the Study: We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy.Methods: PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding.Results: Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR with the bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77).Conclusions: TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Observational data suggest that the use of a single internal thoracic artery (SITA) may result in inferior outcomes compared with bilateral internal thoracic artery (BITA) use for coronary artery bypass grafting (CABG)—a finding not yet supported by randomized trial outcomes. However, the optimal number of internal thoracic artery grafts in patients with left main coronary artery disease has not been investigated. METHODS The EXCEL trial randomized 1905 patients with left main coronary artery disease to percutaneous coronary intervention with everolimus-eluting stents versus CABG. Among the 905 patients undergoing CABG, 688 (76.0%) received SITA and 217 (24.0%) received BITA. Differences in clinical event rates were estimated using the Kaplan–Meier method and compared with the log-rank test. Multivariable Cox regression was used to adjust for differences in baseline covariates. RESULTS Compared to SITA, patients treated with BITA were younger (66.1 ± 9.5 vs 64.5 ± 9.3 years, P  =   0.020), were less likely female (24.3% vs 14.3%, P  =   0.002) and diabetic (28.8% vs 15.2%, P  <   0.001), and had a lower prevalence of peripheral vessel disease (10.2% vs 5.5%, P  =   0.040). The unadjusted 3-year composite primary endpoint of death, stroke or myocardial infarction (MI) occurred in 15.6% of SITA vs 11.6% of BITA patients (P  =   0.17). The SITA group tended to have a higher 3-year rate of all-cause death compared with the BITA group (6.7% vs 3.3%; P  =   0.070). Stroke, MI and ischaemia-driven revascularization outcomes were not significantly different between groups. After adjusting for baseline differences, neither the composite of death, stroke or MI [hazard ratio (HR) 1.12, 95% confidence interval (CI) 0.71–1.78; P  =   0.62] nor mortality (HR 1.36, 95% CI 0.60–3.12; P  =   0.46) was significantly higher with SITA. The rehospitalization rate after 3 years was higher in the SITA group (35.8% vs 26.0%, P  =   0.008), a difference which was no longer present after multivariable adjustment (HR 1.27, 95% CI 0.93–1.74; P  =   0.13). Sternal wound dehiscence within 30 days did not occur more often in the BITA group compared to the SITA group (1.8% vs 2.2%, P >  0.99). CONCLUSIONS In the EXCEL trial, there were no clinical differences at 3 years between SITA or BITA revascularization in patients with left main coronary artery disease. [ABSTRACT FROM AUTHOR]

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

BackgroundBilateral internal thoracic artery grafting (BITA) is associated with improved survival. However, surgeons do not commonly use BITA in patients after myocardial infarction (MI) because survival is good with single internal thoracic artery grafting (SITA). We aimed to compare the outcomes of BITA with those of SITA and other approaches in patients with multivessel disease after recent MI. Methods and ResultsIn total, 938 patients with recent MI (

Purpose: To analyse the outcome of coronary artery bypass grafting (CABG) in octogenarians with coronary multivessel disease and the impact of different graft strategies and other factors., Methods: Out of 1654 patients with multivessel disease who underwent CABG at our institution between January 2014 and March 2020, we investigated 225 consecutive patients with a median age of 82.1 years for survival prediction and need for coronary reintervention; a detailed outcome analysis was performed., Results: At mean follow-up of 3.3 years, the overall survival was 76.4%. An indication for emergency operation (p = 0.002), age (p <0.001), chronic pulmonary disease (p = 0.024), and reduced renal or ventricular function (p <0.001) had the highest impact on limited survival. The combination outcome of survival and coronary reintervention was 1.7-fold improved (p = 0.024) after use of the bilateral internal thoracic artery (BITA) (66.2%). Off-pump CABG (12%) revealed no impact on survival. Smokers showed a poorer outcome (p = 0.004). The logistic European System for Cardiac Operative Risk Evaluation was highly effective for evaluating long-term outcomes (p <0.001)., Conclusions: BITA grafting normalizes survival and reveals a better outcome in octogenarians with multivessel disease. However, patients at risk of poorer survival were operated under emergency conditions and those with pulmonary disease and reduced ventricular or renal function.

Totally endoscopic multi-vessel coronary artery bypass grafting is an advanced surgical technique that offers the least-invasive alternative to traditional sternotomy bypass surgery. Although robotic-assisted minimally invasive left internal thoracic artery to left anterior descending artery bypass has been adopted widely, the application of a robotic totally endoscopic approach for multi-vessel bypass still remains limited. This case report demonstrates the surgical technique of robotic totally endoscopic multi-vessel coronary artery bypass using bilateral internal thoracic artery grafts., (© The Author 2023. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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 longterm 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 longterm 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. [ABSTRACT FROM AUTHOR]

Aims: Whether bilateral internal thoracic artery (BITA) grafting benefits elderly patients in coronary artery bypass grafting (CABG) remains unclear since they tend to have a limited life expectancy and severe comorbidities. We aim to evaluate the outcomes of BITA vs. single internal thoracic artery (SITA) grafting in elderly patients., Methods and Results: A meta-analysis was performed by database searching until May 2021. Studies comparing BITA and SITA grafting among elderly patients were included. One randomized controlled trial, nine propensity score matching, and six unmatched studies were identified, with a total of 18 146 patients (7422 received BITA grafting and 10 724 received SITA grafting). Compared with SITA grafting, BITA grafting had a higher risk of deep sternal wound infection (DSWI) [odds ratio: 1.67; 95% confidence interval (CI): 1.22-2.28], and this risk could not be significantly reduced by the skeletonization technique. Meanwhile, BITA grafting was associated with a higher long-term survival [hazard ratio: 0.83; 95% CI: 0.77-0.90], except for the octogenarian subgroup. Reconstructed Kaplan-Meier survival curves revealed 4-year, 8-year, and 12-year overall survival rates of 85.5%, 66.7%, and 45.3%, respectively, in the BITA group and 79.3%, 58.6%, and 34.9%, respectively, in the SITA group. No significant difference was observed in early mortality, perioperative myocardial infarction, perioperative cerebral vascular accidents, or re-exploration for bleeding., Conclusion: Compared with SITA grafting, BITA grafting could provide a long-term survival benefit for elderly patients, although this benefit remained uncertain in octogenarians. Meanwhile, elderly patients who received BITA were associated with a higher risk of DSWI and such a risk could not be eliminated by the skeletonization technique., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. [Extracted from the article]

Background: Pedicled bilateral internal thoracic artery grafting (BITA) has been discouraged in historical high-risk groups such as diabetes mellitus (DM), renal failure, old age, and obesity because of reported high incidence of mediastinitis. However, considering the fact that there are abundant short and long-term results including angiography study about the conventional pedicled grafts, it might be worthwhile reassessing the results of pedicled BITA grafting with modern techniques by a disciplined surgical team before abandoning the method. Methods: Between September 1989 and September 1999, 1371 patients underwent isolated coronary artery bypass grafting (CABG) in Kumamoto central hospital. Of these patients, 558 patients who had bilateral ITA strategy (mean age 63.0±9.2 years, 13–79) were studied. The method of harvest of ITAs is consistently the use of conventional pedicled grafts. The use of bone wax and unnecessary electrocautery injury to the periostium or cartilage were avoided as much as possible. The only change in the surgical technique in the study period is the application of the pinpoint hemostasis for the presternal tissues from August 1997 (late period). Results: In late period, there were significantly more patients with sternal sepsis risk factors such as diabetes mellitus (early: late; 19.3% vs. 34.8%, P<0.00003), and renal failure (0.3 vs. 9.7%, P<0.0001) as well as patients who had gastroepiploic artery grafting (16.9 vs 48.5%, P<0.0001) and those who required aortic non-touch technique (2.1 vs. 7.9%, P<0.001). The percentage of the patients receiving BITA grafting among the isolated CABG patients increased in the late period from 31.7% (331/1043) to 69.2% (227/328) (P<0.001), reflecting that a more aggressive approach towards bilateral ITA and arterial grafting has been taken in the late period. Overall operative mortality was 1.1% (n=6). Mediastinitis occurred in seven patients (1.3%). Of these, only one mediastinitis occurred in late period (0.4%). No mediastinitis occurred in 23 chronic renal dialysis patients. Among the 143 DM patients, there were three mediastinitis (2.1%). Of three, only one occurred in late period, yielding 1.3% mediastinitis rate. There was one mediastinitis (0.7%) among 134 elderly patients more than 70 years of age. Univariate analysis identified obesity as a risk factor for mediastinitis. And there was a trend of decreasing mediastinits in late period but did not reached a statistical significance (P<0.2). Multivariate analysis identified obesity and arteriosclerosis obliterates as independent risk factors. Neither diabetes mellitus, dialysis, female gender, nor old age were significant independent predictors of mediastinitis. Despite the significantly high percentage of high-risk patients in late group, there were no significant difference in mortality and morbidity between the two groups. Conclusion: Pedicled BITA grafting is feasible with acceptable morbidity and shouldn''t be abandoned even in high-risk patients such as DM, old age, and dialysis, especially combined with pinpoint-hemostasis, avoiding excessive use of bone wax, and strict aseptic technique. These point require a surgical team familiar with these techniques to maintain adequate skills in conduit procurement. [Copyright &y& Elsevier]

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'What is the best choice for third conduit when using bilateral internal mammary arteries for coronary artery bypass grafting-radial artery or saphenous vein graft?'. Altogether >525 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Overall, there was no survival benefit demonstrated with the use of a radial artery over the use of a saphenous vein graft as a choice of third conduit following bilateral internal mammary artery grafts for coronary artery bypass grafting. The main limitation of the current evidence available is the restricted follow-up periods and the high attrition rates with small sample sizes affecting the strength of conclusions that can be drawn beyond 10 years of follow-up. We conclude that despite previous evidence supporting improved long-term patency of radial arterial grafts, there is no strong evidence that the use of a radial artery, over a saphenous vein graft, has any survival benefit when used as the third conduit following bilateral internal mammary artery grafts., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

The study objective was to determine the impact on outcome associated with using the second internal thoracic artery as a free compared with an in situ graft among patients who received the first internal thoracic artery as an in situ internal thoracic artery to the left anterior descending artery. Among 2600 patients who underwent bilateral internal thoracic artery with an in situ internal thoracic artery to the left anterior descending artery, the second internal thoracic artery was used as a free graft bilateral internal thoracic artery in 136 patients and as an in situ graft (in situ bilateral internal thoracic artery) in 2464 patients. One-to-many propensity score matching was performed to produce a cohort of 134 patients with a second free graft internal thoracic artery matched to 2359 patients with a second in situ internal thoracic artery. Early and long-term outcomes including survival, hospital readmission, and repeat revascularization up to a maximum of 25.8 years were compared. There were no differences between the 2 matched groups' preoperative baseline characteristics and early adverse events. Long-term survival at 5, 10, and 15 years was significantly higher among patients with an in situ bilateral internal thoracic artery compared with patients with a free graft bilateral internal thoracic artery (hazard ratio free graft bilateral internal thoracic artery vs in situ bilateral internal thoracic artery, 1.53; 95% confidence interval, 1.14-2.10; P =. 004). However, the long-term risk of readmission to the hospital for cardiovascular reasons and need for repeat revascularization were not significantly different between the 2 matched groups. In a small, propensity-matched cohort of patients undergoing coronary artery bypass grafting, the use of a second in situ internal thoracic artery was associated with an increase in late survival compared with the use of a second internal thoracic artery as a free graft. However, the risk of late hospital readmission and the need for repeat revascularization were similar. [Display omitted] [ABSTRACT FROM AUTHOR]

Objectives: We have investigated the effects and outcome from grafting the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting. Methods: We analyzed the findings in 185 patients who underwent coronary artery bypass grafting involving right internal thoracic artery-left anterior descending artery bypass. The survival rate, cardiac events related to the right internal thoracic artery-left anterior descending artery graft, and graft patency were investigated. In cardiac catheterization, the production of nitric oxide from the endothelium of the internal thoracic artery was measured as the plasma nitrite and nitrate levels by the Griess reaction. The reactions to acetylcholine infusion (5 μg) in the right internal thoracic artery (n = 4) were compared to those in the left internal thoracic artery (n = 9) grafts. Results: The hospital mortality rate was 0.5%. The actuarial survival rate at 11 years after operation was 98.81%. The rate of freedom from cardiac events at 11 years after operation was 92.08%. The rate of patency of the right internal thoracic artery-left anterior descending artery was 97.0% in 133 patients. Nitric oxide production was calculated as (total nitrite plus nitrate production in response to stimulation by acetylcholine-total nitrite plus nitrate level before acetylcholine load) / (total nitrite plus nitrate level before acetylcholine load). There was no significant difference in changes in plasma concentration in response to acetylcholine stimulation between the right internal thoracic artery-left anterior descending artery and left internal thoracic artery-left anterior descending artery groups (20 ± 29% versus 5 ± 10%). Conclusions: The right internal thoracic artery-left anterior descending artery grafts exhibited good patency and release of nitric oxide in response to acetylcholine loading, similar to left internal thoracic artery-left anterior descending artery grafts. [ABSTRACT FROM AUTHOR]

Coronary artery bypass grafting, Bilateral internal thoracic artery Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. Bilateral internal thoracic artery grafting: propensity analysis of the left internal thoracic artery versus the right internal thoracic artery as a bypass graft to the left anterior descending artery. [Extracted from the article]

We report our initial experience of an off-pump total arterial minimally invasive coronary arterial bypass grafting (MICS CABG) with the use of bilateral internal thoracic arteries (BITA) and the right gastroepiproic artery. A 47-year old male with renal dysfunction secondary to diabetes mellitus was admitted for heart failure due to severe triple-vessel disease. Off-pump MICS CABG with total arterial grafts was elected because the patient refused to undergo median sternotomy due to the strong desire to regain the baseline function promptly. Total arterial grafts were selected to maximize the potential long-term outcome. There were no postoperative complications except temporary dialysis. Postoperative coronary computed tomography revealed the patency of all grafts. Our experience suggests that BITA can be safely harvested under direct vision in MICS CABG. Total arterial graft revascularization with BITA via minimally invasive approach may offer the benefits of MICS CABG while providing the undetermined but potentially superior conduit longevity of arterial grafts. [ABSTRACT FROM AUTHOR]

The lack of benefit in terms of mid-term survival and the increase in the risk of sternal wound complications published in a recent randomized controlled trial have raised concerns about the use of bilateral internal thoracic artery (BITA) in myocardial revascularization surgery. For this reason, we decided to explore the current evidence available on the subject by carrying out a meta-analysis of propensity score-matched studies comparing BITA versus single internal thoracic artery (SITA). PubMed, EMBASE and Google Scholar were searched for propensity score-matched studies comparing BITA versus SITA. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The DerSimonian and Laird method was used to compute the combined risk ratio of 30-day mortality, deep sternal wound infection and reoperation for bleeding. Forty-five BITA versus SITA matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival in favour of the BITA group [HR 0.78; 95% confidence interval (CI) 0.71-0.86]. These results were consistent with those obtained by a pooled analysis of the matched populations comprising patients with diabetes (HR 0.65; 95% CI 0.43-0.99). When compared with the use of SITA plus radial artery, BITA did not show any significant benefit in terms of long-term survival (HR 0.86; 95% CI 0.69-1.07). No differences between BITA and SITA groups were detected in terms of 30-day mortality or in terms of reoperation for bleeding. Compared with the SITA group, patients in the BITA group had a significantly higher risk of deep sternal wound infection (risk ratio 1.66; 95% CI 1.41-1.95) even when the pooled analysis was limited to matched populations in which BITA was harvested according to the skeletonization technique (risk ratio 1.37; 95% CI 1.04-1.79). The use of BITA provided a long-term survival benefit compared with the use of SITA at the expense of a higher risk of sternal deep wound infection. The long-term survival advantage of BITA is undetectable when compared with SITA plus radial artery., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Abstract Objectives Despite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). The present study investigated the early outcome of BITA grafting and analyzed the risk of DSWI using a Japanese national database (the Japan Adult Cardiovascular Surgery Database). Methods Data from 560 hospitals were used. Between April 2012 and December 2015, BITA was harvested in 14,249 patients, corresponding to 32.6% of isolated coronary artery bypass cases. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple logistic regression analysis was employed to model the risk of DSWI. Results The mean age was 67.1 years. The prevalence of diabetes, renal failure, hemodialysis, and liver dysfunction was 51.8%, 21.2%, 7.8%, and 1.2%, respectively. The incidence of DSWI and operative mortality was 1.6 (234 patients) and 1.6% (226 patients), respectively. The operative mortality rate in patients with DSWI was 13.7% (32 patients). The off-pump technique was used in 72.8%, with a conversion rate of 2.5%. Female sex, diabetes mellitus, chronic lung disease, renal failure, liver dysfunction, ejection fraction ≤60%, shock status, reoperation, preoperative intra-aortic balloon pump use, and an increased operative time were independent risk factors for DSWI after BITA grafting. The off-pump technique did not reduce the risk of DSWI. Conclusions The present study showed that early outcomes of BITA grafting were satisfactory regarding DSWI and operative mortality. The current data are informative to predict the risk of DSWI when performing BITA grafting. [ABSTRACT FROM AUTHOR]