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Background: The Arterial Revascularization Trial has been designed to answer the question whether the use of bilateral internal thoracic arteries can improve 10-year outcomes when compared with single internal thoracic arteries. In the Arterial Revascularization Trial, a significant proportion of patients initially allocated to bilateral internal thoracic arteries received other conduit strategies. We sought to investigate the incidence and clinical implication of bilateral internal thoracic artery graft conversion in the Arterial Revascularization Trial., Methods: Among patients enrolled in the Arterial Revascularization Trial (n = 3102), we excluded those allocated to single internal thoracic arteries (n = 1554), those who did not undergo surgery (n = 16), and those who underwent operation but withdrew after randomization (n = 7). Propensity score matching was used to compare converted versus nonconverted bilateral internal thoracic artery groups., Results: A total of 1525 patients were operated with the intention to receive bilateral internal thoracic artery grafting. Of those, 233 (15.3%) were converted to other conduit selection strategies. Incidence of conversion largely varied across 131 participating surgeons (from 0% to 100%). The most common reason for bilateral internal thoracic artery graft conversion was the evidence of at least 1 internal thoracic artery that was not suitable, which was reported in 77 cases. Patients with intraoperative bilateral internal thoracic artery graft conversion received a lower number of grafts (2.95 ± 0.84 vs 3.21 ± 0.74; P < .001). However, the hospital mortality rate was comparable to that of those who did not require bilateral internal thoracic artery graft conversion (0% vs 1.6%; P = .1), as well as the incidence of major complications. At 5 years, we found a nonsignificant excess of deaths (11.9% vs 8.4%; P = .1) and major adverse events (17.1% 13.2%; P = .1) mainly driven by an excess of revascularization in patients requiring conversion., Conclusions: The incidence of intraoperative bilateral internal thoracic artery graft conversion is not infrequent. Bilateral internal thoracic artery graft conversion is not associated with increased operative morbidity, but its effect on late outcomes remains uncertain., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We sought to identify the trends in bilateral internal thoracic artery use and determine the degree to which the survival advantage of bilateral internal thoracic artery revascularization persists among perceived "high-risk" patients, compared with the use of left internal thoracic artery alone., Methods: A retrospective review was conducted of patients who underwent isolated coronary artery bypass grafting for multivessel coronary artery disease at the Mayo Clinic between January 2000 and December 2015. Propensity score matching was performed between patients with bilateral internal thoracic artery and left internal thoracic artery alone grafts (1011 matched pairs). Effect of bilateral internal thoracic artery use on survival in "high-risk" patients (ejection fraction <40%, body mass index ≥30, age ≥70 years, diabetes, chronic lung disease, cerebrovascular accident) was evaluated., Results: A total of 6468 isolated coronary artery bypass grafts were performed (5431 using left internal thoracic artery alone, 1037 using bilateral internal thoracic artery). There was an increasing trend in bilateral internal thoracic artery use (P value for linear trend = .005), with the percentage of coronary artery bypass grafting cases with bilateral internal thoracic artery doubling over the last 4 years (13% in 2012 to 27% in 2015). Propensity-matched comparisons showed a survival advantage for bilateral internal thoracic artery (hazard ratio, 0.81; 95% confidence interval, 0.66-0.99; P = .043). Risk of deep sternal wound infection, although higher in the bilateral internal thoracic artery group, was not significant (1.2% vs 0.5%; P = .088). None of the "high-risk" subsets of patients showed an adverse effect of bilateral internal thoracic artery on survival., Conclusions: Bilateral internal thoracic artery use in coronary artery bypass grafting is increasing over time. There is a consistent survival benefit with bilateral internal thoracic artery use, extending to patients with higher-risk comorbidities, suggesting the need for further expansion in use of this technique., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The goal of this study was to characterize the adoption rate and regional variation in bilateral internal mammary artery (BIMA) use during coronary artery bypass grafting (CABG) in the United States., Methods: Observational study of 100% sample of fee-for-service Medicare beneficiaries aged 65 years or older, continuously enrolled in Parts A and B from 2009 to 2014 (n = 162,860,439). Rates of beneficiaries receiving a BIMA versus single internal mammary artery (SIMA) during CABG are expressed per 1,000 beneficiaries and aggregated by Hospital Referral Region (HRR). An HRR is a validated unit for quantifying regional variation in health care., Results: The absolute national rate of BIMA use declined during the study period from 0.21 claims per 1,000 beneficiaries in 2009 to 0.13 in 2014 (p < 0.001). When indexed to overall CABG volume, no change was seen in the frequency of BIMA use over time (p = 0.883). SIMA use ranged from 1.3 to 8.5 claims per 1,000 Medicare beneficiaries, whereas BIMA use ranged from 0 to 1.5 (p < 0.001). A significant correlation was found between regional volume of SIMA use and likelihood of BIMA use (correlation coefficient 0.673, p < 0.001). Although both SIMA and BIMA use correlated with regional volume of diagnostic cardiac catheterization, the correlation was stronger for SIMA use (correlation coefficient 0.962 versus 0.682, p < 0.001)., Conclusions: Over the past 5 years, no growth was seen in BIMA use among Medicare beneficiaries, and the frequency of BIMA use during CABG remained low. There was significant regional variation in BIMA use, however, which demonstrates opportunity for continued growth of BIMA grafting., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The internal mammary artery (IMA) is the preferred conduit for bypassing the left anterior descending (LAD) artery in patients undergoing coronary artery bypass grafting. Systematic evaluation of the frequency and predictors of IMA failure and long-term outcomes is lacking., Methods and Results: The Project of Ex-vivo Vein Graft Engineering via Transfection (PREVENT) IV trial participants who underwent IMA-LAD revascularization and had 12- to 18-month angiographic follow-up (n=1539) were included. Logistic regression with fast false selection rate methods was used to identify characteristics associated with IMA failure (≥75% stenosis). The relationship between IMA failure and long-term outcomes, including death, myocardial infarction, and repeat revascularization, was assessed with Cox regression. IMA failure occurred in 132 participants (8.6%). Predictors of IMA graft failure were LAD stenosis <75% (odds ratio, 1.76; 95% confidence interval, 1.19-2.59), additional bypass graft to diagonal branch (odds ratio, 1.92; 95% confidence interval, 1.33-2.76), and not having diabetes mellitus (odds ratio, 1.82; 95% confidence interval, 1.20-2.78). LAD stenosis and additional diagonal graft remained predictive of IMA failure in an alternative model that included angiographic failure or death before angiography as the outcome. IMA failure was associated with a significantly higher incidence of subsequent acute (<14 days of angiography) clinical events, mostly as a result of a higher rate of repeat revascularization., Conclusions: IMA failure was common and associated with higher rates of repeat revascularization, and patients with intermediate LAD stenosis or with an additional bypass graft to the diagonal branch had increased risk for IMA failure. These findings raise concerns about competitive flow and the benefit of coronary artery bypass grafting in intermediate LAD stenosis without functional evidence of ischemia., Clinical Trial Registration: URL: http:/www.clinicaltrials.gov. Unique identifier: NCT00042081., (© 2015 American Heart Association, Inc.)

Objective: The internal thoracic artery is the gold standard conduit in coronary artery bypass grafting. Although the right and left internal thoracic arteries are excellent conduits, the use of the bilateral internal thoracic artery is not widespread. A recent report of the Society of Thoracic Surgery revealed that only a small percentage of patients receive a bilateral internal thoracic artery in North America. The aim of this study was to determine the current use of the bilateral internal thoracic artery during coronary artery bypass grafting among cardiac surgeons in Canada and identify the main concerns that limit the use of these conduits., Methods: We developed an online survey with 17 questions about the use of the bilateral internal thoracic artery in different clinical scenarios. An invitation to participate was sent to all the adult cardiac surgeons currently in practice in Canada., Results: A total of 101 surgeons (69%) of 147 currently in practice across 27 different hospitals completed the survey. Forty percent of surgeons use the bilateral internal thoracic artery only sometimes (6%-25% of cases), 37% of surgeons use the bilateral internal thoracic artery very infrequently (<5% cases), 16% of surgeons use the bilateral internal thoracic artery often (26%-50%), and only 7% of surgeons use the bilateral internal thoracic artery very often (>50%). The most common concerns in the use of the bilateral internal thoracic artery are the risk of sternal wound infection and the unknown superiority of the right internal thoracic artery over other conduits., Conclusions: The majority of Canadian cardiac surgeons consider few clinical features, such as insulin-dependent diabetes mellitus or morbid obesity, as contraindications to the use of bilateral internal thoracic artery. However, the reported use of the bilateral internal thoracic artery is low. A wider diffusion of this technique is warranted to improve the results of coronary surgery., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Use of the left internal mammary artery (LIMA) in multivessel coronary artery disease improves survival after coronary artery bypass graft surgery; however, the survival benefit of multiple arterial (MultArt) grafts is debated., Methods and Results: We reviewed 8622 Mayo Clinic patients who had isolated primary coronary artery bypass graft surgery for multivessel coronary artery disease from 1993 to 2009. Patients were stratified by number of arterial grafts into the LIMA plus saphenous veins (LIMA/SV) group (n=7435) or the MultArt group (n=1187). Propensity score analysis matched 1153 patients. Operative mortality was 0.8% (n=10) in the MultArt and 2.1% (n=154) in the LIMA/SV (P=0.005) group, which was not statistically different (P=0.996) in multivariate analysis or the propensity-matched analysis (P=0.818). Late survival was greater for MultArt versus LIMA/SV (10- and 15-year survival rates were 84% and 71% versus 61% and 36%, respectively [P<0.001], in unmatched groups and 83% and 70% versus 80% and 60%, respectively [P=0.0025], in matched groups). MultArt subgroups with bilateral internal mammary artery/SV (n=589) and bilateral internal mammary artery only (n=271) had improved 15-year survival (86% and 76%; 82% and 75% at 10 and 15 years [P<0.001]), and patients with bilateral internal mammary artery/radial artery (n=147) and LIMA/radial artery (n=169) had greater 10-year survival (84% and 78%; P<0.001) versus LIMA/SV. In multivariate analysis, MultArt grafts remained a strong independent predictor of survival (hazard ratio, 0.79; 95% confidence interval, 0.66-0.94; P=0.007)., Conclusions: In patients undergoing isolated coronary artery bypass graft surgery with LIMA to left anterior descending artery, arterial grafting of the non-left anterior descending vessels conferred a survival advantage at 15 years compared with SV grafting. It is still unproven whether these results apply to higher-risk subgroups of patients.

Objective: To identify possible avenues of sparing the internal mammary artery (IMA) for coronary artery bypass grafting (CABG) in women undergoing autologous breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps., Background: Optimal autologous reconstruction of the breast and coronary artery bypass grafting (CABG) are often mutually exclusive as they both require utilisation of the IMA as the preferred arterial conduit. Given the prevalence of both breast cancer and coronary artery disease, this is an important issue for women's health as women with DIEP flap reconstructions and women at increased risk of developing coronary artery disease are potentially restricted from receiving this reconstructive option should the other condition arise., Methods: The largest clinical and cadaveric anatomical study (n=315) to date was performed, investigating four solutions to this predicament by correlating the precise requirements of breast reconstruction and CABG against the anatomical features of the in situ IMAs. This information was supplemented by a thorough literature review., Results: Minimum lengths of the left and right IMA needed for grafting to the left-anterior descending artery are 160.08 and 177.80 mm, respectively. Based on anatomical findings, the suitable options for anastomosis to each intercostals space are offered. In addition, 87-91% of patients have IMA perforator vessels to which DIEP flaps can be anastomosed in the first- and second-intercostal spaces., Conclusion: We outline five methods of preserving the IMA for future CABG: (1) lowering the level of DIEP flaps to the fourth- and fifth-intercostals spaces, (2) using the DIEP pedicle as an intermediary for CABG, (3) using IMA perforators to spare the IMA proper, (4) using and end-to-side anastomosis between the DIEP pedicle and IMA and (5) anastomosis of DIEP flaps using retrograde flow from the distal IMA. With careful patient selection, we hypothesize using the IMA for autologous breast reconstruction need not be an absolute contraindication for future CABG.

Objectives: The aim of this article is to make an evaluation on the clinical features of patients with Kawasaki disease who require a cardiac surgical procedure including coronary artery bypass grafting, coronary arterial aneurysmorrhaphy or heart transplantation., Methods: English literature of Kawasaki disease for cardiac surgery (1990-2011) was retrieved in the Pubmed database. The clinical features of the patient setting from the representative articles were collected and analyzed., Results: Patients with Kawasaki disease were very young, with some requiring a cardiac surgical procedure at a very early age. The interval between the onset and the surgical operation was 9.5±9.4 years. The prevalence of myocardial infarction and re-infarction was high. Giant aneurysm, critical stenosis with calcification and thrombus formation of the coronary arteries often warrant coronary artery bypass, heart transplantation or coronary arterial aneurysm plication. The left internal mammary artery to the left anterior descending coronary artery was the most commonly used graft in coronary artery bypass. Graft patency rate was 82.4% at 21.4±32.3 (range 0.1-252) month follow-up. The early and late mortalities of this patient setting were 0.6 and 3.0%, respectively., Conclusions: Patients with Kawasaki disease may develop coronary artery lesions prone to aneurysmal formation with calcification and thrombus and may require coronary artery bypass at a very early age. With the left internal mammary artery as the first choice of bypass graft, the long-term patency and patient survival was satisfactory.

Background: The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Quality Collaborative is a voluntary, surgeon-directed quality initiative involving all cardiac surgery programs in Michigan. Understanding that internal mammary artery (IMA) use during coronary artery bypass grafting is an important process measure associated with improved outcomes, this analysis reviews our methodology to understand IMA use and increase appropriate IMA use statewide., Methods: Adult cardiac Society of Thoracic Surgeons data were collected at each Michigan site and submitted quarterly to the Duke Clinical Research Institute and the MSTCVS. Seven cardiac surgery programs with IMA use less than 90% in isolated coronary artery bypass grafting were identified as low IMA users. An improvement plan was adopted at the state level and included quarterly monitoring of IMA use, documenting the rationale for IMA exclusion, evidence-based lectures, feedback letters to sites, and physician-led site visits if no improvement was noted., Results: From 2005 through 2008, 29,114 patients underwent coronary artery bypass grafting in Michigan. Internal mammary artery utilization varied widely at the beginning of this investigation, ranging from 66.2% to 98.4%. Seven Michigan programs were identified as low IMA users. Using the MSTCVS Quality Collaborative's process-improvement plan, collectively the seven low IMA users increased IMA grafting from 82.0% to 92.7% (p < 0.0001). Michigan IMA use increased from 91.9% to 95.8% (p < 0.0001) and is now higher than The Society of Thoracic Surgeons' average., Conclusions: The MSTCVS Quality Collaborative identified programs with low IMA use and created an environment to enhance IMA utilization during coronary artery bypass grafting, a significant operative process. These findings illustrate the value of a statewide surgeon-directed quality initiative in improving processes and outcomes for patients., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Use of an internal mammary artery (IMA) is a well-recognized, nationally endorsed quality indicator for evaluating the process of operative care for coronary artery bypass graft surgery. An objective assessment of the current status of IMA use has not been systematically performed., Methods and Results: This cross-sectional observational study analyzed data on 541 368 coronary artery bypass graft surgery procedures reported by 745 hospitals in the Society of Thoracic Surgeons National Cardiac Database from 2002 through 2005. We assessed the current status of IMA use, the association of hospital volume and IMA use, and disparities in IMA use by patient gender and race and by region of hospital location. Rates of using at least 1 IMA and bilateral IMA were 92.4% and 4.0%, with increasing trends over the years. Hospital volume was not significantly associated with IMA use. IMAs were used less frequently in women than men (for at least 1 IMA: odds ratio, 0.62; 95% confidence interval, 0.61 to 0.63; for bilateral IMA: odds ratio, 0.65; 95% confidence interval, 0.63 to 0.68) and less frequently in nonwhite patients than white patients (for at least 1 IMA: odds ratio, 0.84; 95% confidence interval, 0.81 to 0.87; for bilateral IMA: odds ratio, 0.79; 95% confidence interval, 0.75 to 0.83). There were significant differences in frequency of IMA use by hospital region., Conclusions: Frequency of IMA use in coronary artery bypass graft surgery is increasing; however, many patients still do not receive the benefits of IMA grafts, and some hospitals have a very low IMA use rate. Hospital volume is not associated with IMA use in coronary artery bypass graft surgery. Analysis of this critical performance measure reveals significant gender and race disparities.

Purpose: Bilateral in situ internal thoracic artery (ITA) bypassing may result in excellent myocardial revascularization without increasing the risk of deep sternal wound infection. Although there have been concerns with the use of pedicled bilateral ITA, the risk of infection may not be greater than the use of skeletonized ITA., Materials and Methods: The present study was retrospectively undertaken to determine if pedicled BITA grafts are associated with a higher risk of sternal wound complications. A total of 207 patients who underwent bilateral ITA bypasses with or without existing diabetes mellitus, and 162 patients of those received bilateral pedicled ITA and 98 patients received unilateral ITA bypass grafts., Results: No sternal wound complications were noted in either the bilateral ITA or unilateral left ITA groups., Conclusion: Bilateral pedicled ITA harvesting was not associated with a greater incidence of infectious sternal complications compared to patients receiving unilateral ITA bypass grafts.

Background: The evidence respecting the superior patency of ITA-grafts compared to SVG is conclusive. This study evaluates the angiographic findings in 1,189 symptomatic patients who received either one or both ITA-grafts with or without additional SVG., Methods: 1,189 patients (975 males, aged 62.4 +/- 9.1 years), operated between 2/93 and 7/05, underwent angiography due to reappearance of angina. Data were compared for patency of single ITA (n = 618), bilateral ITA (n = 416) or SVG (n = 2,218). Re-catherization was performed after 3.8 +/- 2.7 years. Severe bypass stenosis or graft occlusion was related to the target vessels., Results: 3,668 bypasses were performed in 1189 patients. The occlusion rate was 16.5 % for SVG and 7.0 % for all ITAs ( P < 0.001). Severe stenosis was detected in 4.8 % of SVG and in 3.7 % of ITAs ( P < 0.05). Patency was 89.6 % for LITA, 88.7 % for RITA, and 78.7 % for SVG. The occlusion rate for LITA was: to LAD 6.6 %, DIA 8.5 %, obtuse marginal branch/CX 11.5 %. The occlusion rate for RITA was: to LAD 4.6 %, RCA 9.1 %., diag. branch 7.1 %. The occlusion rate for vein grafts was: to LAD 17.3 %, DIA 14.4 %, obtuse marginal branch/CX 15.9 %, to RCA 17.0 %. Patency for all ITAs was 89.3 % vs.78.7 % for all SVG ( P < 0.05). Despite symptoms, bypass patency was found in 711 patients (59.8 %)., Conclusion: The superior patency of ITA-grafts could be documented angiographically in a negatively selected, symptomatic population. Graft occlusion was at least twofold higher for SVG.

Background: This study was designed to evaluate if patients in whom in-stent restenosis developed had an higher risk of early venous graft failure compared with normal patients., Methods: The study cohort comprised 120 patients (60 with previous in-stent restenosis and 60 controls) who received a total of 165 complementary venous grafts on the circumflex or right coronary artery system (84 in the restenosis group and 81 in the control group). All patients were prospectively followed-up and underwent reangiography at 5-years follow-up., Results: In the restenosis group, 28 venous grafts (33.%) were perfectly patent, 10 showed major irregularities, and 46 were occluded. In the control patients, 50 grafts (61.7%) were perfectly patent (p < 0.001 compared with the restenosis series), 12 showed major irregularities (p = .74), and 19 were occluded (p < 0.0001). In contrast, the 5-year outcome of internal thoracic artery grafts was not affected by history of in-stent restenosis., Conclusions: Patients who developed in-stent restenosis have an higher risk of early venous graft failure compared with the control patients. Arterial grafts should probably be preferred in these patients.

Background: Continuous quality improvement (CQI) is widely used in other industries and has been promoted as a method for quality control in medicine. The national databases developed by the American College of Cardiology and the Society of Thoracic Surgeons have greatly facilitated data collection for CQI. Hospitals can encounter barriers to CQI, however, which include creating the proper organizational infrastructure and engaging physicians and hospital administrators in the process. These barriers are particularly evident in large community hospitals., Methods: We describe the organizational infrastructure for CQI, including committee structure, methods of repeated data collection and feedback, and maintenance of data integrity and confidentiality. We report demographic data and clinical outcomes for patients undergoing percutaneous coronary intervention and coronary artery bypass surgery before and after implementation of our CQI program., Results: Since 1995, we have maintained a CQI process driven by repeated collection of valid, confidential, operator-specific data. We have observed sustained physician and administration participation and buy-in. During the follow-up period, patient complexity increased and observed outcomes improved, although the improvement was clearly multifactorial., Conclusions: We describe the organization of a CQI program at a large complex community hospital. Our CQI program was successfully implemented, has been sustained, and is associated in observed improvement in patient outcomes. The program described here may be a useful model for other similar hospitals that are attempting to create a program to address quality improvement.

Background: Aim of this study was to compare the outcome of beating heart versus conventional coronary artery bypass graft (CABG) strategies in acute coronary syndromes for emergency indications., Methods and Results: 638 consecutive patients with acute coronary syndrome (ACS) receiving emergency CABG surgery via midline sternotomy from January 2000 to September 2005 were evaluated. Propensity score analysis was used to predict the probability of undergoing beating heart (BH) (n=240) versus cardioplegic cardiac arrest (CA) (n=398) strategies. Patients presented with stable hemodynamics (n=531) or in cardiogenic shock (CS) (n=107). Hospital and follow-up outcome was compared by propensity score adjusted multiregression analysis. BH included 116 on-pump and 124 off-pump (OPCAB) procedures. There was a propensity to operate CS patients on the beating heart (multivariate odds ratio [OR], 3.8; P=0.001). Under stable hemodynamics significant predictors for BH selection were logEuroSCORE >20% (OR, 2.05), creatinine >1.8 mg/dL (OR, 4.12), complicated percutaneous coronary intervention (OR, 1.88), ejection fraction <30% (OR, 2.64), whereas left main disease (OR, 0.68), circumflex artery (OR, 0.32), and 3-vessel disease (OR, 0.67) indicated preference for cardioplegic arrest. Time from skin incision to culprit lesion revascularization was significantly reduced in BH patients. BH surgery led to a significant benefit in terms of less drainage loss, less transfusion requirement, less inotropic support, shorter ventilation time, lower stroke rate, and shorter intensive care unit stay. In CS, BH was associated with lower incidence of stroke, inotropic support, acute renal failure, new atrial fibrillation and sternal wound healing complications. In CS patients, hospital mortality rate was reduced when using beating heart strategies (P=0.048). Overall survival, major adverse cerebral and cardiovascular event rate, and repeated revascularization was comparable during a 5-year follow-up., Conclusions: Beating heart strategies are associated with an improved hospital outcome and comparable long-term results for high-risk patients presenting acute coronary syndrome with or without CS.

Background: The influence of an internal mammary artery (IMA) graft on long-term outcomes after percutaneous saphenous vein graft (SVG) intervention is currently unknown., Methods and Results: To examine the impact of IMA on outcomes in patients undergoing SVG interventions, we analyzed 2119 patients from the Duke Cardiovascular Disease Database (1986-2003) with prior coronary artery bypass surgery undergoing cardiac catheterization who had at least 1 SVG graft. Patients were categorized into 4 groups: group I, SVG intervention and patent IMA; group II, no SVG intervention and patent IMA; group III, SVG intervention without patent IMA; and group IV, no SVG intervention without patent IMA. At a median follow-up of 4.8 years (interquartile range, 2.1 to 8.8 years), adjusted survival rates in groups I, II, III, and IV were 72.8%, 72.3%, 64.5%, and 58.9%, respectively. Multivariate Cox proportional hazards modeling showed similar survival for groups I and II (P=0.63) and for groups III and IV (P=0.33). The presence of IMA graft was related to lower long-term mortality (adjusted hazard ratio [HR], 0.69; 95% CI, 0.58 to 0.82), whereas SVG intervention was not associated with long-term mortality (adjusted HR, 0.94; 95% CI, 0.81 to 1.10). In contrast, the adjusted event-free rates for nonfatal myocardial infarction were lower in the SVG intervention groups (groups I and III) than in the non-SVG intervention groups (groups II and IV) (HR for SVG intervention versus no SVG intervention, 3.19; 95% CI, 2.18 to 4.66), with the presence of patent IMA conferring no significant benefit on this outcome (HR, 1.37; 95% CI, 0.91 to 2.08)., Conclusions: In patients undergoing SVG interventions, survival, but not nonfatal myocardial infarction, is favorably influenced by the presence of patent IMA. In contrast, SVG intervention had no measurable survival benefit but was associated with an increased risk of nonfatal myocardial infarction.

Background: Reintervention after coronary artery bypass grafting (CABG) is common. We sought to determine its occurrence and identify patient characteristics and operative techniques that influence the need or bias for reintervention., Methods and Results: From 1971 to 1998, 48,758 patients underwent primary isolated CABG, and 1000 patients per year were actively followed-up every 5 years (n =26,927). A multivariable time-related analysis was performed to model freedom from first coronary reintervention (either reoperation or percutaneous coronary intervention) and identify patient and operative characteristics associated with first reintervention. A total of 3997 patients underwent coronary reintervention, percutaneous in 1638 and reoperation in 2359. Freedom from reintervention was 99%, 96%, 88%, 73%, 60%, and 46% at 1, 5, 10, 15, 20, and 25 years, respectively. Risk of reintervention (hazard function) demonstrated a short, rapidly declining early phase followed by a longer, slow-rising late phase. Patient variables increasing the likelihood of coronary reintervention included younger age (P<0.0001), higher triglycerides (P=0.002), lower high-density lipoprotein (P=0.006), diabetes mellitus (P<0.0001), and more extensive coronary artery disease (P=0.0005). Increasing extent of arterial grafting performed at primary operation decreased the likelihood of coronary reintervention (P<0.0001)., Conclusions: Reintervention after primary CABG is common. Risk factors for arteriosclerosis and type of bypass conduit influence the need or bias for repeat coronary therapy. Aggressive post-CABG risk factor reduction and extensive arterial grafting at primary operation should decrease coronary reinterventions.

Background: For patients with ischemic mitral regurgitation (MR), it is not clear whether adjunctive mitral valve (MV) repair at the time of coronary artery bypass graft surgery (CABG) is beneficial. We sought to test the hypothesis that MV repair with CABG is superior to CABG alone in improving MR without increasing operative or long-term mortality., Methods and Results: A total of 107 consecutive patients with moderate or severe ischemic MR, as determined by preoperative echocardiography, underwent CABG with concomitant MV repair (repair group, n=50) or CABG only (CABG group, n=57). Degree of MR was graded as none, mild, moderate, or severe by the proximal isovelocity surface area method. The groups were similar with respect to age, gender, baseline New York Heart Association class, ejection fraction, and number of bypass grafts. The repair group had a higher percentage of patients with atrial fibrillation or severe MR than the CABG group. The operative mortality was significantly higher for the repair group (12%) than the CABG group (2%), whereas the 5-year actuarial survival rate of the 2 groups was similar (88%+/-5% versus 87%+/-6%). On multivariate logistic regression analysis, older age, higher New York Heart Association class, and atrial fibrillation were independent predictors of operative mortality (P<0.05). Among patients with severe MR, ischemic MR was improved in all patients of the repair group and in 67% of patients in the CABG group (P<0.001), whereas improvement rates in patients with moderate MR were similar in the 2 groups (75% versus 67%, P=NS)., Conclusions: Although MV repair appears to be more effective at reducing ischemic functional MR, CABG alone may be a preferable treatment option for patients with moderate MR and high operative risk factors such as old age or atrial fibrillation.

Background: The purpose of this study is to compare sex-specific, long-term outcomes after combined valve and coronary artery bypass graft surgery (CABG)., Methods: Between 1990 and 2000, 1,567 patients underwent combined valve and CABG surgery at our institution. Our surgical database was linked to a governmental administrative hospital discharge database and a registry of deaths to obtain long-term follow-up. All patients underwent CABG plus aortic (62%), mitral (31%), or multiple valve surgery (7%)., Results: Women had more preoperative risk factors than men (namely, hypertension, diabetes mellitus, congestive heart failure, atrial fibrillation, and stroke; all p < 0.001). The prevalence of triple-vessel disease was the same between men and women, but women received fewer mammary grafts and fewer total bypass grafts (both p < 0.01). Women received fewer mitral valve repairs and more mitral valve replacements than men (p = 0.014). Length of follow-up was 5.3 +/- 3.2 years (mean +/- SD; range, 0 to 12.5) and was 99.8% complete. Both sexes had similar long-term survival rates. Women were at higher risk of stroke during follow-up (risk ratio = 1.52, 95% confidence interval: 1.1 to 2.1). There were no sex differences in rehospitalization for acute myocardial infarction (p = 0.9), heart failure (p = 0.4), redo cardiac surgery (p = 0.5), or endocarditis (p = 0.4)., Conclusions: Women have a higher preoperative risk profile than men undergoing combined valve and CABG surgery, but long-term survival rates are similar. Female sex is an independent predictor of stroke during follow-up. Further studies should focus on the cause of increased risk of stroke and methods of prevention.

Objective: Current evidence suggests arterial grafting improves freedom from cardiac events after coronary artery bypass graft surgery. It has been shown that 2 arterial grafts provide improved outcome compared with 1 arterial graft. This population study seeks to understand trends in arterial graft use and midterm outcomes of patients receiving 1, 2, or 3 arterial grafts., Methods: This study is a retrospective population-based cohort of 53,727 patients (47,214 with 1 arterial graft, 5466 with 2 arterial grafts, and 1047 with 3 arterial grafts) undergoing isolated coronary artery bypass graft surgery in Ontario (1991-2001). The patients were followed by using linked clinical and administrative data, with complete follow-up until December 31, 2003 (average patient years of follow-up: 6 years for those with 1 arterial graft, 5 years for those with 2 arterial grafts, and 4 years for those with 3 arterial grafts). Propensity matching was used to compare outcomes between patients receiving 1 versus 2 arterial grafts, 2 versus 3 arterial grafts, and 1 versus 2 or 3 arterial grafts. The outcomes included death, repeat revascularization (angioplasty or coronary artery bypass grafting), cardiac readmission (readmission for angina, heart failure, and myocardial infarction), and a composite comprising all of these outcomes. Cox proportional hazards models were used to compare outcomes for propensity-matched patients. Subgroup analyses of various patient risk categories defined by the tercile of predicted 30-day mortality risk were conducted between propensity-matched individuals., Results: The use of multiple arterial grafts (defined as >1 arterial graft) increased mainly in the latter part of the study, from 4% in 1991 to 27% in 2001. Four thousand nine hundred sixty-eight patients were propensity matched (91% of patients receiving 2 arterial grafts) to compare outcomes with those of patients receiving 1 arterial graft. One thousand twenty-eight patients were propensity matched (98% of those receiving 3 arterial grafts) to compare outcomes with those of patients receiving 2 arterial grafts. Five thousand four hundred ninety-one patients were propensity matched (84% of those receiving 2 or 3 arterial grafts) to compare outcomes with those of patients receiving 1 arterial graft. Two arterial grafts were shown to be protective for cardiac readmission (0.8; 95% confidence interval, 0.76-0.92) and a composite outcome (0.9; 95% confidence interval, 0.72-0.95) compared with 1 arterial graft. Two or 3 arterial grafts were further found to improve survival (0.8; 95% confidence interval, 0.72-0.99). In all patient operative risk categories, 2 or 3 arterial grafts were protective for cardiac readmission (hazard ratio, 0.7-0.8) and the composite outcome (hazard ratio, 0.8). There was no difference in the Cox hazard ratios of propensity-matched patients in the comparison of the groups receiving 3 versus 2 arterial grafts., Conclusions: Few patients received more that 1 arterial graft in our region. There was a survival benefit in receiving 2 or 3 arterial grafts. Patients with low, moderate, and high operative risk receiving 2 or 3 arterial grafts had lower rates of cardiac readmission compared with patients receiving only 1 arterial graft. This suggests that the standard of care should include the use of at least 2 arterial bypasses in all categories of operative risk to allow for optimal midterm outcomes.

Background: The purpose of this study was to assess the use of arterial revascularization and to compare the in-hospital mortality with other CABG grafting strategies., Methods: A total of 71,470 CABG patients (1992-2001) in 27 centers in the United Kingdom were studied. The proportion of patients with arterial revascularization was compared. In-hospital mortality was compared for various grafting strategies: all-arterial (n = 5,401), all non-all-arterial patients (n = 66,069), one artery any number of veins (n = 49,801). The groups were compared for in-hospital mortality using multivariate logistic regression to assess the independent effect of the grafting strategies on mortality; logistic EuroSCORE-predicted mortality was compared to actual mortality, and all arterial and one artery and veins patients were compared with propensity score analysis., Results: There was a significant increase in the proportion of all-arterial patients over time (3.2% to 11.7%, p < 0.001) with evidence of variability across centers. Crude mortality for all-arterial patients was 2% vs 3% for all non-all-arterial patients (p < 0.001). In multivariate analysis, all-arterial was associated with a slight but insignificant increase in in-hospital mortality (odds ratio [OR] 1.13; [95% confidence interval {CI} 0.86-1.48], p = 0.36). There was a trend toward higher mortality in the all-arterial group when compared with the one artery and veins group (OR 1.19 [95% CI 0.91-1.56], p = 0.10). The one artery and veins group was the only group where actual mortality was significantly lower than predicted by EuroSCORE (p < 0.001). In propensity analysis the mortality was 1.51% for one artery and veins and 1.74% of all-arterial patients (p = 0.56)., Conclusions: The use of arterial grafting has increased over time, varies by center, and appears to be safe in terms of in-hospital mortality.

Background: The purpose of this study was to evaluate mortality after coronary artery bypass grafting (CABG) comparing the use of only in situ arterial grafts with the use of arterial and venous conduits., Methods and Results: From April 1985 to March 1999, 1159 patients with multivessel disease underwent elective, isolated, primary, multiple CABG with at least one in situ arterial conduit. Patients who were on chronic dialysis, had active malignant disease, or had free arterial conduits were excluded. The long-term results were compared between 532 patients who had CABG using only in situ arterial conduits (group A; mean follow-up, 7.8 years) and 627 patients who underwent CABG using in situ arterial conduits and saphenous vein grafts (group B; mean follow-up, 10.3 years). Actuarial survival and freedom from cardiac death were determined by the Kaplan-Meier method. Propensity score was included in the Cox multivariable regression model for adjustment of selection bias. Survival at 10 years after surgery was 81.4% in group A and 76.9% in group B (P=0.11). Freedom from cardiac death at 10 years was 93.4% in group A and 90.4% in group B. Hazard ratio for cardiac death was significantly lower in group A (0.61; 95% confidence interval, 0.38 to 1.00; P=0.05)., Conclusions: Our data suggest that the exclusive use of in situ arterial grafts in CABG achieves significantly better long-term survival compared with combined use of arterial and vein grafts.

Background: In patients who develop in-stent restenosis, successful revascularization can be difficult to achieve using percutaneous methods. This study was designed to verify the surgical results in this setting and to evaluate the potential beneficial role of arterial bypass conduits., Methods and Results: Sixty consecutive coronary artery bypass patients with previous in-stent restenosis and 60 control cases were randomly assigned to receive an arterial conduit (either right internal thoracic or radial artery; study group) or a great saphenous vein graft (control group) on the first obtuse marginal artery to complete the surgical revascularization procedure. At a mean follow-up of 52+/-11 months, patients were reassessed clinically and by angiography. Freedom from clinical and instrumental evidence of ischemia recurrence was found in 19 of 60 subjects in the study group versus 45 of 60 in the control series (P=0.01). The results of the arterial grafts were excellent in both the study and control groups (right internal thoracic artery patency rate, 19 of 20 for both, and radial artery patency rate, 20 of 20 versus 19 of 20; P=0.99). Saphenous vein grafts showed lower patency rate than arterial grafts in both series and had extremely high failure rate in the study group (patency rate, 10 of 20 in the study group versus 18 of 20 in the control group; P=0.001). Use of venous graft was an independent predictor of failure in the study group, whereas hypercholesterolemia was associated with graft failure in both series., Conclusions: Venous grafts have an high incidence of failure among cases who previously developed in-stent restenosis, whereas the use of arterial conduits can improve the angiographic and clinical results. Arterial grafts should probably be the first surgical choice in this patient population.

Background: The long-term clinical advantages of using routine multiple internal mammary artery (IMA) grafts for coronary artery bypass (CAB) are not clear. This study was designed to test the hypothesis that multiple IMA grafts would provide better 15-year outcomes when compared with single IMA and vein grafts., Methods and Results: Between 1984 and 1987, 1067 consecutive patients undergoing isolated CAB were referred to 1 surgeon practicing primarily single and another surgeon maximizing multiple IMA grafts (clinical practice trial). A 207-patient subset with multiple IMAs underwent postoperative graft angiography at 1 to 32 weeks to define initial IMA patency. Patients were followed-up yearly, and the groups were analyzed as (I) surgical strategy (surgeon operating) (single=413 versus multiple=654), (II) ultimate operation performed (single=418 versus multiple=449), or (III) single versus multiple coronary systems revascularized with IMAs (single=490 versus multiple=377). Advantages of this study design were that an entire referral population was examined, multiple IMAs were applied to the entire spectrum of baseline patient risk, 15-year follow-up provided a complete prognostic picture, and the subgroups were potentially comparable at baseline. In all 3 analyses, single and multiple groups were statistically similar with respect to baseline, operative, and immediate postoperative variables. Early IMA patency was 98.5% (333/338 grafts patent), validating the quality of IMA procedures. Unadjusted and adjusted 15-year outcome analyses for I, II, and III for death, myocardial infarction, percutaneous coronary intervention, redo coronary bypass, and the composite of all events identified multiple versus single as a significant predictor of outcome for the composite end point in adjusted analysis III (hazard ratio=0.808; 95% CI, 0.689 to 0.948; P=0.009), because of a 5% to 10% absolute reduction in each of the outcome variables at 15 years. Moreover, >50% reduction in reoperation rate was observed at 15 years in every analysis., Conclusions: At 15-year follow-up, multiple IMA grafting was associated with a 19.2% adjusted risk reduction in death and cardiac events, caused by decreases in all adverse end points and fewer reoperations. These data indicate that the clinical advantages of maximizing IMA conduits are significant. Based on this information, it is suggested that multiple IMA grafting to 2 coronary systems should be applied liberally to patients with noncardiac risk profiles predictive of long-term survival.

Background: Internal mammary artery conduits (IMA) have an excellent long-term patency rate. Nevertheless, graft closure does occur and significantly limits future revascularization options. We sought to investigate the relationship between the long-term patency of IMA with clinical and angiographic parameters. Particularly, the preoperative degree of stenosis of the relevant bypassed coronary vessel was assessed to analyze the importance of chronic competitive flow on the arterial graft closure rate., Methods and Results: Consecutive patients in whom occlusion of at least 1 IMA had been documented at angiography (OCC group) were compared with a group of patients with patent IMA grafts (PAT group). The degree of stenosis in the native coronary artery on which the IMA was placed was analyzed by off-line quantitative coronary angiography. Multivariate stepwise logistic regression was used to identify independent clinical and angiographic predictors of occlusion. The OCC group comprised 96 patients (67+/-10 years) with 103 native bypassed arteries analyzed. The PAT group comprised 127 patients (69+/-8 years) with 170 native bypassed arteries analyzed. Both groups were similar except for gender (42% versus 32% female; P=0.04), height (166+/-8 versus 169+/-8 cm; P=0.006), minimum lumen diameter (0.76+/-0.7 versus 0.51+/-0.5; P=0.001), and diameter stenosis of the native artery (73+/-25% versus 84+/-16%; P<0.0001) in OCC versus PAT, respectively. In the multivariate analysis, only percent diameter stenosis was an independent and statistically significant predictor for graft patency. Among IMA placed on coronary arteries with a diameter of stenosis <50% (n=28), the occlusion rate was very high (79%)., Conclusions: The degree of stenosis in the native vessel is a major predictor of internal mammary artery bypass graft patency. The association between nonsignificant stenosis of the native artery and high occlusion rate of the arterial bypass conduit raises concerns about the use of IMA in the treatment of native vessels with only mild or moderate stenosis.

Background: The left internal mammary artery to the left anterior descending artery is recognized as the gold standard for revascularization. Several studies have shown the benefits of the left internal mammary artery. However, a substantial portion of patients undergoing coronary artery bypass grafting does not receive this conduit. We sought to identify reasons for nonusage of the left internal mammary artery to the left anterior descending artery, while evaluating short- and medium-term outcomes., Methods: Between April 1997 and September 2001 a total of 4406 consecutive patients underwent coronary artery bypass grafting with revascularization to the left anterior descending artery. All data were collected prospectively except reasons for nonusage of the left internal mammary artery. Logistic regression and Cox proportional hazards analyses were used to adjust in-hospital and medium-term outcomes, respectively. Selection bias was controlled by constructing a propensity score. A case note review was carried out to determine reasons for nonusage., Results: A total of 4047 patients (91.8%) received the left internal mammary artery to the left anterior descending artery leaving 359 patients (8.2%) who did not. We found no difference in hospital mortality or morbidity, however, patients receiving the left internal mammary artery had a survival advantage at 4 years. Reasons for not using the left internal mammary artery were damage to the conduit (n = 44), poor flow (n = 43), poor lung function (n = 45), unstable symptoms (n = 24), vascular problems (n = 12), and 19 patients with "other" reasons (previous radiotherapy, chest wall deformity, and obese patients). Case notes had no reason stated for 146 patients and reasons for 26 patients were unobtainable., Conclusions: Left internal mammary artery usage is not associated with any increase in hospital mortality and morbidity, but these patients have better medium-term survival. Injury on harvesting, poor flow, and poor lung function were the most common reasons for not using this conduit.

Context: A rigorous evaluation of continuous quality improvement (CQI) in medical practice has not been carried out on a national scale., Objective: To test whether low-intensity CQI interventions can be used to speed the national adoption of 2 coronary artery bypass graft (CABG) surgery process-of-care measures: preoperative beta-blockade therapy and internal mammary artery (IMA) grafting in patients 75 years or older., Design, Setting, and Participants: Three hundred fifty-nine academic and nonacademic hospitals (treating 267 917 patients using CABG surgery) participating in the Society of Thoracic Surgeons National Cardiac Database between January 2000 and July 2002 were randomized to a control arm or to 1 of 2 groups that used CQI interventions designed to increase use of the process-of-care measures., Intervention: Each intervention group received measure-specific information, including a call to action to a physician leader; educational products; and periodic longitudinal, nationally benchmarked, site-specific feedback., Main Outcome Measure: Differential incorporation of the targeted care processes into practice at the intervention sites vs the control sites, assessed by measuring preintervention (January-December 2000)/postintervention (January 2001-July 2002) site differences and by using a hierarchical patient-level analysis., Results: From January 2000 to July 2002, use of both process measures increased nationally (beta-blockade, 60.0%-65.6%; IMA grafting, 76.2%-82.8%). Use of beta-blockade increased significantly more at beta-blockade intervention sites (7.3% [SD, 12.8%]) vs control sites (3.6% [SD, 11.5%]) in the preintervention/postintervention (P =.04) and hierarchical analyses (P<.001). Use of IMA grafting also tended to increase at IMA intervention sites (8.7% [SD, 17.5%]) vs control sites (5.4% [SD,15.8%]) (P =.20 and P =.11 for preintervention/postintervention and hierarchical analyses, respectively). Both interventions tended to have more impact at lower-volume CABG sites (for interaction: P =.04 for beta-blockade; P =.02 for IMA grafting)., Conclusions: A multifaceted, physician-led, low-intensity CQI effort can improve the adoption of care processes into national practice within the context of a medical specialty society infrastructure.

Background: There is clear evidence that patients having coronary artery bypass graft surgeries with an internal mammary artery (IMA) have better long-term survival. Some studies have suggested a short-term protective effect as well but, because older and sicker patients are less likely to receive an IMA graft, there has been concern that the apparent protective effect of the IMA on short-term mortality has been confounded by other risk factors. This study was intended to examine the independent effect of IMA grafts on in-hospital mortality while adjusting for patient and disease factors., Methods and Results: We studied the use of the left IMA (LIMA) in 21 873 consecutive, isolated, first-time coronary artery bypass graft procedures from 1992 through 1999. A total of 87% of the patients received a LIMA graft. LIMA graft use was associated with a significantly decreased risk of mortality. The crude odds ratio for death (LIMA versus no LIMA) was 0.26 (95% confidence intervals, 0.22, 0.31; P:<0.001). LIMA grafts were protective across all major patient and disease subgroups. The odds ratios by subgroup ranged from 0.13 to 0.48. After adjustment for all major risk factors, the odds ratio for death was 0.40 (95% confidence intervals, 0.33, 0.48; P:<0.001). Rates of cerebrovascular accident, return to cardiopulmonary bypass, return to the operating room for bleeding, and mediastinitis or sternal dehiscence requiring surgery were also less in the LIMA group, although not significantly so., Conclusions: These data suggest that in addition to its well-documented patency and long-term beneficial effect, LIMA grafting has a strong protective effect on perioperative mortality.

The assessment of results of medical treatment, angioplasty and coronary bypass surgery in diabetic coronary patients is difficult because of the absence of distinction in the subgroups of type 1 and 2 diabetes and of stable and unstable angina. With respect to medical therapy, betablockers are practically without deleterious effects and are effective in diabetic populations. The same is true of other antianginal drugs. Conventional coronary angioplasty is associated with poorer results than the general population in the long-term, partly because of progression of the coronary artery disease and partly because of an increased incidence of restenosis. The use of stents improves these results, which are similar to those of the general population with single vessel disease or those without proteinuria. Coronary bypass surgery, despite a certain perioperative morbidity, is associated with an identical survival rate at 5 years as non-diabetics, providing the internal mammary artery is grafted. The comparison between these methods is resumed in the ACIP study which opposes the 3 strategies, in Morris et al's study comparing medical and surgical approaches and, finally, in the recent BARI trial where patients were randomly allocated to angioplasty or surgery. It would appear that the surgical strategy gives better results in multivessel disease. However, many reserves have been voiced because of the small numbers of patients, the high number of excluded patients and the fact that recent progress in angioplasty with widespread use of stenting associated with the prescription of new antiaggregant drugs was not taken into account.

Background: A tendency to reduce the operative trauma seems to be the prominent sign of development in cardiac surgery. The combination of the previously introduced minimally invasive "Dresden Technique" with the robotically enhanced endoscopic system enables further progress in coronary artery surgery., Methods: From May 1999, 25 patients (19 male, 6 female, mean age 63 +/- 8.0 years) suffering from multivessel coronary artery disease (CAD) were treated surgically using arterial revascularization through the bilateral internal mammary arteries (BIMA). Both mammaries were harvested endoscopically using the da Vinci robotic system. Further, the "Dresden Technique" was applied for anastomosis of these vessels with the coronaries., Results: All patients survived the surgery. Mean duration of surgery amounted (244 +/- 82.1 min). BIMA dissection took (87 +/- 18.1 min). An average of 2.2 anastomoses were performed per patient. Postoperatively, the patients remained on ICU for 19 +/- 18 hrs. One patient needed reexploration for bleeding (4%)., Conclusions: The addition of robotically enhanced endoscopic mammary artery harvesting method to the "Dresden Technique" for coronary artery surgery enables the introduction of a new treatment method for CAD into surgical practice, helping to perform an arterial revascularization with a distinctly reduced surgical trauma.

Background: With the introduction of a wrist-enhanced robotic surgical system into minimally invasive cardiac surgery, the outlook of performing closed chest coronary artery bypass operations became a reality., Methods: Since May, 1999, this new wrist-enhanced instrumentation has been used in 109 (79 male, 30 female, median age 63 +/- 9.9 years) patients. Seven suffering from single vessel coronary artery disease (SVD) and double vessel disease (DVD) were treated as totally endoscopic coronary artery bypass (TECAB). 60 with SVD underwent a wrist-enhanced, minimally invasive direct coronary artery bypass procedure. 25 with DVD were treated using the robotically enhanced Dresden Technique coronary artery bypass., Results: Survival was 100%. In all patients the IMAs were safely harvested totally endoscopically. In the TECAB group, all patients were operated via a three-point stab incision. Data were observed during and after the operation., Conclusions: Our preliminary experiences with this new surgical technique for the robotically enhanced, minimally invasive treatment of coronary artery disease promote an optimistic way of thinking about the further development of these procedures.

Introduction and Objectives: To establish the results obtained with the classical technique of mammary anastomosis of the anterior descending artery., Materials and Methods: Between January 1982 and July 1997, 154 patients received an anastomosis of the left internal mammary artery to the left anterior descending coronary artery with use of the classical technique (sternotomy and extracorporeal circulation)., Results: There was no operative mortality in our group, nor paraoperational myocardial infarction, nor cephalic vascular accidents. One (0.6%) patient had sternal wound infection, and another (0.6%) required another reoperation for postoperational bleeding. All (100%) were followed-up from 3-183 months (average 64. 4 months). Actuarial global survival at 5, 10 and 15 years was 95.6%+/-2.1; 92.1%+/-4 and 85.5+/- 7.5 respectively, and the actuarial probability of being free from cardiac death was 99%+/-0.9; 99% and 99%. The actuarial probability of being free from myocardial infarction was 99%+/-0.9; 99%+/-0.9 and 99%; and from angina was 95%+/-2.2; 86.9%+/-4.9 and 74.5%+/-12.2 at 5, 10 and 15 years.Finally, the actuarial probability of being free from reoperation was 99%+/-0.9; 99%; 99% and from angioplasty 96.9%+/-1.7; 91.4%+/-4.1; 91.4%+/-4.1 at 5, 10 and 15 years, respectively. The average hospital charges in the last 10% of the patients was U$ 6.200., Conclusions: Revascularization of the left anterior descending with the left internal mammary artery and the classical technique (sternotomy and extracorporeal circulation) is a safe, minimal risk, effective, long lasting and cost efficient procedure with excellent results at 10 and 15 years.

Objective: The main objective of the present study was to analyze the in-hospital and mid term results obtained in 1,023 consecutive patients undergoing coronary artery bypass surgery (CABG) in whom a combination of arterial grafts was used: radial arteries (RA) and one or both internal mammary arteries (IMA)., Methods: From May 1995 to May 1998, 1,023 consecutive patients underwent CABG alone, using arterial conduits (AC) (one or two IMA and RA) for myocardial revascularization. The left internal mammary artery (LIMA) was employed as an "in situ" graft, and the right internal mammary artery (RIMA) as a free graft or "in situ" both in combination with the RA. The latter was connected to the LIMA through a T or Y anastomosis, or emerged directly from the ascending portion of the aorta., Results: An average of 3.2 bypasses per patient were performed. The LIMA was used in 100% of the patients. The RIMA was used in 21.7% and the RA in 100% of the cases. Operative mortality was 2.5% (26 patients) and 32 (3.1%) suffered perioperative acute myocardial infarction. The first 62 patients were angiographically re-studied before discharge, and a 98.4% patency of the AC used was found. Mean follow up time was 25.0 +/- 9.6 months (range, 1 to 48 months)., Conclusions: a) myocardial revascularization procedures using a combination of mammary and RA grafts are safe; b) in-hospital and mid term morbidity and mortality are not higher than those observed with saphenous vein grafts; c) it is possible to achieve complete myocardial revascularization with only AC, even in patients with impaired left ventricular function, and d) AC can be used in elderly patients.

Objective: To evaluate our initial experience in the combination of two less invasive procedures for myocardial revascularization, coronary artery bypass grafting without cardiopulmonary bypass and immediate posterior angioplasty, on untreated lesions (hybrid revascularization) as an alternative treatment to conventional surgery in selected patients., Material and Methods: From october 1996 to September 1998, 19 patients received hybrid revascularization. The mean age was 64 (47-76). Two patients underwent urgent surgery. Two patients had left main coronary disease, and 9 three-vessel disease. In general, we considered this procedure for patients with high-risk factors for cardiopulmonary bypass and two or more vessel disease. The internal mammary artery was connected to the left anterior descending artery in all 19 patients. All patients were moved to the hemodynamic ward immediately after surgery in 7 cases and before 48 h in the rest, 24 angioplasties were performed. A mean of 2.6 vessels per patient were revascularized and revascularization was complete in 15 patients (79%)., Results: One patient had perioperative myocardial infarction. There was no hospital mortality. Length of stay in the intensive care unit was 44 h (IQR = 49) and global postoperative stay was 8 days (IQR = 3.5). In the postoperative angiographic study, before the angioplasty, 95% of mammary arteries (CI 95% 74-100%) and 100% of saphenous grafts (CI 95% 59-100%) were patent., Conclusions: Combined revascularization allows almost complete revascularization, avoiding complications of cardiopulmonary bypass and minimizing surgical aggression. At the same time, it secures the graft of internal mammary artery to left anterior descending artery.

Background: Elective coronary artery bypass surgery can be performed with low operative mortality. There is a controversial discussion whether short-term and long-term results of CABG justify this procedure in elderly patients., Methods: To add to this discussion, we evaluated retrospectively, the clinical profile, operative technique, short- and long-term results of 1127 patients over 70 years of age who underwent myocardial revascularization between January 1985 and December 1996., Results: Mean age of the cohort was 73.9 years and it rose continuously. In 1996, septuagenarians represented 21.5% of our coronary patients, in comparison to 6.4% in 1985. Analysis of risk factors showed an increasing prevalence of renal failure, obesity, hyperuricemia and a history of smoking. Preoperatively, 87% of our patients were in NYHA-class III or IV, and thus operated to relieve severe symptoms. The percentage of emergent operations decreased over the observed period by 10.3%. The internal mammary artery was used with rising frequency (44.8% in 1985-1992 vs 61.5% in 1993-1996). The number of simultaneous valve replacements increased, too. Postoperatively, we noted a rising incidence of respiratory failure (17.1%) and neurological disorders (13.7%). On the other hand, the need for intra-aortic balloon pumping and hemofiltration declined by 6.6% and 2.9%, respectively. Perioperative mortality (< or =24 hrs) was 3.65%, hospital mortality (< or =30 days) was 9.64%. The actuarial survival (standard error) at 1 year was 82% (+/-4.3%), and 65.7% (+/-3.8%) at 5 years., Conclusions: Our data suggest that coronary artery bypass grafting can be performed in septuagenarians at an acceptable risk. Since the large majority of patients improve symptomatically, surgery is a recommendable option for a growing number of elderly patients suffering from severe angina.

The use of the left internal thoracic artery anastomized to the left anterior descending coronary artery via a small left thoracotomy to revascularize the anterior wall of the left ventricle has gained wide acceptance since its introduction into clinical practice a few years ago. A mandatory, postoperative angiographic control was suggested in order to check the surgical results of this new method of revascularization. We herein analyze the results of the in-hospital angiographic control of a series of 100 consecutive patients who underwent minimally invasive coronary artery bypass. In all 100 patients the thoracic graft, the anastomosis and the target vessel were patent, with no anomalies in 90 subjects. In 4 patients, a sharp angulation of the thoracic artery in the last third before the anastomosis to the native vessel was observed; in 3 subjects, the arterial graft had been anastomized to a diseased tract of the target vessel and in 3 cases a significant stenosis of the target vessel beyond the anastomosis was documented; in 2 cases the persistence of a thoracic artery branch was discovered. Since 1) neither in-hospital total occlusion of the thoracic graft to the left anterior descending coronary artery via a small thoracotomy was documented nor a significant incidence of major anomalies was observed; 2) the anomalies documented seem to be clinically negligible and may regress in the midterm postoperative period; 3) Doppler flow analysis is able to detect not only the patency but also the presence of significant stenosis in the arterial graft; the in-hospital angiographic control of this surgical technique should be limited to patients with abnormal ultrasonic data or with reappearance of myocardial ischemia in the anterior wall of the left ventricle, thus not reducing the advantages in terms of speed and cost-control of this type of myocardial revascularization.

Background: The internal mammary artery is used as coronary artery graft conduit because of its superior patency. According to some authors, the bilateral IMA can increase perioperative morbidity. The aim of this study was to determine the risk factors increasing perioperative mortality and morbidity in the use of bilateral IMA., Methods: We analyzed the data of 474 patients operated consecutively with the use of bilateral IMA between January 1987 and December 1995 at the Department of Cardiac Surgery of the Varese Hospital. The univariate analysis was done on 17 ordinal variables using a "Fisher exact test" and on 4 continuous variables by "pooled-variance t-test" to investigate risk factors for mortality, mediastinitis, superficial wound infection and aseptic dehiscence of the sternum; a p-value lower than 0.1 was used as cut-off point to introduce the variables into a stepwise multiple logistic regression analysis., Results: From the univariate analysis are: postoperative low-output syndrome (p = 0.01), LVEF (p = 0.02) and number of grafts (p = 0.04) are correlated to hospital mortality (1.5%); obesity (p < 0.001) and peripheral arteriopathy (p = 0.009) are correlated to postoperative mediastinitis (5%); obesity (p < 0.001), peripheral arteriopathy (p = 0.009), surgeon (p = 0.001), year of operation (p < 0.001), reoperation for bleeding (p = 0.004) and length of extracorporeal circulation (p = 0.02) are correlated to superficial wound infection (7%); obesity (p = 0.002) and COPD (p = 0.05) are correlated to aseptic dehiscence of the sternum (2%). The multivariate analysis identified low LVEF as the only independent risk factor for hospital mortality (p = 0.03), whereas obesity (p = 0.01) and peripheral vasculopathy (p = 0.03) proved to be correlated to postoperative mediastinitis; obesity (p < 0.001), year of the operation (p < 0.001), low LVEF (p = 0.007) and reoperation for bleeding (p = 0.01) were correlated to superficial infection of the wound and obesity turned out to be the only risk factor for aseptic dehiscence for the sternum (p = 0.003). The infection of the wound did not increase mortality, but it did increase the mean postoperative length of hospital stay (6 days for patients free of any complications of the wound versus 29.7 days for patients with complications of the wound)., Conclusions: In patients with bilateral mammary grafts, obesity is the main risk factor for complications of the wound and this event greatly increases the length of the patient's hospital stay. Consequently, we suggest that bilateral mammary artery grafts be used carefully in this subset of patients.

Objective: The recent concept of minimally invasive coronary artery surgery in selected patients has dramatically affected surgical management of coronary artery disease. We explored the possibility of coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy on beating heart., Method: Minithoracotomy and direct coronary artery surgery without cardiopulmonary bypass (CPB) was attempted in 116 patients. The procedure was completed in 108 cases while in eight cases minithoracotomy was converted to mid sternotomy. In 107 cases, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery anastomosis was done through left anterior minithoracotomy and in one case LIMA to LAD and right internal mammary artery (RIMA) to right coronary artery (RCA) anastomosis was done through bilateral minithoracotomy. Left anterior minithoracotomy through 4th intercostal space and right anterior minithoracotomy through 5th intercostal space was used for left and right internal mammary artery dissection respectively. With this approach 4-8 cm length of mammary artery was easily dissected. Mammary coronary artery anastomosis were performed on a beating heart without CPB through window pericardiotomy. Two patients also underwent left carotid endarterectomy along with LIMA to LAD anastomosis. In two patients complementary percutaneous transluminal coronary angioplasty (PTCA) to circumflex artery was done 5 days after minithoracotomy and LIMA to LAD anastomosis., Results: Forty-two patients were extubated in the operating room and 66 in the intensive care unit 2-10 h after surgery. Blood transfusion was used in one case who was reexplored for postoperative bleeding due to a displaced hemoclip from the internal mammary artery branch. None of these patients required inotropic support. Postoperative predischarge check angiogram in 53 cases revealed adequate mammary coronary flow in 51 cases, the remaining two had anastomotic problems, one was subjected to PTCA and the other for redo coronary bypass grafting through mid sternotomy. Doppler flow assessment of anastomosis was done in 102 cases, of which two showed problems which was confirmed on check angiography. One-hundred and six patients are in our regular follow-up (mean follow-up 10+/-1.5 months), 98 of them are in functional class I., Conclusion: In our experience mammary coronary artery anastomosis without CPB through minithoracotomy is a safe, simple and minimally invasive procedure. Favorable cost/benefit ratio, has been achieved due to no early/late mortality and minimal early morbidity. Postoperative check angiogram and Doppler flow study revealed excellent mid term results.

This study was undertaken to assess our experience with the first 50 patients who underwent CABG without cardiopulmonary bypass. In seven patients left internal mammary artery to left anterior descending artery (LIMA-LAD) grafting was performed through a short left anterior thoracotomy. In 43 other patients median sternotomy was used. Primary CABG was performed in 48 patients; there were two reoperations. Eleven patients had unstable angina. Three patients had left ventricular ejection fraction (LVEF) equal to or lower than 25%. One patient had carcinoma of the right lung coexisting with unstable angina and underwent also right lower lobectomy. In each patient the clinical course, 12-lead ECG, transthoracic echocardiography and the serum levels of creatine kinase (CPK), alanine aminotransferase (ALAT), aspartate aminotransferase (AspAT) were assessed. The need for inotropic or intraaortic balloon counterpulsation (IABP) support and blood transfusion was also recorded. There were three deaths, all in the sternotomy group (6%). A patient with systemic lupus erythemetodes (SLE) died of postoperative MI due to graft thrombosis. Another patient who was found to have porcelain aorta and had LIMA-LAD grafting as a rescue procedure died of MI with low cardiac output. The third patient with unstable angina and ejection fraction of 30% developed postoperative MI with ventricular arrhythmia. One patient with LIMA-LAD graft in whom percutaneous translaminal coronary angioplasty (PTCA) had been abandoned because of coronary spasm developed acute myocardial ischaemia 5 h postoperatively. He had a vein graft placed to LAD in cardiopulmonary bypass, his further course was uneventful. Six patients had IABP support. Nine patients needed inotropic support. Ten patients received blood transfusion. Twelve-lead ECG did not show acute ischaemia or MI, apart from the above described cases. Echocardiographic check showed improved IVS contractility in three patients and better apex motion in one case. In the other survivors the echocardiographic findings were the same as before the procedure. ALAT and AspAT serum levels were normal in all the survivors, and the CPK levels did not exceed 200 IU/ml. One patient from the mini-thoracotomy group had recurrent angina 2 months after the procedure. His left internal mammary artery (LIMA) graft was occluded; we replaced it with a vein graft. All 47 survivors remain asymptomatic, with the mean follow-up time of 6 months. Coronary surgery without cardiopulmonary bypass seems a valuable alternative for high-risk patients.

Objective: At present, few studies directly comparing minimally invasive and conventional coronary artery bypass grafting are available. The aim of the present study was to evaluate the clinical outcome of the two techniques., Methods: We retrospectively compared our first consecutive 20 patients undergoing minimally invasive coronary artery single bypass grafting on the beating heart (group I) with 23 consecutive patients receiving single coronary artery bypass via sternotomy using cardiopulmonary bypass and cardioplegia (group II). The procedures were performed during the period from Jan 1, 1994 to Feb 20, 1997. There were no significant differences in demographic data., Results: Statistically significant differences were found concerning total operative time (172.6 min in group I and 149.6 min in group II P = 0.0009) and myocardial ischemic time (23.7 min local coronary occlusion time in group I and 17.6 min aortic cross-clamp time in group II P = 0.03. Patients treated minimally invasive received significantly fewer blood transfusions (25.0% vs. 69.6% P = 0.0035) and were discharged significantly earlier from the hospital (admission rate on the fifth postoperative day 68.4% in group I vs. 100.0% in group II P = 0.0004)., Conclusion: We conclude that minimally invasive coronary artery bypass grafting on the beating heart in comparison to conventional single coronary artery bypass grafting during the learning curve requires longer operative times but can reduce blood transfusion requirements and hospital stay.