Should Bilateral Internal Thoracic Artery (BITA) Grafting Be Used...

Kramer and Dmitry PevniBenjamin Medalion, Rephael Mohr, Osnat Frid, Gideon Uretzky, Nachum Nesher, Yosef Paz, Amir

Undergoing Coronary Artery Bypass Grafting?Should Bilateral Internal Thoracic Artery (BITA) Grafting Be Used In Elderly Patients

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2013 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation published online May 8, 2013;Circulation.

http://circ.ahajournals.org/content/early/2013/05/08/CIRCULATIONAHA.112.001330World Wide Web at:

The online version of this article, along with updated information and services, is located on the

http://circ.ahajournals.org//subscriptions/

is online at: Circulation Information about subscribing to Subscriptions:

http://www.lww.com/reprints Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer available in the

Permissions in the middle column of the Web page under Services. Further information about this process isOnce the online version of the published article for which permission is being requested is located, click Request

can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Circulation Requests for permissions to reproduce figures, tables, or portions of articles originally published inPermissions:

at FMRP BRAZ 35042 MEDIC RIB 80 on May 14, 2013http://circ.ahajournals.org/Downloaded from

http://circ.ahajournals.org/content/early/2013/05/08/CIRCULATIONAHA.112.001330

http://www.ahajournals.org/site/rights/

http://www.lww.com/reprints

http://circ.ahajournals.org//subscriptions/

http://circ.ahajournals.org/

DOI: 10.1161/CIRCULATIONAHA.112.001330

1

Should Bilateral Internal Thoracic Artery (BITA) Grafting Be Used In

Elderly Patients Undergoing Coronary Artery Bypass Grafting?

Running title: Medalion et al.; Effect of age on outcome of BITA grafting

Benjamin Medalion, MD1; Rephael Mohr, MD2; Osnat Frid, MD2; Gideon Uretzky, MD2;

Nachum Nesher, MD2; Yosef Paz, MD2; Amir Kramer, MD2; Dmitry Pevni, MD2

1Dept of Cardiothoracic Surgery, Rabin Medical Center, Petah Tikva & Sackler Faculty of

Medicine, Tel Aviv University; 2Dept of Cardiothoracic Surgery, Tel Aviv Sourasky Medical

Center, Tel Aviv & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Address for Correspondence:

Rephael Mohr, M.D.,

Dept of Cardiothoracic Surgery

Tel Aviv Sourasky Medical Center

6 Weizman Street

Tel Aviv 64239, Israel

Tel: +972-3-6973322

Fax: +972-3-6974439

E-mail: [email protected]

Journal Subject Code: Cardiovascular (CV) surgery:[36] CV surgery: coronary artery disease

Nachum Nesher, MD2; Yosef Paz, MD2; Amir Kramer, MD2; Dmitry Pevevvniii, MDMDMD222

1DeDeDeptptpt ooofff CaCC rdrddioioiotthoracic Surgery, Rabin Medididicacacall Center, Petah Tikkvavava & Sackler Faculty of

MMeMedicine, TeTel ll AvAvivivv UUnininiveveversrrsititity;y;; 222DeDeDeptpt of ff CaCaCarddiooothhhoracacaciicic SSSuururgegeeryy,y, TTTeelel AAAviivvv SoSoSouururaasaskykyky MMMedededicccala rr

CeCenttererr,, TeTeT ll AAvAvivivv &&& SSacccklkllerere FFFacaca uuultytyy ooff f MMeMedidiciinene,, TTeTell AvAviviv UUUniniiveveersssitity,y,y, TTTelel AAAviviviv,v, Issrsraeaelll

AdAdddress ffor CCorrespo dndence:




2

Abstract:

Background—Although Bilateral Internal Thoracic Artery (BITA) grafting is associated with

improved survival, the use of this technique in elderly is controversial due to their increased

surgical risk and shorter life expectancy. The purpose of this study is to evaluate the effect of

age on outcome of patients undergoing BITA grafting.

Methods and Results—Between 1996 and 2001, 1714 consecutive patients underwent

skeletonized BITA grafting, of whom 748 were 65 years of age or younger, 688 were between 66

and 75 and 278 were 76 or older. Operative mortality of the three age groups (1.2%, 4.1% and

5.8%) was lower than the logistic Euroscore predicted mortality (3.9%, 6.5%, 9.3%, respectively,

p<0.001). There was no significant difference between groups in occurrence of sternal infection

(1.3%, 2.6% and 1.4% respectively, p=0.171). Mean follow-up was 11.5 years. Kaplan-Meier

10-year survival for patients 65, 66-75 and >75 years of age was 85%, 65% and 40%,

respectively (p<0.001). They were better than the corresponding predicted Charlson

Comorbidity Index survivals (68%, 37% and 20%, respectively, p<0.001 for all age groups),

approaching survival of gender and age-matched general population (90%, 70% and 41%,

respectively). Age 65 or younger (HR 0.232, 95% Ci 0.188-0.288) and 66-75 (HR 0.499, 95%

Ci 0.414-0.602) were independent predictors of improved survival (Cox Model)

Conclusions—BITA grafting should be considered in patients older than 65, due to the

significant survival benefit obtained with this surgical technique without additional risk of sternal

wound infection related to age.

Key words: cardiac surgery, elderly, bypass surgery

5.8%) was lower than the logistic Euroscore predicted mortality (3.9%, 6.5%, 9.3.33%,%,% resese pepepectctctiiviveelyy

p<0.001). There was no significant difference between groups in occurrence of sternal infection n

11.3.33%,%,%, 222 6.6.6%%% aand dd 11.1.4%4 respectively, p=0.171). MMMeaan follow-up wwwasa 111.1.1 555 years. Kaplan-Meier

1100-yyyear survivvalall fooor ppaatieieientntnts s 66565, 666666-7-775 anddd >>>75 yeyeyearss s oofof aagegee wwaasas 885%5%%, 6565%%% anand dd 40400%,%%,

eespspspececectitit vevelylyly (((p<p<000.0000011)1). TThehey y y wewewererere bbetettteteerr r thththannn ttthehee cccororrrerespspspoonondididingngg ppprereredidiicttteded CCChhaharlrlsososonn

Comorbidity y y InInIndededex xx sususurvrvrvivalalalss s (6(68%8%8%, , 37373 % % % ananand d d 202020%,%,%, rrresese pepeectctctivivivelelly,y,y, pp<0<0<0.0.0.0010101 fffororo aaallllll aaagegege gggroups),




3

Introduction

With the expansion in life expectancy, an increasing number of elderly patients are referred for

coronary artery bypass grafting (CABG), and the current trend is to use the internal thoracic

artery (ITA) in all patients operated on, including the older ones. The current conventional and

most commonly used operative procedure for myocardial revascularization includes one pedicled

ITA together with one or more vein grafts1,2. Vein graft exhaustion is a major drawback of

CABG, and surgical techniques of complete arterial myocardial revascularization without veins

have been attempted. Two popular techniques for achieving this goal are bilateral and sequential

ITA grafting3.

When the ITA is dissected as a skeletonized artery4, it becomes longer and its

spontaneous blood flow is probably greater5, 6 than that of the pedicled ITA, allowing the use of

both ITAs to almost all coronary territories requiring bypass. In many patients, no additional

vein grafts are required7. Another advantage of using ITA as a skeletonized artery is the

preservation of collateral blood supply to the sternum8, enabling more rapid healing, and

decreasing the risk of infection9, 10. The bilateral skeletonized ITA technique was adapted in our

service as the preferred method for myocardial revascularization11, 12. The purpose of the current

report is to analyze the impact of age on the outcome of the first 1714 consecutive patients in

whom we used this surgical technique.

Patients and Methods

From 1996 to 2001, 1714 consecutive patients underwent myocardial revascularization with

BITAs that were dissected as skeletonized arteries12. They comprised 73% of the 2346 isolated

CABG procedures for multi-vessel disease performed in the Tel Aviv Sourasky Medical Center

When the ITA is dissected as a skeletonized artery4, it becomes longer annnddd ititits

pontaneous blood flow is probably greater5, 6 than that of the pedicled ITA, allowing the use of

booththh IIITATATAsss tototo almmmoosost t all coronary territories requuuiriririnnng bypass. In mamm nyny pppaaatients, no additional

vveinnn grafts are e rereequuuirredede 77. AAAnononotththererr aaadvdvananntaggee oof uusiinng ITITITA A sass aa ssskekeleletotooninizezed d d aararteteryryry iiis s thththe e e

prpresesesererervavav titiononon oof f cccolllllatateeeraalal bblooododod sssupupuppplply y y totoo ttthhehe ssstetet rnrnnuumum888, , enenenabaablililingngng mmmororore e rarapipip d dd heheealalininingg,g, aandndnd

decreasing thehee rrrisiskk k ofofo iiinfnn eccctitit onoo 999, 101010. TThehehe bbbilililatataterereralalal ssskekekelel totoonininizezezed d d ITITITA A tetetechchchnininiquququee wawawas s s adadadapa ted in ourrr




4

during this period. Pre-operative and operative patients' data were collected from the hospital

medical records after Institutional Review Board approvals. In order to evaluate the effect of age

on early and long-term outcome, patients were stratified into three age groups: 65 years of age or

younger, between 66 and 75 years, and 76 years or older. In order to evaluate the operative-

period effect, patients were stratified according to their operative date into two groups: early

(1996 to 1999) and late (2000-2001).

Expected operative mortality was calculated using the "Logistic Euroscore"13 and

compared to the observed early mortality. Expected mid- and long-term mortality without

operation was calculated using the "Charlson Co-Morbidity Index" (C.C.I.)14, 15, 16 (Table 1) and

compared to the expected survival of the Israeli population of the same age and gender17 and to

the Kaplan-Meier actuarial survival. Follow-up was obtained using the Israeli National Registry

database and a telephone questionnaire.

Surgical Techniques

Operations were performed using standard cardiopulmonary bypass (CPB) or off-pump coronary

artery bypass (OPCAB). Myocardial preservation during CPB involved intermittent, antegrade

or retrograde blood cardioplegia (30°C-32°C). Coronary stabilization during OPCAB was

facilitated using CTS stabilizers (Curpentino, Calif.), or the Octopus system (Medtronic,

Minneapolis, Minn.). ITAs were mobilized from the chest wall as skeletonized vessels. In 1515

of the cases3, BITA were used to graft the left coronary system, i.e. the myocardial territory

supplied by the left anterior descending and circumflex arteries. Left-sided revascularization

was achieved using two basic arrangements: a free ITA (in most cases right ITA [RITA])

attached proximally end-to-side on the in-situ ITA (mostly left ITA) in a T-graft configuration

(composite T-graft) and an in situ BITA with an ante-aortic crossover Right Internal Thoracic

compared to the expected survival of the Israeli population of the same age and gggennndederr171717 aaandndnd ttoo

he Kaplan-Meier actuarial survival. Follow-up was obtained using the Israeli National Registry

daatataabababassese aaandndnd a tteleleleepephone questionnaire.

SSSurrgrgical Technhniqiqi ueuess

OpOpperere atatatioionsnss wwwereree pepeerfrfooormmemed d uususinininggg stststanandadadardrdrd cccardrdrdioioopupuulmlmmononnarararyy y bybybyppapassssss ((CCPCPB)B)B ooor r ofofo f-f-f-pupupummpmp cccororoononarary

artery bypass s (O(O(OPCPCPCABABAB).).) MyMyMyocococararardididialala ppprerer seseservrvrvaaatitit ononon dddururu innng gg CPCPCPBBB inininvovoolvlvvededed iiintntnterermimimittttttenennt,t,t, antegrade




5

Artery (RITA). The choice of configuration was determined by previously detailed technical

considerations18. The type of conduit selected for right coronary artery (RCA) grafting was not

related to the configuration of the ITAs. Our strategy was to use RITAs, Right Gastro-Epiploic

Arteries (RGEA) and Radial Arteries (RA) as grafts to the RCA branches only in the presence of

a significant stenosis (i.e. >80%)19. When the right coronary artery (RCA) system was unsuitable

for arterial grafting, such as in cases with a potential for high competitive flow in the RCA, we

selected saphenous vein grafts (SVG) as the conduit for revascularization of the RCA. To

decrease the risk of spasm of the arterial grafts, all patients were treated with a high-dose

intravenous infusion of isosorbide dinitrate (Isoket, 4 to 20 mg/h) during the first 48 hours

postoperatively. Calcium-channel blockers (Dilitiazem; 90 to 180 mg/d, orally) were given to

patients operated on using RGEA or RA from the second postoperative day for at least three

months12.

Definition of Terms and Data Collection

Patients' data were analysed according to ACC/AHA Clinical Data Standards20. Chronic renal

failure (CRF) was diagnosed if the creatinine level exceeded 1.8 mg/dL. PVD included all

symptomatic and asymptomatic extra-coronary arteriopathy. Cerebrovascular disease (CVD)

included past history of any cerebrovascular event with or without permanent neurological

damage. Our definition of "emergency operation" is based on the Society of Thoracic Surgeons

guidelines and includes patients operated on within 24 hours of cardiac catheterization, with

ongoing angina, acute evolving myocardial infarction, pulmonary edema or cardiogenic shock21.

Patients who needed emergency surgery and were not stabilized after intra-aortic balloon

counterpulsation were usually operated on using one ITA combined with SVGs and therefore

were not included (Table 2). A perioperative myocardial infarction was defined by the

postoperatively. Calcium-channel blockers (Dilitiazem; 90 to 180 mg/d, orally) ) wewewererr gggivivivenenen tto o

patients operated on using RGEA or RA from the second postoperative day for at least three

momontntnthshshs121212.

DDeffifinin tion of TeTeTermmms s anannddd DaDaDatatata CCColololleleccctiion

PaPatititienenntstst ' dadaatatata wweeeree e ananaalyysyseded aaaccccororordididingngg tooo AAACCCCCC/A/A/AHAHAHA CCCliliinininicacalll DaDaDataaa SSStataandddararddsds20202 .. CCChhrhrononniccc rrenennaall

failure (CRFF)) wawaw s s s dididiagagagnonn seseed d d ifif tttheheh cccrer atatatininnininne e e lelelevevevell l exexexceeeedededededed 111.8.8.8 mmmg/g/g/dLdLdL.. PPPVDVDVD iiincncnclululudeded d all




6

appearance of new Q waves in the ECG associated with elevated levels of creatine

phosphokinase-MB fraction >50 mU/ml. A cerebrovascular accident was defined as a new

permanent neurological deficit and computed tomographic evidence of cerebral infarction. Deep

sternal infection was defined as the sum of deep infection and late dehiscence requiring

sternectomy.

Statistical Analysis

Data are expressed as the mean + standard deviation or as a proportion. The 2 test and 2-sample

t tests were used to compare discrete and continuous variables, respectively. Multivariable

logistic regression analysis was used to predict early mortality and early morbidity events by

various risk factors. The odds ratios (ORs) and 95% confidence intervals (CIs) are given.

Postoperative survival of each age group was expressed by the Kaplan-Meier method and

survival curves were compared by the Log Rank test. Cox proportional hazard model was used

to evaluate the influence of preoperative variables (sex, period of surgery, age group, diabetes,

COPD, CHF, CRF, PVD, recent MI, old MI, acute MI, unstable angina, preop IABP, emergency

operation, EF<25%, number of vessels disease, left main disease), and operative data (repeat

operation, OPCAB, number of grafts, bypass time, aortic cross clamp time, composite T-graft),

on late and overall mortality. Cox model was used to compare adjusted survival between the

various age groups after controlling for differences between groups in preoperative and operative

characteristics. Results of Cox analysis were expressed as Hazard Ratios (HR) and the 95%

Confidence Interval (CI).

To present the expected annual survival of the general population based on our sample of

patients, we used the 2005-2009 Complete Life Tables published by the National Central Bureau

of Statistics17 to calculate the annual survival for each patient according to age and gender, up

various risk factors. The odds ratios (ORs) and 95% confidence intervals (CIs) aaarre ggivivvenenen.

Postoperative survival of each age group was expressed by the Kaplan-Meier method and

uurvrvvivivivalalal ccurururveves wewewerere compared by the Log Rank k k tetesst. Cox propoortrtr ionanaall l hhah zard model was used

oo eeevav luate the e inininflfllueennncee e ofofof ppprrreeoeopepeerararatitivevee varrriaaablesss ((sex,x,x, ppererriooodd oooff susurgrgeeeryyy, aaagegee ggrorooupupp, ddid abababetetteseses,,d

COCOOPDPDPD, , CHCHHF,F,F, CCRFRFRF,,, PVPVVDD,D, rrecccenennttt MIMIMI, , oolold dd MIMIMI, acacacututte MIMII,, unununsststababblelel angngngininaaa, ppprereeopopop IIABABABPP,P, eeemmemergrggennncycy

operation, EF<F<<25252 %,%,%, nnnumumumbebeberr ofofo vvvesese seseselsss dddisisiseaeaeasesese,, leleeftftf mmmaiaiinnn dddisisiseaeaasesese),) aaandndnd ooopepeperarar tiiiveveve dddatatataa a (repeat




7

to 15 years. In addition, we used the Charlson index formulation to calculate the expected ten

year survival of our patients, assuming no surgery was performed. The Charlson index

formulation estimates survival of people according to their age and certain co-morbidities

(Charlson index). It was validated for ten years survival14. For presentation purposes only, we

extended the Charlson index formulation principal to calculate the estimated annual survival of

each patient according to age and Charlson index, up to 15 years. The Charlson index

formulation uses a ten year survival of a 40 year old person with no co-morbidities (98%) as the

baseline survival for its calculations. We used the relative annual survival of a 40 years old

person taken from the Israeli complete life tables17 as the baseline survival, to calculate the

annual estimated survival of each patient without surgery. However, since the Charlson index

formulation was validated for ten years survival only, we performed formal statistical

comparison of survival between the expected general population survival, observed actuarial

survival, and estimated survival of the patients if no operation would have been performed, only

at ten years using a one sample t test.

Statistical analysis was performed using SPSS for Windows version 19. Statistical

significance was considered when p<0.05.

Results

Patients' preoperative characteristics by age groups are presented in Table 3. Patients'

characteristics by operative period are presented in Table 4. Table 2 compares patients'

preoperative and operative characteristics to those of patients with multi-vessel disease operated

on during the study period using single ITA (SITA). Operative mortality of the three age groups

(1.2%, 4.1% and 5.8%) was lower than the Logistic Euroscore predicted mortality (3.9%, 6.5%

annual estimated survival of each patient without surgery. However, since the CChhaharlrllsoon nn ininindededexxt

formulation was validated for ten years survival only, we performed formal statistical

coompmpmpararariisisononon ooof susuurvrvrvivi al between the expected geeenenen rral population sssuru vivivavavall, observed actuarial

uurvvvivi al, and esestitit mmamateted d sususurvrrvivivivaalal ooff f tththee ppaatiennnttss if nonoo opepeperaratitiionnn wwwouuuldld hhhavvve e bbebeenen ppperere fofoforrmmededed,, onononly

att tttenenen yyyeaearsrss uuusisingngng aaa oonnne ssamamplplplee ttt tttesesest.t. ttt

Statisstititicacacal l anananalallysysysis wwwasaa ppperererfofoformrmmededed uuusssinining g g SPSPSPSSSSS fffororor WWWininindododowswss vvvererersisisiononon 119.9.9 SSStatatatitiists ical




8

and 9.3%, respectively, p<0.001). COPD (O.R. 3.145, 95% C.I. 1.402-7.042, p=0.005),

preoperative old (O.R. 1.990, 95% C.I. 1.089-3.603, p=0.025) or acute (O.R. 2.915, 95% C.I.

1.570-5.405, p=0.001) MI, emergency operation (O.R. 3.39, 95% C.I. 1.855-6.211, p<0.001),

and EF <25% (O.R. 3.47, 95% C.I. 1.036-11.627, p=0.044) were independent predictors of

increased operative mortality. Age <65 was associated with reduced operative mortality (O.R.

0.236, 95% C.I. 0.098-0.566, p=0.001). Sternal infection occurred in 32 patients (1.9%) (Table

5). Increased prevalence of sternal complications was observed in patients with COPD (11.3%,

p<0.001), repeat operation (9.5%, p<0.001), PVD (3.5%, p=0.004). Diabetes (3.4%, p=0.001)

and patients operated on between 1996 and 1999 (early period 2.4%, p=0.001). Repeat operation

(O.R. 6.289, 95% C.I. 1.945-20.408, p=0.002), COPD (O.R. 9.524, 95% C.I. 4.255-20.276,

p<0.001), PVD (O.R. 2.155, 95% C.I. 1.036-4.484, p=0.04), Diabetes (O.R. 3.472. 95% C.I.

1.645-7.299, p=0.001), and early (1996-1999) operative period (O.R. 8.835, 95% C.I. 1.184-

65.910, p=0.034) were identified as independent predictors of sternal wound infection.

Mean follow-up was 11.5 years. Kaplan-Meier 10-year survival for patients <65, 66-75

and >75 years of age were 85%, 65% and 41%, respectively (p<0.001). They were better than

the corresponding predicted Charlson Comorbidity Index survivals (68%, 37% and 20%,

respectively, p<0.001) for all age groups, approaching survival of gender and age-matched

general population (90%, 70% and 40%, respectively) (Figs. 1,2). Predictors of decreased

survival (Cox model) (Table 6) were older age (Fig. 3, p<0.001), congestive heart failure,

diabetes, COPD, chronic renal failure, EF<25%, repeat operation, PVD, preoperative IABP

support and early operative period (Fig. 4, p=0.004).

Discussion

Surgical revascularization of the left anterior descending (LAD) artery with the internal thoracic

O.R. 6.289, 95% C.I. 1.945-20.408, p=0.002), COPD (O.R. 9.524, 95% C.I. 4.2255555-2-2- 0.0.0.2727276,6,6,

p<0.001), PVD (O.R. 2.155, 95% C.I. 1.036-4.484, p=0.04), Diabetes (O.R. 3.472. 95% C.I.

1..646445-5-5-7.77.2929299,9,9, pp=0=00 0.0.0010 ), and early (1996-1999) oopepep rraative period (O.OO R. 888 8.8.8353 , 95% C.I. 1.184-

6655.99910, p=0.03034)4)4 wwwereree ididdenenentititifififieded aaasss inindedeepenndndeeent pprpreediiccttotorsrs oof f ststerrnanal l wowowoununddd iininfefectctc ioioionn..

MeMeeananan ffolollolow-w-uupup wwasa 111.11 555 yeyeyeararss.s KaKaKaplplananan-M-MMeeieerer 1110-0-0-yeyeyearara sssururrviviv vvaaal fforor pppatatatieientntntsss <<66565,,, 66666-77755

and >75 yearrs s s ofofo aaagegege wwweree e e 858585%,%,, 6665%5%% aaandndnd 4441%1%1%, , rererespspspecece titiivevevelylyly ((p<p<p<0.00 0000001)1)1).. TTTheheh y y y wewewererere bbbete ter than




9

artery (ITA) in patients with multi-vessel disease, is still the only proven method of improving

event-free survival22, 23. ITA grafts, because of their resistance to atherosclerosis, have better

long-term patency than saphenous vein grafts and this improved patency of ITA grafts is

believed to be responsible for the better survival and decreased recurrence of angina and the need

for reintervention when they are used to bypass the LAD24.

Bilateral ITA (BITA) grafting is associated with improved survival, compared to single

ITA and saphenous vein (SVG) grafting25. Besides improved survival, BITA patients had better

event-free survival and reduced occurrence of re-interventions25. Despite the improved long-

term outcome, the application of this technique in the elderly remains controversial due to their

shorter life expectancy and in view of the excellent survival benefit obtained with single ITA. In

addition, BITA grafting was associated with increased risk of sternal dehiscence and sternal

infection26, 27, 28 associated with the more extensive devascularization caused by harvesting two

ITAs29, 30.

In a later study by Lytle and associates2, the number of patients older than 60 years

operated on with bilateral ITA grafts was relatively small; however, bilateral ITA grafting

improved survival of this subset of older patients when compared with patients older than 60

years with a single ITA graft.

In the above and other series31, 32, extensive arterial grafting with bilateral ITAs was used

preferentially in a selected group of young male non-obese non-diabetic patients. Patients were

preselected for BITA grafting according to their life expectancy, and only few of the patients

older than 70 years were offered the option of bilateral ITA grafting. The only large series (1467

patients) comparing bilateral with single ITA grafting in elderly patients was reported by Galbut

and associates33, 34. In Galbut's study, patients with bilateral ITAs had a lower hospital mortality

horter life expectancy and in view of the excellent survival benefit obtained wiiththh ssinini glglgle e ITITITA.AA. Inff

addition, BITA grafting was associated with increased risk of sternal dehiscence and sternal

nnfefeectctctioioionn26,26,26, 272727, 2, 8 aaassssssoociated with the more extenssivivivee devascularizatattioi n cacacauuused by harvesting two

TTAAsAs29, 30.

InIn aaa lllataterer sttutudydyy bbby y y LyLyytltt e e ananand d d asassososociciciatatatesss22,, ththhee nuuumbmbmbeerer ooof f f papapatitiienenentstss oololdedeer rr ththhanann 666000 yyeyeaarars s

operated on wiwiwiththth bbbilillatatateeerarar l ITITITA AA grgrgrafafa tststs wwwasasas rererelalalatitit vevevelylyy sssmamaallllll;; hohohowewewevevv r,r,r, bbbilililatataterereralala IIITATATA gggraraaftf ing




10

(3.1%) than patients with a single ITA (6.4%), and the late survival (mean 43 months) was better

as well (69.7% vs 60.7%).

Unlike in the above reports, in our series and that of Galbut and coworkers33, old age was

not a contraindication for BITA grafting. In our study, complete arterial grafting with bilateral

ITAs was the preferred method of myocardial revascularization for all age groups. During the

study period bilateral ITA grafting was performed in 61% of the patients referred for CABG, and

41% of them were 70 years or older.

Although this is a selected group of patients (Table 2), mortality and morbidity of our

patients 70 years or older (3.7%) compared favorably with mortality described in procedures in

which one ITA was used1.

In the report by Lytle and colleagues2, the only morbid event that differed between the

bilateral and single ITA groups was the difference in sternal wound complication (2.5% and

1.4%, respectively). Harvesting the ITA as a wide musculo- fascial pedicle with the aid of

electrocautery was shown to devascularize sternal collateral blood supply and expose the sternum

to increased risk of poor healing, dehiscence, and infection30. The problem of poor healing due

to insufficient collateral blood supply may be more important in the elderly patient. The sternum

of elderly patients is sometimes more fragile because of osteoporosis and suboptimal blood

supply.

Collateral blood flow to the sternum can be significantly improved by using the

skeletonization technique when harvesting ITAs for BITA grafting4, 5. This new technique of

ITA harvesting was already used in patients in the recently published ART trial. The ART trial

is an ongoing randomized multicenter trial where 3102 patients were randomized to receive

either BITA or SITA during CABG, with a primary outcome of survival at 10 years. Currently,

which one ITA was used1.

In the report by Lytle and colleagues2, the only morbid event that differed between the

biilalaateteterararalll ananandd d ssingngglelele IITA groups was the differenncecece iinn sternal woununnd d coompmpmplication (2.5% and

11..4%%%, respectiivevelyly)). HHHarrr evevesststinining g ththhee e ITITA A as aaa wwwideee mmmusscscuululoo-- fffasasccciaall pepeddid ccle e wiwiwithth ttthehehe aaididid ooofff

ellececectrtrrococo auauteteterryry wwasss sshohoowwnwn too dededevavavascscscululaararizizizeee ssstererrnanan lll ccoollllatatterereralaal bbblololooodod sssupupu ppplyy y anannd d exexe popopossse ttthehee ssteteernnnumu

o increased ririisksksk ooof f f popopoororor heaeaealililingngg, ,, dededehihh scsccenenencecee,, ananandd d inininfefef ctttioioionnn303030.. TTThehh ppprorooblblblememem oof f f popopoororor hhheae ling due




11

only one year follow up is available35. Perioperative mortality was similar between groups

(1.2%) and one year survival was not significantly different between groups.

Sternal wound reconstruction was higher in the BITA group (1.9%) compared to the SITA group

(0.6%).

The authors concluded that BITA grafting is feasible. They also stressed that this are

only early data from a long-term trial and follow-up will, in time, provide more definitive

evidence on survival and morbidity.

The sternal wound reconstruction rate of the BITA group in the ART trial is identical to

the occurrence of sternal complications in our previous publication describing routine use of

skeletonized BITA grafting in a cohort of 1515 patients3. Occurrence of sternal complications

(deep infection and dehiscence) in that study in patients older than 70 years was not significantly

different than that of younger patients, and old age was not found to be an independent predictor

of sternal complications.

A larger cohort of patients with longer follow-up is described in the current report.

Occurrence of sternal complications in the three age groups was similar (1.3%, 2.4% and 1.4%,

respectively, for ages <65, 66-75 and >75). The observed hospital mortality increased with

increase in age (1.2%, 4.1% and 5.8%, respectively, for the three age groups in our report).

However, it was significantly lower than the Euroscore calculated mortality (3.7%, 8.1% and

17.2%, p<0.001). Moreover, the actual ten year survival (Kaplan-Meier), as well as risk-

adjusted (COX) survival estimates, are significantly better than the calculated Charlson's index

ten year survival for all age groups (<65, 66-75 and >75), suggesting significant survival benefit

in BITA grafting, especially in the older age groups (Figs. 1,2), despite the fact that older age

was associated with significantly decreased long-term survival.

keletonized BITA grafting in a cohort of 1515 patients3. Occurrence of sternal l cccompmpmpliliicacacatititionono ss

deep infection and dehiscence) in that study in patients older than 70 years was not significantly

diifffffereerenenenttt thththananan thahaatt t oof younger patients, and old agagage wwas not found d tot bbe ee aanan independent predictor n

off sssteternal commplpllicii aaatioionsns.

AA lalaargrgrgerer ccoohohororrtt oofof ppatattieientntntsss wiwiw ththh llonononggger rr fofof lllllooww--u-up pp isisis desesescrcrribbbededed iinnn ttthehe cccurururrerentntnt rrepepporrrt.t.

Occurrence oof f f ststs ererrnananal cococompmppliliicacac tititionono ss s ininn ttthehehe ttthrhrhreeeee aaagegege gggroooupupupsss wwwasasas ssimmmilillararar (((1.1.1.3%3%3%,, , 2.2.2.4%4%4% and 1.4%,




12

In an effort to reduce the risk of sternal complications, we analyzed our long-term

survival results and became more careful, in the later period, in patient selection for BITA

grafting, especially in diabetic patients with COPD, repeat operations, female gender and

obesity3, 12, 18, 36, 37. The decreased prevalence of COPD and obese diabetic females in the later

period may be the explanation for decreased occurrence of sternal complications in that period.

Limitations:

1. This is a retrospective study and potential long-term benefits of BITA for elderly patients

could not be demonstrated without comparing its outcome to that of CABG procedures

incorporation one ITA and other conduits, such as SVG or radial arteries.

2. Postoperative angiograms and coronary CT angiograms were available only in a small

number of patients, mostly in symptomatic patients. Therefore, they could not be included in

this report.

In conclusion, our study suggests that the survival benefit of BITA grafting for all age

groups outweighs the early adverse effect of sternal wound complications. Occurrence of these

complications can be reduced by selective use of BITA grafting in patients undergoing CABG

procedures.

Further studies are required to compare long-term outcome of BITA versus single

internal thoracic artery (SITA) in elderly patients.

Conflict of Interest Disclosures: None.

References: 1. Leavitt BJ, Olmstead EM, Plume SK, Charlesworth DC, Maislen EL, James TW, Baribeau YR, Quinn R, O'Connor GT. Use of the internal mammary artery graft in Northern New England Cardiovascular Disease Study Group. Circulation. 1997;96:11-32-36.

ncorporation one ITA and other conduits, such as SVG or radial arteries.

2. Postoperative angiograms and coronary CT angiograms were available only in a small

nuumbmbmbererer oofff papap tit ennntststs, mostly in symptomatic patienenentss. Therefore, tthehh y cocoouululd not be included in

hhhiss rreport.

InIn ccconononclcluuusiioion,n,, ouurur sstuuudydydy sssuguguggegeststs s ss thththaaat tttheheh ssuururvvivivi alalal bbbennnefefe iitit oooff f BIBIITTAA gggrararaftftf ininng g g fforr r allll l agagge

groups outweweigigighshsh tttheheh eeearaa lyyy aaadvdvd erererseses eeeffffecece tt t ofofof ssstterere nananal l wowow ununund d d cococompmpmplicacacatititiononons.s.s OcOcccucucurrrrrrenenencec of these




13

2. Lytle BW, Blackstone EH, Loop FD, Houghtaling PL, Arnold JH, Akhrass R, McCarthy PM, Cosgrove DM. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117:855-872. 3. Pevni D, Uretzky G, Mohr A, Braunstein R, Kramer A, Paz Y, Shapira I, Mohr R. Routine use of bilateral skeletonized internal thoracic artery grafting: long-term results. Circulation. 2008;118:705-712. 4. Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection. Ann Thorac Surg. 1992;54:947-950. 5. Choi JB, Lee SY. Skeletonized and pedicled internal thoracic artery grafts: effect on free flow during bypass. Ann Thorac Surg. 1996;61:909-913. 6. Wendler O, Tscholl D, Huang Q, Schafers HJ. Free flow capacity of skeletonized versus pedicled internal thoracic artery grafts in coronary artery bypass grafts. Eur J Cardiothorac Surg. 1999;15:247-250. 7. Tector AJ, Kress DC, Downey FX, Schmahl TM. Complete revascularization with internal thoracic artery grafts. Semin Thorac Cardiovasc Surg. 1996;8:29-41. 8. Parish MA, Asai T, Grossi EA, Eposito R, Galloway AC, Colvin SB, Spencer FC. The effects of different techniques of internal mammary artery harvesting on sternal blood flow. J Thorac Cardiovasc Surg. 1992;104:1303-1307. 9. Calafiore AM, Vitolla G, Iaco AL, Fino C, Di Giammarco G, Marchesani F, Teodori G, D'Addario G, Mazzei V. Bilateral internal mammary artery grafting: midterm results of pedicled versus skeletonized conduits. Ann Thorac Surg. 1999;67:1637-1642. 10. Sofer D, Gurevitch J, Shapira I, Paz Y, Matsa M, Kramer A, Mohr R. Sternal wound infection in patients after coronary artery bypass grafting using bilateral skeletonized internal mammary arteries. Ann Surg. 1999;229:585-590. 11. Lev-Ran O, Paz Y, Pevni D, Kramer A, Shapira I, Locker C, Mohr R. Bilateral internal thoracic artery grafting: midterm results of composite versus in-situ crossover graft. Ann Thorac Surg. 2002;74:704-711. 12. Gurevitch J, Kramer A, Locker C, Shapira I, Paz Y, Matsa M, Mohr R. Technical aspects of double-skeletonized internal mammary artery grafting. Ann Thorac Surg. 2000;69:841-846. 13. Roques F, Michel P, Goldstone AR, Nashef SA. The Logistic EuroSCORE. Eur Heart J. 2003;24:882-883. 14. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40:373-383.

7. Tector AJ, Kress DC, Downey FX, Schmahl TM. Complete revascularizationn wwititi hh h inininteteternrnrnalal horacic artery grafts. Semin Thorac Cardiovasc Surg. 1996;8:29-41.

8. Parish MA, Asai T, Grossi EA, Eposito R, Gaalloway AC, Colvin SB,, Spencer FC. The effectsoff dddifififfefefererentntnt ttteeechnhnniqiqiquues of internal mammary artererery y harvesting on n stss errnanaall l blb ood flow. J Thorac CaCaCardrddioi vasc SSSururggg.. . 191992922;1;1;1040404:1:1303003-3-3 13130707..

9.9.. CCCala afiore AAMM,, VVVitoollaaa GG, , Iaaacoco AAL,L,L FFininno CCC, Di GGGiaiammmmmmaararccoco G, MMMarchhehesasannni FF, Teeeododdororri GG, D'D'AdAdAddadadaririoo G,G,G, MMazazazzezeii V.V. BiBilalalateteerararalll inininteteernrnnalalal mmmamamammamamaryry aartrtrterereryyy grgrgrafafftitingngng:: mimimidtdtererrm m m reresususulltlts oofof ppededdiccleledversrsusus skekeleletooninized d cocondduiuits. AnAnn n ThT oracac SSururg. 11999;9;6767:1:163637-7-1664242..

1010 SoSofeferr DD GGururevevititchch JJ ShShapapiriraa II PPazaz YY MaMatstsaa MM KKraramemerr AA MMohohrr RR StSterernanall wowounundd




14

15. Li B, Evans D, Faris P, Dean S, Quan H. Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases. BMC Health Serv Res. 2008;8:12. 16. Schmidt M, Jacobsen JB, Lash TL, Botker HE, Sorensen HT. 25-year trend in first-time hospitalization for acute myocardial infarction, subsequent short and long-term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study. BVMJ. 2012;344:e.356. 17. Israel Central Bureau of Statistics: Population and Demography: Health. Complete Life Tables of Israel, 2005-2009. Publication No. 1450, Israel Central Bureau of Statistics, 2011. 18. Pevni D, Mohr R, Lev-Ran O, Paz Y, Kramer A, Frolkis I, Shapira I. Technical aspects of composite arterial grafting with double skeletonized internal thoracic arteries. Chest. 2003;123:1348-1354. 19. Sabik JF, III, Blackstone EH. Coronary artery bypass graft patency and competitive flow. JAm Coll Cardiol. 2008;51:126-128. 20. Radford MJ, Arnold JM, Bennett SJ, Cinquegrani MP, Cleland JG, Havranek EP, Heidenreich PA, Rutherford JD, Spertus JA, Stevenson LW, Goff DC, Grover FL, Malenka DJ, Peterson ED, Redberg RE; American College of Cardiology; American Heart Association Task Force on Clinical Data Standards; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Failure Society of America. ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Heart Failure Clinical Data Standards): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung transplantation: endorsed by the Heart Failure Society of America. Circulation. 2005;112:1888-1916. 21. Clark RE for the Committee for the National Database for Thoracic Surgery: The STS Cardiac Surgery National Database: an update. Ann Thorac Surg. 1995;59:1376-1380. 22. Loop FD, Lytle BW, Cosgrove DM. Influence of internal mammary artery graft on 10 year survival and other cardiac events. N Eng J Med. 1986;314:1-6. 23. Barner HB, Swartz MI, Mudd JG, Tyras DH. Late patency of the internal mammary artery bypass conduit. Ann Thorac Surg. 1982;34:408-412. 24. The BARI Investigators. The final 10 year follow up results from the BARI randomized trial. J Am Coll Cardiol. 2007;49:1600-1606. 25. Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularization on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001;358:870-875.

Am Coll Cardiol. 2008;51:126-128.

20. Radford MJ, Arnold JM, Bennett SJ, Cinquegrani MP, Cleland JG, Havranekek EEEPPP, Heidenreich PA, Rutherford JD, Spertus JA, Stevenson LW, Goff DC, Grover FL, Malenka DJ, Peterson ED,, Redberg RE; American College of Cardiology; American Heart Association Task Foorcrcrcee oonon CCClililinnnicaaall l DDData Standards; American Cololllelel ggge of Chest Phhysyy iciaiaansnsns; International Society fofoor HHeHeart annd dd LuLungngng TTraraansnsnsplplplanantataatititionono ; ; HeHearart t FaFaililuru eee SSociietetety y y ofoo AAmememeriricaca. . AAACCCC/A/AAHAHAH kkeyeyey ddatatataa a ellemmments and ddefefefinnnittioioionsnss ffforoor mmmeaeasususurriringngg ttthe cccliinicaaal mmaananaagagememmenentt aannd d ououuttccomommeeses oofff papaatitiieenentststs wwwitthhh chchhrooonin c hearrt t failluurre: aa rrrepoorrt ofo tthee AAmemericcaannn Cooolllegege e e ofofof CCCarrrdiooolooogy/AmAmAmererricccanan HHHeaeaartrt AsAssosos ciciciatatioionn n TaTTaskskk FFFororccce oonn CClClininnicicicalalal DDaatata aa StStStanana dadadardrddss (W(WWririitititinngng CCComommmimimitttteeee ttoo DeDeDevevev lololoppp HHeeaarart tFaililurure e ClClininicalal Datata a SStannddardrds)s): ded veloopeped d inin cocollabbororatatioion n wiw thh tthehe AAmemeriricacan n CoC lllegege ofof CCheestPhysicians aandndd ttthehee IIIntntntererernanatititionononaal l l SoSoS cicic ettty y y fofofor r r HeHeHeararrt t ananand d LuLuLungngng ttrrranananspsplalalantntntatata ioioion:nn eeendndndorororsesesed d by the HeHearartt FaFaililururee SoSocicietetyy ofof AAmemeriricaca CiCircrcululatatioionn 2200005;5;11112:2:18188888 1-1919166




15

26. Lytle BW, Cosgrove DM, Loop FD, Borsh J, Goormastic M, Taylor PC. Perioperative risk of bilateral internal mammary artery grafting: analysis of 500 cases from 1971-1984. Circulation. 1986; 74:III37-III41. 27. Kouchoukaos NT, Wareing TH, Murphy SF, Pelate C, Marshall WG Jr. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg. 1990;49:210-219. 28. Borger MA, Rao V, Weisel RD, Ivanov J, Cohen G, Scully HE, David TE. Deep sternal wound infection risk factors and outcomes. Ann Thorac Surg. 1998;65:1050-1056. 29. Arnold M. The surgical anatomy of sternal blood supply. J Thorac Cardiovasc Surg.1972;64:596-610.

30. Carrier M, Gregoire J, Tronc F, Cartier R, Leclerc Y, Pelletier LC. Effect of internal mammary artery dissection on sternal vascularization. Ann Thorac Surg. 1992;53:115-119.

31. He GW, Acuff TE, Ryan WH, Mack MJ. Risk factors for operative mortality in elderly patients undergoing internal mammary artery grafting. Ann Thorac Surg. 1994;57:1453-1460. 32. Buxton BF, Komeda M, Fuller JA, Gordon I. Bilateral internal thoracic artery grafting may improve outcome of coronary artery surgery. Circulation. 1998;98(Suppl.):II-1-6.

33. Galbut DL, Traad EA, Dorman MJ, DeWitt PL, Larsen PB, Kurlansky PA, Carrillo RG, Gentsch TO, Ebra G. Coronary bypass grafting in the elderly: single versus bilateral internal mammary artery grafting. J Thorac Cardiovasc Surg. 1993;106:128-135. 34. Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Zucker M, Ebra G. Thirty-year follow-up defines survival benefit for second internal mammary artery in propensity-matched groups. Ann Thorac Surg. 2010;90:101-108. 35. Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM, Campbell H, Flather M: ART Investigators. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). Eur Heart J. 2010;20:2470-2481. 36. Matsa M, Paz Y, Gurevitch J, Shapira I, Kramer A, Pevny D, Mohr R. Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus. J Thorac Cardiovasc Surg. 2001;121:668-674. 37. Lev-Ran O, Mohr R, Amir K, Matsa M, Nesher N, Locker C, Uretzky G. Bilateral internal thoracic artery grafting in insulin-treated diabetics: should it be avoided? Ann Thorac Surg. 2003;75:1872-1877.

patients undergoing internal mammary artery grafting. Ann Thorac Surg. 1994;577:1:1145454 3-3-14146060..

32. Buxton BF, Komeda M, Fuller JA, Gordon I. Bilateral internal thoracic arterry y grgrgrafaftititingngng mmmayay mprove outcome of coronary artery surgery. Circulation. 1998;98(Suppl.):II-1-6.

333. . GaGaGalblblbututut DDDLLL, TTTrararaada EA, Dorman MJ, DeWitt PPLPL,, Larsen PB, KKKuru laansnsnskkyky PA, Carrillo RG,GeGeGentntntsch TOTO,, EbEbraraa GG.. CCCororronono arary yy bybybypapap ssss ggraraftftining g innn tthe elelldedederlrlr y:y sssinininglglg e e veveersrsr uss bbilililatatatereralal iintntnterernananal l mmammmm ary arteeryry ggraraftftftiningg.g. JJ J ThThThororaacac CCaararddiovvvasssc SSuurrrg. 1199999333;11006:6:121228-8 13131355.

3444. KuKuKurlrlananskskskyy PAPAA,, TrTraaaad d d EAEAA,,, DoDoDormrmrmanann MMMJJ,J, GGGalalalbububut DLDLDL, , ZuZuZucckckererer MMM, EbEbE rrara GGG. TTThhihirtrty-y-y-yyeyeaarar fffolollolooww-w-up ddefefini ess ssurrvivivaal l bebenefifit t foor r seseccond intnterernanall mmaammamaryry aartrterery y inn pproropep nsnsiti y-y-mamatct hehedd grrououpsp . Ann Thorac SSSurururg.g.g 2220101010;0;;9000:1:1: 0100 -1-11080808..




16

Table 1. Charlson’s Comorbidity Index.

Assigned weights for diseases Conditions 1 Myocardial infarction 1 Congestive heart failure 1 Peripheral vascular disease 1 Cerebrovascular disease 1 Dementia 1 Chronic pulmonary disease 1 Connective tissue disease 1 Ulcer disease 1 Mild liver disease 1 Diabetes 2 Hemiplegia 2 Moderate or severe renal disease 2 Diabetes with end organ damage 2 Any tumor 2 Leukemia 2 Lymphoma 3 Moderate or severe liver disease 6 Metastatic solid tumor 6 AIDS Assigned weights for each condition that a patient has. The total equals the score. Example: chronic pulmonary (1) and lymphoma (2) = total score (3).

2 Moderate or severe renal disease 2 Diabetes with end organ damage 2 Any tumor 2 Leukemia 2 Lymphomamama 3 3 MoModed raratete oorrr seveverere lliverr dddiisiseaasese 66 MMMetaaastttaticcc ssooliddd tttumummoorr 6 6 AAAIDSS AsAssisiigngngnededed wwweieieighghghtsts fffooor eeeacachh h cooondndn itiooon nn ththhatat aaa ppatatieiei ntntnt hhhasaa . TTThehehe toootatal l eqeqequauaualslsl tthehehe sscococ rerere. EEExaaampmpm lelele:: chchchrororonininicc pupupulmmmononaarary y (1(1( )nd lylympm ohomam (2)2 = tototalal scoree (3)).




17

Table 2. Patients' Characteristics by surgical technique (SITA vs. BITA for Multi-Vessel Disease, 1996-2001).

P BITA (n=1714)

SITA (n=632)

Prevalence

% N % N % N Risk Factor 43.6 748 37.3 236 39.7 982 Age <65 40.1 688 41.1 259 40.3 947 Age 66-75 (0.002) 16.2 278 21.7 137 17.7 415 Age 76+

0.000 22.6 237 33.7 213 25.6 600 Female 0.01 32.7 561 39.9 252 34.7 813 Diabetes

0.000 5.7 97 16.2 99 3.4 196 COPD 0.000 25.5 437 15.1 92 22.8 529 CHF 0.004 7.4 127 11 67 8.4 194 CRF 0.142 41.6 713 38.1 241 40.7 954 Old. MI >1 week 0.324 22.5 386 21.5 136 22.3 522 Acute MI < 1 week 0.000 57.9 992 82.1 518 64.4 1510 Unstable Angina 0.043 8.9 153 6.6 42 8.3 195 EF < 30% 0.002 5.8 100 9.5 60 6.8 160 Preop. IABP 0.006 15.4 264 20 126 16.6 390 Emergency op. 0.004 2.5 42 4.7 30 3.1 72 Repeat operation 0.000 9.0 154 14.2 90 10.4 244 Chronic CVD 0.141 25.2 432 22.9 145 24.6 577 PVD 0.001 76.5 1310 69.9 441 74.7 1751 3 Vessel Disease 0.001 74.5 1277 66.6 421 72.9 1698 Bypass Grafts >3 0.486 27.1 464 27.3 172 27.1 636 Left Main 0.052 20.7 354 17.6 111 19.8 465 OPCAB

Abbreviations: IDDM: Insulin-dependent diabetes mellitus;COPD: Chronic obstructive pulmonary disease; CHF: Congestive heart failure; CRF: Chronic renal failure; MI: Myocardial infarction; EF: Ejection fraction; IABP: Intra-aortic balloon pump; SITA: Single internal thoracic artery; BITA: Bilateral internal thoracic artery; OPCAB: Off-pump coronary artery bypass grafting; PVD: Peripheral vascular disease; CVD: Cerebro-vascular disease *Critical preoperative state: any one or more of the following: ventricular tachycardia or fibrillation or aborted sudden death, preoperative cardiac massage, preoperative ventilation before arrival in the anaesthetic room, preoperative inotropic support, intra-aortic balloon counterpulsation or preoperative acute renal failure (anuria or oliguria<10 ml/hour).

0.0.0.3232324 4422222 5.5.5 386 21.5 136 22.3 522 Acute MI < 1 week 0.0.0 00000000 057577.9.9.9 992 82.1 518 64.4 1510 Unstable Angina0.043 8.9 153 6.6 42 8.3 195 EF < 30% 0.002 5.8 10100 9.5 60 6.8 160 Preop.p. IABA PP0.006 15.4 26262644 20 126 16.66 390 EmEmmererrgegenccy y y oopop.0.0.0 0000004 42.2.2.555424242 4.4.777303030333.11 72722 RRReppepeat operaratitiononon 0.0000000 9.000 151554 114.222990 0 0 1000.4 2424444CChC roroonic CVDD0.0.11141125255.2.22 4343432 2222222.9.99 11445 552444.6.6. 57575 777PVPVVD D D 00.000011776.5 131 100 6969.99 444411774.77 1751 3 VeVesss el DDisi eaase 0.001 747474.5.55 121212777777 666666.6.66 42424 111727272.9.99 1616698988 Bypass Graaftftfts ss >>>333




18

Table 3. Patients characteristics and age groups (N= 1714).

Factor Total Age < 65 Age 66-75 Age > >75 P No. 748 43.6% 688 40.1% 278 16.7% Age (mean±SD) 65.6±10.9 56 ± 7.2 70 ± 2.8 79.3 ± 3.3 <0.001 Female gender 386 22.5% 114 15.2% 180 26.2% 92 33.1% <0.001 NIDDM 529 30.9% 212 28.3% 242 35.2% 75 27% 0.006 IDDM 34 2% 19 2.5% 15 2.2% 0 0% 0.031 COPD 97 5.7% 33 4.4% 49 7.1% 15 5.4% 0.083 Congestive heart failure 437 25.5% 153 20.5% 182 26.5% 102 36.7% <0.001 Chronic renal failure 127 7.4% 33 4.4% 53 7.7% 41 14.7% <0.001 Peripheral vascular disease 432 25.2% 142 19% 189 27.5% 101 36.3% <0.001 Cerbero-vascular disease 154 9% 39 5.2% 71 10.3% 44 15.8% <0.001 EF 25% 27 1.6% 12 1.6% 7 1.0% 8 2.9% 0.109 EF<30% 153 8.9% 56 7.5% 66 9.6% 31 11.2% 0.137 3-vessel disease 1310 76.5% 552 73.8% 538 78.2% 220 79.4% 0.177 Acute MI 1wk 386 22.5% 184 24.6% 148 21.5% 54 19.4% 0.151 Old MI >1 wk 713 41.6% 301 40.2% 287 41.7% 125 45% 0.393 Unstable angina pectoris 992 57.6% 409 54.7% 397 57.7% 186 66.9% 0.002 Left main disease 464 27.5% 162 21.7% 200 29.1% 102 36.8% <0.001 Preop. IABP 100 5.8% 40 5.3% 37 5.4% 23 8.3% 0.166 Critical preoperative state 114. 6.7% 45 6.0% 43 6.3% 26 9.4% 0.140 Emergency operation 264 15.9% 108 14.4% 100 14.5% 56 20.1% 0.057 Repeat operation 42 2.5% 17 2.3% 17 2.5% 8 2.9% 0.855 Early operative period 1287 75% 567 76% 526 77% 194 70% 0.08 Logistic Euroscore (Mean±SD) 7.7 ±9.6 3.7 ± 3.8 8.1 ± 8.3 17.2 ± 15.0 <0.001 Charlson Comorbidity index score (Mean±SD)

2.03 ±1.60 1.74 ± 1.42 2.13 ± 1.66 2.56 ± 1.75 <0.001

OPCAB 354 20.7% 140 29.7% 137 20.0% 77 27.7% 0.006 Bypass grafts 3 1288 75.1% 590 78.9% 516 82.5% 182 65.4% 0.002 Composite T-graft 1023 59.7% 429 57.4% 415 60.3% 179 64.4% 0.113 NIDDM=noninsulin-dependent diabetes mellitus; IDDM=insulin dependent diabetes mellitus; lure; MI= myocardial infarction; EF= ejection fraction; IABP= intra-aortic balloon pump.

3-vessel disease 1310 76.5% 552 73.8% 538 78.2% 220 7779.9.4%4% 00.17Acute MI 1wk 386 22.5% 184 24.6% 148 21.5% 544 19.9.9.4%4%4% 00.15Old MI >1 wk 713 41.6% 301 40.2% 287 41.7% 12255 45455%%% 000.39393Unstable angina pectoris 992 57.6% 409 54.7% 397 57.7% 186 66.9% 0.00Leftft mmaiainn did seseeasa e e 464 27.5% 16622 21.7% 200 29299.1.1. % 102 36.8% <0.0Prreeoeopp.p. IIABBPPP 100 5.8% 4400 5.3% 377 7 5.5.4%4% 23 8.3% 0.16CCrCritticical preoppereratatatiiviveee ststtaatate e 1111114.4. 66.77. % %% 454 666.0.0.0%%% 4434 666.3.3% 262626 999..4.4%%% 0.0 14EmEmE eere gency opperatttioion 264 4 1515..9% 10888 1414.4.4.4%%% 10000 144.55%% 56 22000.1%% 000.05ReReepepep atatat oopeperaraatititionon 424242 22.5.55% % % 1717 22.3.33%%% 11717 222.555% % 88 2..9%%% 000.8. 5Earlrly y opoperratativi e e pep riodod 1128287 7 7575%% 565677 7676% % 52266 777 % % 19194 4 707 % % 0.0.0Logistic Eurososcococorerer (((MeMeMeananan±S±SD)D)D) 777.7.77 ±9.9.9.6 6 3.3.3 777 ±±± 3.3..8 88 8.8 111 ±±± 8.8.8.333 171717.2.2.2 ±±± 115.0 <0.000ChCh ll CC bibididit ii dd 22 0303 ±11 6060 11 7744 ± 11 4242 22 1133 ± 11 6666 22 5566 ± 11 7575 <00 000




19

Table 4. Patients' characteristics and operative period (early vs late)

Patient characteristics Early (1996-1999) N=128

Late (2000-2001) N=427

P

Female 306 (23.8%) 80 (18.7%) 0.017 Emergency op. 214 (16.6%) 60 (11.2%) 0.008 Left main 333 (25.9%) 131 (30.8%) 0.029 COPD 80 (6.2%) 17 (4%) 0.05 MI (Old+Acute) 796 (61.8%) 221 (51.85) <0.001 Acute MI 319 (24.8%) 67 (15.7%) <0.001 EF<30% 128 (9.95) 25 (5.9%) 0.005 Repeat operation 39 (3%) 3 (0.75) 0.003 OPCAB 181 (14.1%) 173 (40.6%) <0.001 2VD 291 (22.6%) 76 (17.8%) 0.002 Bypass No. 2 271 (21.1%) 164 (36.1%) <0.001 Composite graft 807 (62.7%) 216 (50.6%) <0.001 Abbreviations: COPD: Chronic obstructive pulmonary disease; MI: Myocardial infarction; EF: Ejection fraction; OPCAB: Off-pump coronary artery bypass grafting

Table 5. Morbidity and Mortality By Age Group

Factor Total Age <65 Age 65-75 Age >75 P No. % No. % No. % No. %30 day mortality 53 3.1 9 1.2 28 4.1 16 5.8 <0.001 Deep sternal infection 32 1.9 10 1.3 18 2.6 4 1.4 0.171 Postop. CVA 53 3.1 12 1.6 31 4.5 10 3.6 0.006 Periop. MI 18 1.1 5 0.7 0 1.3 4 1.4 0.387 3 year actuarial survival 93+10 95.8+7% 88.1+12 77.5+25 0.001 5 year actuarial survival 88+10 94.1+9% 81.5+15 69.6+28 <0.001 10 year actuarial survival 70+10 84.7+13% 65.5+18 40.9+30 <0.001 CCI-10 year predicted survival

48+8 69+10 38+10 20+10 <0.001

NNNo.o %%% NoNo. %%% NNo.. %% NoNo.. %%

yp ( ) ( )Composite graft 807 (62.7%) 216 (50.6%) <0<0<0.0.0.0010101 Abbreviations: COPD: Chronic obstructive pulmonary disease; MI: Myocardial infarction; EF: EjEjececectitioonon fffraraactctc ioioion;n;; OPCAB: Off-pump coronary artery bypass grafting

TTTabblble 5. Moorbrbidididiitityyy anananddd MoMoMortrttalalalititity y y ByByBy AAAggege GGGrorooupu

FaFaactcttororo TTTototalal AAgegege <<656565 AAggege 6665-5 757575 AAAgege >>>7775 PP

30 day morrtatatalililitytyty 53535 333.1.11 999 11.2.2.2 222888 4.4.4.111 161616 555.8.8.8 <0.001 D l i f i 32 1 9 10 1 3 18 2 6 4 1 4 0 171




20

Table 6. Independent predictors for overall mortality

P Age <65 HR 0.236, 95% C.I. 0.191-0.299 <0.001 Age 66-75 HR 0.503, 95% C.I. 0.417-0.606 DM HR 1.526, 95% C.I. 1.317-1.811 <0.001 COPD HR 1.652, 95% C.I. 1.333-2.288 0.037 CHF HR 1.834, 95% C.I. 1.449-2.212 <0.001 CRF HR 1.360, 95% C.I. 1.067-1.731 0.031 PVD HR 1.801, 95% C.I. 1.538-2.114 <0.001 IABP HR 1.626, 95% C.I. 1.074-1.980 0.001 Redo HR 1.623, 95% C.I. 1.076-2.445 0.021 EF 25 HR 2.132, 95% C.I. 1.201-3.021 0.001 Early period HR 1.351, 95% C.I. 1.101-1.658 0.004 Abbreviations: DM: Diabetes mellitus; COPD: Chronic obstructive pulmonary disease; CHF: Congestive heart failure; CRF: Chronic renal failure; PVD: Peripheral vascular disease; IABP: Intra-aortic balloon pump; EF: Ejection fraction

Figure Legends:

Figure 1. Kaplan-Meier survival and expected survival without operation (Israeli Population and

Charlson Comorbidity Index, C.C.I.).

Figure 2. Expected (Charlson's Comorbidity index) versus Israeli Population expected survival

without operation and observed (Kaplan-Meier) 10 year survival by age groups (p<0.001) for all

pairwise comparisons of each age group – a. age <65, b. age 66-75, c. age >75.

Figure 3. Cox-adjusted survival by age group.

Figure 4. Long-term adjusted survival (Cox) by operative period.

; p y ; ggailure; CRF: Chronic renal failure; PVD: Peripheral vascular disease; IABP: Intra-aortic balloonn pppumumump;p;p EEEF:F:F

Ejection fraction

FiFigugugurerere LLLegeggenenndss:::

FiFigugugureree 111.. KaKaKaplplananan-MMMeieieierrr ssuru vivivivavalll ananand d eexexpepepectctcteddd ssuururvvvivivi aala wwwititithohohoututu ooopepeperarratttiononn ((IsIsIsraraaeleleliii PoPPopupupulaaatitiononn aaandn

Charlson Comomomorororbibibidididitytyty IIIndndexexex,, , C.C.C C.C.C I.I..).))



Figure 1 at FMRP BRAZ 35042 MEDIC RIB 80 on May 14, 2013http://circ.ahajournals.org/Downloaded from


Figure 2A at FMRP BRAZ 35042 MEDIC RIB 80 on May 14, 2013http://circ.ahajournals.org/Downloaded from


Figure 2B at FMRP BRAZ 35042 MEDIC RIB 80 on May 14, 2013http://circ.ahajournals.org/Downloaded from


Figure 2C at FMRP BRAZ 35042 MEDIC RIB 80 on May 14, 2013http://circ.ahajournals.org/Downloaded from


Should Bilateral Internal Thoracic Artery (BITA) Grafting Be Used...

Documents

Transcript of Should Bilateral Internal Thoracic Artery (BITA) Grafting Be Used...