Revascularization of multiple bypassable extended right coronary arteries
Mehmet Raşit Güney1, Ergin Eren
1Siyami Ersek Chest and Cardivascular Surgery Center, Istanbul. Turkey. mrguney@e-kolay.tr
Insights
Complete revascularization of extended right coronary arteries is beneficial for patients with poor ventricular function, preventing perioperative ischemic events. For those with normal function, conventional single bypassing is comparable to multiple bypassing.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Cardiac Surgery Outcomes
Background:
- Extended right coronary arteries are common in coronary surgery.
- Revascularization can be achieved via single or multiple bypass grafting.
- Objective data comparing these methods for extended right coronary arteries is lacking.
Purpose of the Study:
- To compare the effectiveness of multiple-bypassing versus single-bypassing for revascularizing extended right coronary arteries.
- To evaluate perioperative ischemic events and functional outcomes based on ventricular function.
Main Methods:
- Patients with extended right coronary arteries were randomized into multiple-bypassing (Group A) and single-bypassing (Group B) groups.
- Four parameters assessing revascularization completeness were compared.
- Subgroup analysis was performed for patients with left ventricular dysfunction (ejection fraction <50%).
Main Results:
- No significant difference in definitive perioperative ischemic events or infarction rates between groups with normal ventricular function.
- Patients with poor ventricular function undergoing single-bypassing had significantly higher overall and definitive perioperative ischemic events and right ventricular dysfunction.
- Reperfusion and graft patency rates were similar regardless of the revascularization method.
Conclusions:
- Complete revascularization offers no apparent advantage over conventional single bypassing in patients with normal ventricular function.
- Multiple-bypassing in patients with poor ventricular function (ejection fraction <50%) prevents perioperative ischemic events and subsequent functional impairment.
- The choice of revascularization strategy for extended right coronary arteries should consider preoperative left ventricular function.
Background:
Extended right coronary arteries are not uncommon in coronary surgery. They can be revascularized optionally either by conventional single or complete multiple bypassing. However, there are still no objective data showing the superiority or appropriateness of one of these methods over the other.
Methods:
Extended right coronary arteries were identified by preoperative angiographic scoring and randomized to multiple-bypassing (group A; n = 32) or single-bypassing (group B; n = 32) groups. Four parameters that show the completeness of right coronary territory revascularization were evaluated and compared between the 2 groups.
Results:
Although overall perioperative ischemic events seemed to increase in the single-bypass group (P =.0059), half of them were reversible, and there were no statistical differences between the definitive perioperative ischemic event rates, namely, infarction rates, and the remaining 3 parameters of the groups. Logistic regression analysis showed that preoperative left ventricular dysfunction (ejection fraction <50%) was the most significant predictor of these perioperative ischemic events. Hence, the subgroups of patients with left ventricular dysfunction were also evaluated (subgroup A, n =13; subgroup B, n = 12). Overall perioperative ischemic event (P =.001), definitive perioperative ischemic event (infarction; P =.0324), and consequent right ventricular dysfunction (P =.0324) rates were significantly higher in the single-bypass subgroup. Postoperative reperfusion status and graft patency rates of the right coronary territory did not change with the different revascularization methods.
Conclusions:
Complete revascularization of extended right coronary arteries did not seem advantageous over its conventional operation in patients with normal ventricular function; however, in patients with poor ventricular function (ejection fraction <50%), it prevented perioperative ischemic events in the right coronary territory and the consequent functional impairment that appeared with conventional operation.
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