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Bilateral internal thoracic artery use in patients with low ejection fraction: is there any additional long-term
Siamak Mohammadi1, Dimitri Kalavrouziotis2, Giovanni Cresce2
1Division of Cardiac Surgery, Quebec Heart and Lung University Hospital, Quebec City, Quebec, Canada siamak.mohammadi@fmed.ulaval.ca.
Insights
Bilateral internal thoracic artery (BITA) grafting does not improve long-term survival in patients with low ejection fraction (EF) undergoing coronary artery bypass graft (CABG) surgery compared to single internal thoracic artery (SITA) grafting.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery Outcomes
Background:
- Bilateral internal thoracic artery (BITA) grafting is associated with improved long-term outcomes in coronary artery bypass graft (CABG) surgery.
- Patients with low ejection fraction (EF) represent a high-risk group undergoing CABG.
Purpose of the Study:
- To evaluate the impact of BITA use on long-term survival in patients with low EF undergoing CABG.
- To compare survival rates between BITA and single internal thoracic artery (SITA) grafting in this patient cohort.
Main Methods:
- Retrospective analysis of 2035 consecutive BITA CABG patients and 1666 SITA CABG patients with EF ≤40% between 1991 and 2011.
- Propensity score matching created comparable BITA and SITA groups (n=111 each).
- Cox regression multivariable analyses identified independent risk factors for long-term mortality.
Main Results:
- No significant difference in operative mortality between matched BITA and SITA groups (1.8% vs 0.9%, P=0.6).
- Five-, 10-, and 15-year survival rates were similar between BITA and SITA groups (e.g., 77.5% vs 68.1% at 10 years, P=0.3).
- Independent predictors of late mortality included insulin-dependent diabetes, intra-aortic balloon pump use, deep sternal wound infection, and neurological complications.
Conclusions:
- BITA grafting does not confer a survival advantage over SITA grafting in patients with low EF undergoing CABG.
- The choice between BITA and SITA is not an independent predictor of long-term mortality in this high-risk population.
Objectives:
The use of bilateral internal thoracic arteries (BITA) has been associated with improved long-term outcomes following coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the impact of BITA use on long-term survival among patients with low ejection fraction (EF) undergoing CABG.
Methods:
Between April 1991 and October 2011, 2035 consecutive patients underwent primary BITA grafting. Among them, there were 129 patients with left ventricular EF ≤40%. During the same time period, 1666 primary CABGs were performed using a single internal thoracic artery (SITA) in patients with EF ≤40%. A propensity score optimal matching algorithm was used to create the matched SITA and BITA groups (n = 111 in each group). Also, Cox regression multivariable analyses were performed to determine the independent risk factors for long-term mortality. The date of death was obtained from provincial vital statistics.
Results:
There was no difference in operative mortality between matched BITA and SITA (n = 2, 1.8% vs n = 1, 0.9%, respectively, P = 0.6) groups. The mean follow-up was 8.6 ± 5.1 and 7.7 ± 5.5 years for BITA and SITA groups, respectively (P = 0.2). Five-, 10- and 15-year survival rates were 93.7, 77.5 and 59.0% in the matched BITA patients vs 82.8, 68.1 and 65.2% in the matched SITA patients (P = 0.3). In multivariate analysis, the independent risk factors for late mortality among hospital survivors were: insulin-dependent diabetes [adjusted hazard ratio (HR): 3.4, 95% confidence interval (CI): 1.4-8.4, P = 0.008], perioperative intra-aortic balloon pump insertion (HR: 3.2, 95% CI: 1.5-6.9, P = 0.004), postoperative deep sternal wound infection (HR: 7.4, 95% CI: 2.2-24.1, P = 0.001) and neurological complications (HR: 3.5, 95% CI: 1.4-8.4, P = 0.006). Choice of BITA versus SITA was not an independent predictor of long-term mortality (P = 0.3).
Conclusions:
The use of a second internal thoracic artery (ITA) does not prolong late survival in patients with low EF undergoing CABG compared with a propensity-matched group of SITA graft patients.
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