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Bilateral internal thoracic artery grafting in octogenarians: where are the benefits?
Giuseppe Gatti1,2, Luca Dell'Angela3, Bernardo Benussi4
1Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy. gius.gatti@gmail.com.
Insights
Bilateral internal thoracic artery (BITA) grafting is safe for octogenarians undergoing myocardial revascularization, showing similar survival and major adverse events compared to single internal thoracic artery (SITA) grafting. However, BITA use is associated with a higher risk of sternal wound infection.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Geriatric Cardiology
Background:
- Bilateral internal thoracic artery (BITA) grafting is often avoided in elderly patients due to perceived higher risks.
- Octogenarians with multivessel coronary artery disease represent a unique population for surgical intervention.
Purpose of the Study:
- To evaluate the early and late clinical outcomes of BITA grafting versus single internal thoracic artery (SITA) grafting in octogenarians.
- To compare operative risk, perioperative complications, and long-term survival between BITA and SITA groups in this age demographic.
Main Methods:
- Retrospective analysis of 236 octogenarians undergoing primary isolated coronary artery bypass grafting.
- Comparison of 135 BITA patients with 95 SITA patients, excluding emergency cases.
- Assessment of operative risk (EuroSCORE II), hospital mortality, perioperative complications, and long-term outcomes including survival and major adverse cardiac and cerebrovascular events.
Main Results:
- No significant difference in operative risk (EuroSCORE II) or hospital mortality between BITA and SITA groups.
- BITA grafting was associated with a significantly higher incidence of sternal wound infection (5.2% vs. 0%, p=0.022).
- Long-term outcomes, including overall survival, freedom from cardiac/cerebrovascular deaths, MACE, and heart failure readmissions, were similar between groups.
Conclusions:
- Bilateral internal thoracic artery grafting can be safely employed in octogenarians with atherosclerotic ascending aorta.
- While BITA grafting does not increase hospital mortality or major adverse events, it carries an elevated risk of sternal wound infection without clear long-term benefits over SITA grafting.
Abstract:
The use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization is usually discouraged in the very elderly because of increased risk of perioperative complications. The aim of the study was to analyze early and late outcomes of BITA grafting in octogenarians. From January 1999 throughout February 2014, 236 consecutive octogenarians with multivessel coronary artery disease underwent primary isolated coronary bypass surgery at the authors' institution. Six of these patients underwent emergency surgery and were excluded from this retrospective study; consequently, 135 BITA patients were compared with 95 single internal thoracic artery (SITA) patients according to early and late outcomes. Between BITA and SITA patients, there was no significant difference in the operative risk (EuroSCORE II: 8 ± 7.7 vs. 7.6 ± 6.1 %, p = 0.65). There was a lower aortic manipulation in BITA patients. Hospital mortality (3 vs. 4.2 %, p = 0.44) and perioperative complications were similar except that only BITA patients experienced sternal wound infection (5.2 %, p = 0.022). The mean follow-up was 4.7 ± 3.3 years. There were no differences between the two groups in overall survival (p = 0.79), freedom from cardiac and cerebrovascular deaths (p = 0.73), major adverse cardiac and cerebrovascular events (p = 0.63) and heart failure hospital readmission (p = 0.64). Predictors of decreased late survival were diabetes (p = 0.0062) and congestive heart failure (p = 0.0004). BITA grafting can be routinely used in octogenarians with atherosclerotic ascending aorta without an increase in hospital mortality or major adverse cardiac and cerebrovascular complications. However, there is an increased risk of sternal wound infection without a demonstrable long-term benefit.
