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Mid-term follow-up of 183 arterial myocardial revascularization procedures
C Antona1, M Zanobini, A A Lotto
1Department of Cardiac Surgery, Centro Cardiologico Fondazione I Monzino IRCCS, University of Milan, Italy.
Insights
Complete arterial myocardial revascularization using multiple arterial grafts offers excellent mid-term outcomes with low perioperative risks. However, redo-operations and not using the right internal mammary artery (RIMA) are associated with less favorable results.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery
- Thoracic Surgery
Background:
- Coronary artery disease necessitates myocardial revascularization.
- Arterial conduits offer superior long-term patency compared to venous grafts.
- Complete arterial revascularization aims to maximize graft longevity.
Purpose of the Study:
- To assess the mid-term efficacy and safety of complete arterial myocardial revascularization.
- To identify factors influencing outcomes in patients receiving multiple arterial grafts.
Main Methods:
- Retrospective analysis of 183 patients undergoing myocardial revascularization with at least two arterial grafts (internal mammary arteries, radial, or epigastric arteries).
- Data collected included patient demographics, disease severity, graft types used, and perioperative outcomes.
- Follow-up included clinical assessment, angiographic restudy, and survival analysis.
Main Results:
- Low in-hospital mortality (1.1%) and perioperative myocardial infarction (2.2%).
- High graft patency rates observed: LIMA 98.8%, RIMA 97.1%, radial artery 97.05%, internal mammary artery 85.7%.
- Excellent mid-term survival (96% at 5 years) and freedom from angina (91% at 5 years). Perioperative MI was a predictor of mortality.
- Redo-operations and absence of RIMA use were linked to poorer outcomes.
Conclusions:
- Complete arterial myocardial revascularization with multiple arterial conduits is safe and effective, yielding good mid-term results.
- The use of the right internal mammary artery (RIMA) appears protective.
- Redo-operations and non-use of RIMA negatively impact long-term outcomes.
Objective:
To evaluate the mid-term results of complete arterial myocardial revascularization performed with arterial conduits.
Methods:
From July 1987 to December 1994, 183 patients underwent a myocardial revascularization procedure with the use of at least two arterial grafts (IMAs, rGEA, IEA) at our institute. Their mean age was 56 +/- 8.7 years, the redo-operation rate was 16.9% (31/183), two-vessel disease was present in 61 patients (33.3%), three-vessel disease in 122 (66.7%).
Results:
The LIMA was used in 179 patients (97.8%), the RIMA in 116 (63.4%), the rGEA in 66 (36.1%) and the IEA in 41 (22.4%). In-hospital mortality was 1.1% (2/183), while the perioperative myocardial infarction (MI) rate was 2.2% (4/183). The angiographic restudy, performed on 87 (47.5%) patients during the early postoperative period (median 38 days) showed the following grafts patency rates: LIMA 98.8 (86/87), RIMA 97.1 (34/35), IEA 85.7 (24/28), rGEA 97.05 (33/34) and saphenous vein 90.9% (10/11). The median follow-up was 35 months. Kaplan-Meier survival was 96 +/- 2% at 3 and 5 years, freedom from angina 94 +/- 2% at 3 years and 91 +/- 3% at 5 years, while the Kaplan-Meier freedom from cardiac events was 90 +/- 3% at 3 years and 88 +/- 3% at 5 years. Cox regression analysis identified perioperative MI (P = 0.03, relative risk 3.6) as the only prognostic factor for mortality at follow-up. With regards to recurrence of angina, multivariate analysis has shown that incremental risk factors for the return of angina are redo-operation (P < 0.01, relative risk 2.7) and the persistence of hypertension after surgery (P < 0.01; relative risk 3.2), while the use of the RIMA in the operation has emerged as a protective factor (P = 0.02; relative risk 0.43). Finally, only redo-operation (P < 0.01; relative risk 2.3), has emerged as a predictor of cardiac complications.
Conclusion:
Myocardial revascularization with at least two arterial grafts can be performed with very low perioperative morbidity and mortality and good mid-term follow-up. The mid-term results of arterial myocardial revascularization are less favourable in cases of redo-operations or when the RIMA is not used.