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Toumpoulis IK, Kanistras DA, Pappa CK, Zagoriti Z, Anagnostopoulos CE, Toumpoulis SK. Prediction of Long-Term Survival after Coronary Artery Bypass with Bilateral Internal Thoracic Artery Grafting: External Validation of A Contemporary Nomogram. J Cardiovasc Dev Dis 2022; 9:jcdd9110375. [PMID: 36354774 PMCID: PMC9693014 DOI: 10.3390/jcdd9110375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Background: This study aimed to verify the external validation of a contemporary nomogram in predicting long-term survival after an isolated coronary artery bypass with bilateral internal thoracic artery grafting (CABG-BITA). Methods: Consecutive patients who underwent CABG-BITA at a single center were included in the study. All the predictors of the original risk score (age, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic renal failure, old myocardial infarction, ejection fraction, intra-aortic balloon pump and peripheral arterial disease) were available for analysis. Results: Among the 2846 consecutive patients, a total of 1176 (41.3%) deaths were recorded during the 31,383 patient years of follow-up. The median EuroSCORE II was 2.35, and the median follow-up was 11.1 years. The risk score showed 72.7% overall discriminatory ability as measured by Harrell’s concordance statistic. It showed satisfactory calibration at 10, 15 and 20 years of follow-up. The risk score showed a time-varying nonlinear effect, and accordingly, adjusted long-term survival predictions were calculated. There were subgroups (scores < 50 points) with favorable 20-year survival rates ranging from 77% to 60%. Higher risk subgroups (scores > 90 points) showed poor 20-year survival rates ranging from 22% to 4%. Conclusions: The validated risk score represents a useful algorithm for the detection of patients who could benefit after CABG-BITA with respect to long-term survival. Although further multi-center studies are required worldwide to reveal the usefulness of this score in the clinical setting, its wide adoption may act as a motivation for cardiac surgeons resulting in higher numbers of CABG-BITA procedures.
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Affiliation(s)
- Ioannis K. Toumpoulis
- Department of Cardiac Surgery, Mouwasat Hospital, Dammam 32263, Saudi Arabia
- Department of Cardiac Surgery, National and Kapodistrian University of Athens, 12462 Athens, Greece
- 2bull MeDiTherapy P.C., 26222 Patra, Greece
- Department of Cardiac Surgery, Mount Sinai Morningside/St. Luke’s Hospital Center, New York, NY 10025, USA
- Correspondence:
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Surgical strategies for bilateral internal mammary artery grafting. Int J Surg 2015; 16:140-5. [DOI: 10.1016/j.ijsu.2014.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 10/26/2014] [Accepted: 11/04/2014] [Indexed: 11/20/2022]
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Deininger MO, Moreira LFP, Dallan LAO, Oliveira OGD, Magalhães DMS, Coelho JRDM, Deininger EDG, Lopes NDS, Queiroga RW, Belmont EF. Comparative analysis of the patency of the internal thoracic artery in the CABG of left anterior descending artery: 6-month postoperative coronary CT angiography evaluation. Braz J Cardiovasc Surg 2014; 29:192-201. [PMID: 25140469 PMCID: PMC4389462 DOI: 10.5935/1678-9741.20140032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 11/17/2013] [Indexed: 12/02/2022] Open
Abstract
Objective To assess the patency of the pedicled right internal thoracic artery with an
anteroaortic course and compare it to the patency of the left internal thoracic
artery , in anastomosis to the left anterior descending artery in coronary artery
bypass grafting by using coronary CT angiography at 6 months postoperatively. Methods Between December 2008 and December 2011, 100 patients were selected to undergo a
prospective coronary artery bypass grafting procedure without cardiopulmonary
bypass. The patients were randomly divided by a computer-generated list into
Group-1 (G-1) and Group-2 (G-2), comprising 50 patients each, the technique used
was known at the beginning of the surgery. In G-1, coronary artery bypass grafting
was performed using the left internal thoracic artery for the left anterior
descending and the free right internal thoracic artery for the circumflex, and in
G-2, coronary artery bypass grafting was performed using the right internal
thoracic artery pedicled to the left anterior descending and the left internal
thoracic artery pedicled to the circumflex territory. Results The groups were similar with regard to the preoperative clinical data. A male
predominance of 75.6% and 88% was observed in G-1 and G-2, respectively. Five
patients migrated from G-1 to G-2 because of atheromatous disease in the ascending
aorta. The average number of distal anastomoses was 3.48 (SD=0.72) in G-1 and 3.20
(SD=0.76) in G-2. Coronary CT angiography in 96 re-evaluated patients showed that
all ITAs, right or left, used in situ for the left anterior descending were
patent. There were no deaths in either group. Conclusion Coronary artery bypass grafting surgery involving anastomosis of the anteroaortic
right internal thoracic artery to the left anterior descending artery has an
outcome similar to that obtained using the left internal thoracic artery for the
same coronary site.
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Affiliation(s)
| | - Luiz Felipe Pinho Moreira
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Luiz Alberto Oliveira Dallan
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Nambala S, Babu B, Kumar NKS, Rajani I. Off-pump LIMA-RIMA Y graft: a practical option in adult-type ALCAPA. World J Pediatr Congenit Heart Surg 2013; 4:296-8. [PMID: 24327500 DOI: 10.1177/2150135113484161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 29-year-old female was diagnosed to have adult-type anomalous left coronary artery from pulmonary artery (ALCAPA). She underwent a two-coronary system repair using left internal mammary artery and right internal mammary artery Y (LIMA-RIMA Y) off-pump coronary artery bypass grafting and made an uneventful postoperative recovery. The usage of off-pump LIMA-RIMA Y graft can be a suitable option for adult ALCAPA with a potential for good long-term outcomes.
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Affiliation(s)
- Sathyaki Nambala
- Department of Cardiothoracic Surgery, Apollo Hospitals, Bangalore, India
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Off-pump coronary artery bypass may increase late mortality: a meta-analysis of randomized trials. Ann Thorac Surg 2010; 89:1881-8. [PMID: 20494043 DOI: 10.1016/j.athoracsur.2010.03.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 02/27/2010] [Accepted: 03/01/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although a lot of randomized trials of off-pump coronary artery bypass grafting (CABG) versus on-pump CABG were conducted, the majority of them reported only early outcomes. Previous meta-analyses of a few randomized trials found no differences for 1-year to 2-year mortality. METHODS We focused late (> or = 1 year) all-cause mortality and performed a meta-analysis of randomized controlled trials of off-pump versus on-pump CABG. The MEDLINE, the EMBASE, and the Cochrane Central Register of Controlled Trials were searched using PubMed and OVID. For each study, data regarding all-cause mortality in both the off-pump and on-pump groups were used to generate risk ratios (RRs) and 95% confidence intervals. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic RRs in both fixed-effects and random-effects models. RESULTS Our search identified 11 results of 12 randomized trials (4,326 patients) of off-pump versus on-pump CABG. Pooled analysis demonstrated a statistically significant increase in midterm all-cause mortality by a factor of 1.37 with off-pump relative to on-pump CABG (RR, 1.373; 95% confidence interval, 1.043 to 1.808). Exclusion of any single result, except for the largest (>2,000 patients) trial, from the analysis did not substantively alter the overall result of our analysis. Eliminating the largest trial demonstrated a statistically nonsignificant benefit of on-pump over off-pump CABG for midterm all-cause mortality (RR, 1.344; 95% confidence interval, 0.952 to 1.896). CONCLUSIONS The results of our analysis suggest that off-pump CABG may increase late all-cause mortality by a factor of 1.37 over on-pump CABG. Longer term mortality from randomized trials of off-pump versus on-pump CABG is needed.
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Fukui T, Tabata M, Manabe S, Shimokawa T, Morita S, Takanashi S. Angiographic outcomes of right internal thoracic artery grafts in situ or as free grafts in coronary artery bypass grafting. J Thorac Cardiovasc Surg 2010; 139:868-73. [DOI: 10.1016/j.jtcvs.2009.05.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 05/01/2009] [Accepted: 05/31/2009] [Indexed: 10/20/2022]
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Onorati F, Santarpino G, Rubino A, Cristodoro L, Scalas C, Renzulli A. Intraoperative bypass graft flow in intra-aortic balloon pump–supported patients: Differences in arterial and venous sequential conduits. J Thorac Cardiovasc Surg 2009; 138:54-61. [DOI: 10.1016/j.jtcvs.2008.11.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 10/30/2008] [Accepted: 11/26/2008] [Indexed: 11/29/2022]
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Onorati F, Esposito A, Pezzo F, di Virgilio A, Mastroroberto P, Renzulli A. Hospital Outcome Analysis After Different Techniques of Left Internal Mammary Grafts Harvesting. Ann Thorac Surg 2007; 84:1912-9. [DOI: 10.1016/j.athoracsur.2007.06.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Revised: 06/05/2007] [Accepted: 06/06/2007] [Indexed: 11/26/2022]
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Rajagopal K, Lima B, Harrison JK, Swaminathan M, McCann RL, Hughes GC. Endovascular thoracic aortic aneurysm repair with concomitant myocardial and carotid revascularization. Ann Thorac Surg 2007; 84:e1-3. [PMID: 17588370 DOI: 10.1016/j.athoracsur.2007.03.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2006] [Revised: 03/09/2007] [Accepted: 03/13/2007] [Indexed: 10/23/2022]
Abstract
A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.
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Affiliation(s)
- Keshava Rajagopal
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Srivastava S, Gadasalli S, Agusala M, Kolluru R, Naidu J, Shroff M, Barrera R, Quismundo S, Srivastava V. Use of Bilateral Internal Thoracic Arteries in CABG Through Lateral Thoracotomy With Robotic Assistance in 150 Patients. Ann Thorac Surg 2006; 81:800-6; discussion 806. [PMID: 16488676 DOI: 10.1016/j.athoracsur.2005.08.044] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 08/10/2005] [Accepted: 08/22/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND Internal thoracic arteries (ITA) have been shown to offer longer graft patency. Off-pump coronary artery bypass graft surgery (CABG) through small lateral thoracotomy has been reported. The present study deals with feasibility of using bilateral ITAs (BITA) in CABG through small lateral thoracotomy facilitated by the da Vinci robotic system. METHODS Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management. RESULTS Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 +/- 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 +/- 2.9 days. CONCLUSIONS The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.
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Toker ME, Omeroglu SN, Kirali K, Balkanay M, Yakut C. Using the Bilateral Internal Mammary Artery in the Left or Right Coronary Artery System: 5-Year Comparison of Operation Techniques and Angiographic Results. Heart Surg Forum 2005; 8:E462-7. [PMID: 16286279 DOI: 10.1532/hsf98.20051165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Using the bilateral internal mammary artery (IMA) in coronary artery bypass grafting (CABG) surgery has prolonged survival, improved functional capacity, and reduced the rate of reintervention without increasing postoperative early morbidity and mortality. METHODS Between January 1996 and December 1997, 94 CABG operations were performed using the bilateral IMA. In Group A (n = 45), the right IMA was anastomosed to the left coronary artery system; in Group B (n = 49), the right IMA was anastomosed to the right coronary artery system. The left IMA was always anastomosed to the left coronary artery system in both groups. RESULTS There was 1 death (Group A) (1.06%), and 1 late death (Group B) (1.07%). One patient in Group A underwent balloon angioplasty, and 1 patient in Group B underwent reoperation after the follow-up. Pre- and postoperative data were similar between both groups, except for off-pump CABG, which was higher in Group B (2.2% versus 36.7%; P <.001). Twenty-three randomized patients in each group underwent control angiography until May 2002. Angiographic results showed that the patency of the right IMA to the right or left coronary artery system was similar (78.26% versus 82.6%; P = .7). But the left IMA had a better patency rate than the right IMA (95.65% versus 80.43%; P = .02). The patency rates of the left and right IMA anastomosis on the beating heart in Group B were not significantly different (92.3% versus 76.9%; P = .27). The patency of right IMA anastomosis with or without off-pump technique in Group B was similar (76.9% versus 80%; P = .84). CONCLUSIONS Bilateral IMA can be used with low morbidity and mortality. The angiographic and clinical results of off-pump CABG show that bilateral IMA can also be used in off-pump surgery with similar results.
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Affiliation(s)
- Mehmet Erdem Toker
- Department of Cardiovascular Surgery, Kosuyolu Heart and Research Hospital, Istanbul, Turkey.
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Mirchandani S, Phoon CKL. Management of anomalous coronary arteries from the contralateral sinus. Int J Cardiol 2005; 102:383-9. [PMID: 16004881 DOI: 10.1016/j.ijcard.2004.10.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2004] [Revised: 10/11/2004] [Accepted: 10/22/2004] [Indexed: 10/25/2022]
Abstract
Anomalous origin of the coronary artery from the contralateral sinus of Valsalva, coursing between the aorta and pulmonary artery, has garnered much attention because of its association with sudden death. Current medical opinion is heavily skewed toward "successful" intervention. However, two key issues have not been critically analyzed: what is the true risk of sudden death from an anomalous coronary artery, and how does this risk balance against the risk of surgical intervention? Common misconceptions about risk derive from citations of autopsy data. In fact, the scant available data suggest a far lower absolute risk than commonly cited. The risks of surgical intervention, while likely quite low, remain real, and include aortic valve damage and neurological sequelae. The lack of long-term outcomes data precludes any definite recommendations in most patients. The decision to intervene is thus not straightforward, and should be approached cautiously and only after appropriate counseling of the patient.
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Affiliation(s)
- Sunil Mirchandani
- Pediatric Cardiology Program, Department of Pediatrics, New York University School of Medicine, New York, NY 10016, USA
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Abstract
BACKGROUND Use of arterial grafts in coronary surgery is based on the excellent patency of the left internal thoracic artery (LITA) and an expectation that other arterial grafts-right internal thoracic artery (RITA) and radial artery (RA)-will give similar patencies, superior to saphenous vein. We examined patencies of arterial grafts in a practice with extensive use for more than 15 years. METHODS Consecutive postoperative angiograms of 2,127 arterial/coronary conduits were evaluated. Angiograms were performed for cardiac symptoms. Assessment was by two observers. String signs were considered as occlusions. RESULTS There were 2127 arterial conduits. Overall patencies were as follows: LITA, 96.4% (1296 of 1345); RITA, 88.3% (534 of 605); aortocoronary RA, 89.3% (158 of 177). The LITA patency to the left anterior descending artery was 97.1% (1131 of 1165); to the obtuse marginal artery it was 91.7% (165 of 180; p 0.01). The RITA pedicled graft patency was 86% (275 of 321) compared with free RITA, 91% (259 of 284; p = not significant). For RITA there was a hierarchy of patency for coronary territory grafted (left anterior descending artery best, right coronary/posterior descending artery worst) and for degree of coronary stenosis: if stenosis was less than 60%, patency was 65% (47 of 72); if stenosis was more than 60%, patency was 90.9% (485 of 533; p = 0.0001). Similarly for the radial artery there was higher patency with greater coronary stenosis. The LITA patency at 5 years was 98%, at 10 years it was 95%, and at 15 years it was 88%. The RITA patency at 5 years was 96%, at 10 years it was 81%, and at 15 years it was 65%. The radial artery patency at 1 year was 96% and at 4 years it was 89%. For 3,714 vein grafts also studied overall patency was 61% (2266 of 3214) with patencies of 95% at 5 years, 71% at 10 years, and 32% at 15 years. CONCLUSIONS Excellent long-term patencies of arterial grafts are noted, superior to those of vein grafts. Patencies were influenced by conduit, by distribution, and by coronary artery stenosis.
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Affiliation(s)
- James Tatoulis
- Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.
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Battellini R, Borger MA, Climente C, Mohr FW. Extending the in situ right internal mammary artery graft with retrocaval positioning. Ann Thorac Surg 2003; 75:1335-6. [PMID: 12683597 DOI: 10.1016/s0003-4975(02)04392-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bilateral internal mammary artery grafting is associated with improved long-term patient outcomes. In situ right internal mammary artery grafting of the obtuse marginal artery, through the transverse sinus, is often limited by conduit length. We describe the technique of retrocaval positioning of the right internal mammary artery graft to extend its functional length for grafting of the circumflex territory. With careful surgical technique, this procedure can be performed safely during routine coronary bypass operations.
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Affiliation(s)
- Roberto Battellini
- Clinic for Heart Surgery, Heart Center, University of Leipzig, Leipzig, Germany.
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