21-Year Survival of Left Internal Mammary Artery-Radial Artery-Y Graft

Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry

BACKGROUND

Surgical ablation for atrial fibrillation at the time of isolated coronary artery bypass grafting is reluctantly attempted. Meanwhile, complete revascularization is not always possible in these patients. We attempted to counterbalance the long-term benefits of surgical ablation against the risks of incomplete revascularization.

METHODS

Atrial fibrillation patients undergoing isolated coronary artery bypass grafting for multivessel disease between 2012 to 2022 and included in the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry were divided into complete revascularization, complete revascularization with additional grafts, and incomplete revascularization cohorts; these were further split into surgical ablation and non-surgical ablation subgroups.

RESULTS

A total of 8,405 patients (78% men; age 69.3 ± 7.9) were included; of those, 5,918 (70.4%) had complete revascularization, and 556 (6.6%) had surgical ablation performed. Number of anastomoses was 2.7 ± 1.2. The median follow-up was 5.1 [interquartile range 2.1-8.8] years. In patients in whom complete revascularization was achieved, surgical ablation was associated with long-term survival benefit: hazard ratio 0.69; 95% confidence intervals (0.50-0.94); P = .020 compared with grafting additional lesions. Similarly, in patients in whom complete revascularization was not achieved, surgical ablation was associated with a long-term survival benefit of 0.68 (0.49-0.94); P = .019. When comparing surgical ablation on top of incomplete revascularization against complete revascularization without additional grafts or surgical ablation, there was no difference between the 2: 0.84 (0.61-1.17); P = .307, which was also consistent in the propensity score-matched analysis: 0.75 (0.39-1.43); P = .379.

CONCLUSION

To achieve complete revascularization is of utmost importance. However, when facing incomplete revascularization at the time of coronary artery bypass grafting in a patient with underlying atrial fibrillation, concomitant surgical ablation on top of incomplete revascularization is associated with similar long-term survival as complete revascularization without surgical ablation.

Long-term observational angiographic patency and perfect patency of radial artery compared with saphenous vein or internal mammary artery in coronary bypass surgery

OBJECTIVES

It is uncertain if the long-term biological behavior of the radial artery as a conduit for coronary bypass surgery has a similar resistance to the development of atherosclerosis as for the internal mammary artery. We aimed to examine long-term angiographic patency and disease-free patency (perfect patency) for internal mammary artery, radial artery, and saphenous vein grafts.

METHODS

A retrospective, single-center, individual patient cohort study of angiographic observations from patients' latest postoperative angiogram from 1997 to 2020 was performed. Analysis was per anastomosis and assessed for patency and perfect patency. A generalized linear mixed model premised upon logistic regression was used to minimize confounding bias.

RESULTS

A total of 983 patients with 3064 grafts were included, with a median follow-up of 8.6 (interquartile range, 4.4-12.6) years after the operation. Multivariable analysis revealed differences for radial (patency, 86.9%; perfect patency, 86.4%) and internal mammary artery (patency, 93.9%; perfect patency, 93.5%) versus saphenous vein graft (patency, 72.8%; perfect patency, 46.2%). There were no differences between the 2 arterial conduits for patency (odds ratio, 1.40; 95% CI, 0.85-2.33; P = .189) and perfect patency (odds ratio, 1.14; 95% CI, 0.71-1.84; P = .578). If a conduit was patent, then 99.4% of radial artery, 99.6% of internal mammary artery, and 63.5% of saphenous vein graft were reported as perfectly patent.

CONCLUSIONS

Radial artery and internal mammary artery had similar patency and perfect patency while both were superior to saphenous vein graft.

Sex differences in long-term survival after total arterial coronary artery bypass grafting

OBJECTIVES

It is uncertain if the evidence on improved long-term survival of total arterial coronary artery bypass grafting applies to female patients. This study aims to compare the long-term survival outcomes of using total arterial revascularization (TAR) versus at least 1 saphenous vein graft separately for men and women.

METHODS

This retrospective analysis of the Australian and New Zealand Society of Cardiac-Thoracic Surgical Database had administrative linkage to the National Death Index. We identified all patients undergoing primary isolated coronary bypass from June 2001 to January 2020 inclusive. Following sex stratification, propensity score matching with 36 variables and Cox proportional hazard regression were used to facilitate adjusted comparisons. A Cox interaction-term analysis was performed to investigate the impact of sex on TAR survival benefit. The primary outcome was all-cause mortality.

RESULTS

Of the 69 624 eligible patients receiving at least 2 grafts, 13 019 (18.7%) were female patients. Matching generated 14 951 male and 3530 female pairs. Compared to vein-dependent procedures, TAR was associated with significantly reduced incidence of long-term all-cause mortality for both male (hazard ratio, 0.86; 95% confidence interval, 0.81-0.91; P < 0.001) and female (hazard ratio, 0.82; 95% confidence interval, 0.73-0.91; P < 0.001) cohorts. Interaction-term analysis indicated no significant subgroup effect from sex (P = 0.573) on the survival advantage of TAR. The treatment effect provided by TAR remained significant across most sex-stratified disease subgroups.

CONCLUSIONS

TAR, when compared to the use of at least 1 saphenous vein graft, provides comparable superior long-term survival outcomes in both females and males.

From a Position of Known Angiographic Perfect Patency: What Happens Next?

BACKGROUND AND AIM

The biological behaviour of coronary graft conduits over time may be considered by serial angiography.

METHODS

A single institution retrospective cohort received mostly clinically indicated angiography between 1997 and 2020, following coronary bypass surgery. Only perfectly patent grafts (absence of any lumen irregularity) for each conduit type at the first postoperative angiogram were selected for a later comparison. The latest angiograms were at least 5 years postoperatively, and at least 1 year after first postoperative angiogram. Analysis was done according to each graft (anastomosis). Comparisons used generalised estimating equations, adjusted for binary logistic regression.

RESULTS

Of 143 patients, there were 410 of 468 (87.6%) perfectly patent grafts at the first angiogram, analysed at 6.8±4.0 years postoperative, of which 157 were internal mammary arteries, 228 were radial arteries, and 25 were saphenous veins. At the latest angiogram (12.2±3.8 years postoperative), comparison with the first angiogram for each individual graft found preserved perfect patency for internal mammary arteries 156 of 157 (99.4%), and for radial arteries, 227 of 228 (99.6%) but saphenous veins deteriorated considerably 13 of 25 (52.0%). The two arterial grafts (internal mammary and radial) were superior to vein grafts (odds ratio 163; 95% confidence interval [CI] 22-1,211; p<0.001), but not different from each other (odds ratio 0.95; 95% CI 0.78-1.16; p=0.584).

CONCLUSIONS

From a position of known angiographic perfect patency post-CABG, internal mammary artery and radial artery grafts retained their perfect patency in the longer term, but saphenous vein grafts did not.

Defining the Role of Anaortic Coronary Artery Bypass Grafting

As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.

Why and How Should We Treat Chronic Total Occlusion? Evolution of State-of-the-Art Methods and Future Directions

Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization.

Graft flow assessment and early coronary artery bypass graft failure: a computed tomography analysis

OBJECTIVES

We evaluated graft patency by computed tomography and explored the determinants of intraoperative mean graft flow (MGF) and its contribution to predict early graft occlusion.

METHODS

One hundred and forty-eight patients under a single surgeon were prospectively enrolled. Arterial and endoscopically harvested venous conduits were used. Intraoperative graft characteristics and flows were collected. Graft patency was blindly evaluated by a follow-up computed tomography at 11.4 weeks (median).

RESULTS

Graft occlusion rate was 5.2% (n = 22 of 422; 8% venous and 3% arterial). Thirteen were performed on non-significant proximal stenosis while 9 on occluded or >70% stenosed arteries. Arterial and venous graft MGF were lower in females (Parterial = 0.010, Pvenous = 0.009), with median differences of 10 and 13.5 ml/min, respectively. Arterial and venous MGF were associated positively with target vessel diameter ≥1.75 mm (Parterial = 0.025; Pvenous = 0.002) and negatively with pulsatility index (Parterial < 0.001; Pvenous < 0.001). MGF was an independent predictor of graft occlusion, adjusting for EuroSCORE-II, pulsatility index, graft size and graft type (arterial/venous). An MGF cut-off of 26.5 ml/min for arterial (sensitivity 83.3%, specificity 80%) and 36.5 ml/min for venous grafts (sensitivity 75%, specificity 62%) performed well in predicting early graft occlusion.

CONCLUSIONS

We demonstrate that MGF absolute values are influenced by coronary size, gender and graft type. Intraoperative MGF of >26.5 ml/min for arterial and >36.5 ml/min for venous grafts is the most reliable independent predictor of early graft patency. Modern-era coronary artery bypass graft is associated with low early graft failure rates when transit time flow measurement is used to provide effective intraoperative quality assurance.

Multiarterial coronary grafting using the radial artery as a second arterial graft: how far does the survival benefit extend?

OBJECTIVES

Despite the 10-year results of the Arterial Revascularization Trial, the controversy regarding the survival benefit of multiarterial grafting (MAG) remains. Our goal was to present our long-term survival data in this propensity-matched observational study.

METHODS

A primary unmatched population of 4303 patients with first-time isolated coronary artery bypass grafts operated on between 2000 and 2018 were included. A total of 1187 post-matched patients were compared with matched controls. Multivariate logistic regression and Cox proportional hazard analyses were undertaken to assess the contribution of MAG and other covariates to the long-term survival of unmatched and propensity-matched populations.

RESULTS

MAG was associated with increased median survival in both the unmatched and the matched groups; difference: 962 and 1459 days, log-rank tests; P = 0.029 and 0.0004, respectively. MAG was associated with a reduced hazard of death in the unmatched as well as in the matched groups: hazard ratio [95% confidence interval (CI)]: 0.72 (0.62-0.83); P < 0.0001 and 0.75 (0.64-0.88); P ≤ 0.0001, respectively. In the matched group, the prosurvival factors were low logistic EuroSCORE, obesity, no intra-aortic balloon pump, an ejection fraction >30%, age 50-69 years, operation by an experienced surgeon, with and without diabetes, on-pump surgery and 3 distal anastomoses. In a cohort of 242 late-presenting patients with reinfarction or recurrent angina, both MAG and control populations were associated with reduced median survival; median (95% CI): MAG: 3026 (1138-3503); control: 3035 (2134-3991), log-rank P = 0.217 with superior patency of the left internal mammary artery but no difference between radial artery and saphenous vein grafts.

CONCLUSIONS

Multiarterial revascularization, especially using the radial artery as a second arterial conduit, is associated with a significant survival benefit and a lack of in-hospital morbidity.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.

The Use of Radial Artery for CABG: An Update

We used the radial artery as a second target conduit for coronary artery bypass grafting since 1971. However, randomized clinical studies have demonstrated differences in clinical outcomes between the radial artery and other grafts because these trials are underpowered. As we proceed toward 50 years of experience with radial artery grafting, we examined the literature to define the best second-best target vessel for coronary artery bypass grafting. The literature was reviewed with emphasis, and a large number of randomized controlled trials, propensity-matched observational series, and meta-analyses were identified with a large patient population who received arterial conduit and saphenous vein grafts. The radial artery has been shown to be effective and safe when used as a second target conduit for coronary artery bypass grafting. Results and patency rates were superior to those for saphenous vein grafting. It has also been shown that the radial artery is a safe and effective graft as a third conduit into the territory of the artery right coronary artery. However, there is little evidence based on a few comparable series limiting the use of the gastroepiploic artery. In its fifth decade of use, we can finally deduced that the aorto-to-coronary radial bypass graft is the conduit of choice for coronary operations after the left internal thoracic artery to the left anterior descending artery.

Total Arterial Coronary Bypass Graft Surgery is Associated with Better Long-Term Survival in Patients with Multivessel Coronary Artery Disease: a Systematic Review with Meta-Analysis

INTRODUCTION

The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients.

METHODS

The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed.

RESULTS

Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome.

CONCLUSION

This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Long-term Outcomes Associated With Total Arterial Revascularization vs Non-Total Arterial Revascularization

Importance

The optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease.

Objective

To compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study.

Design, Setting, and Participants

This multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019.

Exposures

Total arterial revascularization.

Main Outcomes and Measures

Primary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome.

Results

Of 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization.

Conclusions and Relevance

Total arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.

RARAY Operation: Operative Description and Early Results for Achieving Total Arterial Coronary Revascularisation

BACKGROUND

Total arterial revascularisation may prolong postoperative survival following coronary surgery due to avoidance of late saphenous vein graft (SVG) failure leading to ischaemic cardiac events. The left internal mammary artery (LIMA) is routinely used for CABG but harvest may adversely affect lung function and reduce sternal vascular supply. Early experience of a novel reconstruction with exclusive reliance on two radial arteries (RA) joined as a Y graft (RARAY) is presented.

METHODS

One RA is anastomosed to the ascending aorta and used to revascularise the left anterior descending artery coronary territory; and a second RA is joined to the first 4-6 cm from the origin, approximating the lateral border of the pulmonary artery and used to revascularise the circumflex and right coronary territories. No LIMA is used. The radial artery was harvested open with diathermy and metal clips and since 2008, all patients received intravenous vasoconstrictors from the commencement of the anaesthetic.

RESULTS

From 2002 to 2019, 28 patients underwent RARAY for specific indications of prior use or reasons to avoid LIMA harvest, preservation of lung function, minimisation of bleeding risk from antiplatelet agents and extra length of RA to graft distal coronary targets beyond usual reach for LIMA. There was no RA spasm, no in-hospital death and no patient returned with symptoms of angina.

CONCLUSIONS

The early experience of the RARAY operation for three coronary territory revascularisations are satisfactory.

Patency of conduits in patients who received internal mammary artery, radial artery and saphenous vein grafts

Background

Where each patient has all three conduits of internal mammary artery (IMA), saphenous vein graft (SVG) and radial artery (RA), most confounders affecting comparison between conduits can be mitigated. Additionally, since SVG progressively fails over time, restricting patient angiography to the late period only can mitigate against early SVG patency that may have occluded in the late period.

Methods

Research protocol driven conventional angiography was performed for patients with at least one of each conduit of IMA, RA and SVG and a minimum of 7 years postoperative. The primary analysis was perfect patency and secondary analysis was overall patency including angiographic evidence of conduit lumen irregularity from conduit atheroma. Multivariable generalized linear mixed model (GLMM) was used. Patency excluded occluded or “string sign” conduits. Perfect patency was present in patent grafts if there was no lumen irregularity.

Results

Fifty patients underwent coronary angiography at overall duration postoperative 13.1 ± 2.9, and age 74.3 ± 7.0 years. Of 196 anastomoses, IMA 62, RA 77 and SVG 57. Most IMA were to the left anterior descending territory and most RA and SVG were to the circumflex and right coronary territories. Perfect patency RA 92.2% was not different to IMA 96.8%, P = 0.309; and both were significantly better than SVG 17.5%, P < 0.001. Patency RA 93.5% was also not different to IMA 96.8%, P = 0.169, and both arterial conduits were significantly higher than SVG 82.5%, P = 0.029. Grafting according to coronary territory was not significant for perfect patency, P = 0.997 and patency P = 0.289. Coronary stenosis predicted perfect patency for RA only, P = 0.030 and for patency, RA, P = 0.007, and SVG, P = 0.032.

When both arterial conduits were combined, perfect patency, P < 0.001, and patency, P = 0.017, were superior to SVG.

Conclusions

All but one patent internal mammary artery or radial artery grafts had perfect patency and had superior perfect patency and overall patency compared to saphenous vein grafts.

Active Participation in Outpatient Cardiac Rehabilitation Is Associated With Better Prognosis After Coronary Artery Bypass Graft Surgery - J-REHAB CABG Study

BACKGROUND

There is little evidence regarding the effect of outpatient cardiac rehabilitation (CR) on exercise capacity or the long-term prognosis in patients after coronary artery bypass graft surgery (CABG). This study aimed to determine whether participation in outpatient CR improves exercise capacity and long-term prognosis in post-CABG Japanese patients in a multicenter cohort.Methods and Results:We enrolled 346 post-CABG patients who underwent cardiopulmonary exercise testing during early (2-3 weeks) and late (3-6 months) time points after surgery. They formed the Active (n=240) and Non-Active (n=106) CR participation groups and were followed for 3.5 years. Primary endpoint was a major adverse cardiac event (MACE): all-cause death or rehospitalization for acute myocardial infarction/unstable angina/worsening heart failure. Peak oxygen uptake at 3-5 months from baseline was significantly more increased in Active than in Non-Active patients (+26±24% vs. +19±20%, respectively; P<0.05), and the MACE rate was significantly lower in Active than Non-Active patients (3.4% vs. 10.5%, respectively; P=0.02). Multivariate Cox proportional hazard analysis showed that participation in outpatient CR was a significant prognostic determinant of MACE (P=0.03).

CONCLUSIONS

This unique study showed that a multicenter cohort of patients who underwent CABG and actively participated in outpatient CR exhibited greater improvement in exercise capacity and better survival without cardiovascular events than their counterparts who did not participate.

Patency When Grafted to Coronary Stenosis More Than 50% in LIMA-RA-Y Grafts

BACKGROUND

Recent coronary surgery practice is to graft arterial conduits to more severely stenosed coronary targets than in the past. We aimed to investigate postoperative arterial graft patency with native coronary stenosis at the time of surgery, using the left internal mammary artery and radial artery (RA) as a composite Y graft (LIMA-RA-Y). In the study timeframe, it was routine clinical practice to graft coronary arteries with >50% stenosis.

METHODS

Of 464 patients previously reported 1996-1999, 346 who underwent LIMA-RA-Y at the Royal Melbourne Hospital, 76 had postoperative angiograms at the same institution. Each anastomosis was considered separately. For arterial grafts a "string sign" was analysed as being occluded. Predictor of patency was performed with a generalised linear mixed model (GLMM).

RESULTS

Seventy-six (76) patients had postoperative angiograms at 5.8±5.4 years (range 0.23-19.4; interquartile range 1.7-10.0) years postoperative; with age at operation 62.5±10.7 years and 3.4±0.8 grafts per patient, 82% were male. Of 256 anastomoses, 230 were to coronary targets >50% stenosis. Overall patency was 84.0% (214/256). For coronary stenosis >50%, patency was 88% (201/230) and varied by coronary territory left anterior descending (LAD) 94% (87/93), circumflex 90% (71/79) and right coronary artery (RCA) 74% (43/58). Interaction for coronary territory was significant (p=0.022). Higher preoperative coronary stenosis predicted higher patency; with odds ratio for improved patency of 1.83 (95% CI 1.51, 2.22), p<0.001 for each 10% increase in stenosis.

CONCLUSIONS

Late patency of composite arterial grafts is acceptable when grafted to coronary arteries of greater than 50% stenosis.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019

This highlights in our specialty for 2019 begin with the ongoing major developments in transcatheter valve interventions. Thereafter, the advances in left ventricular assist devices are reviewed. The recent focus on conduit selection and robotic options in coronary artery bypass surgery are then explored. Finally, this special articles closes with a discussion of pulmonary hypertension in noncardiac surgery, anesthetic technique in cardiac surgery, as well as postoperative pneumonia and its outcome consequences.

Multiarterial coronary artery bypass grafting: is the radial artery fulfilling the unkept promise of the right internal thoracic artery?

PURPOSE OF REVIEW

The debate on the second best conduit for CABG is still intense. In this review, we discuss the role of the radial artery and the right internal thoracic artery (RITA) compared with saphenous vein grafts (SVG).

RECENT FINDINGS

The recent RADIAL STUDY has been the first evidence based on randomized trials of a clinical benefit using a second arterial graft in CABG.On the other hand, the definitive 10-year results of the ART trial failed to show a clinical advantage associated with the use of bilateral internal thoracic artery (BITA). A thorough and contextualized analysis of this and other studies, however, may offer a different perspective.

SUMMARY

Arterial conduits in CABG have shown better patency rates than SVG. Whether this leads to better clinical outcomes is still debated. In this setting, the radial artery and the RITA seem to offer a similar advantage, although with different indications and contraindications.

Total arterial revascularization strategies: A meta-analysis of propensity score-matched observational studies

BACKGROUND AND AIM OF THE STUDY

We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy.

METHODS

PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding.

RESULTS

Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR with the bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77).

CONCLUSIONS

TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection.

Editor-in-Chief's Top Picks From 2018

Each week, I record audio summaries for every article in JACC, as well as an issue summary. Although this process is quite time-consuming, I have become familiar with every paper that we publish. Thus, I have personally selected the top 100 papers (both Original Investigations and Review Articles) from 15 distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure, Cardiomyopathies/Myocardial & Pericardial Diseases, Cardio-oncology, Congenital Heart Disease, Coronary Disease & Interventions, CVD Prevention & Health Promotion, CV Medicine & Society, Hypertension, Imaging, Metabolic & Lipid Disorders, Rhythm Disorders, Valvular Heart Disease, and Vascular Medicine (1-100).