TY - JOUR
T1 - Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting
AU - Bakaeen, Faisal G.
AU - Ravichandren, Kirthi
AU - Blackstone, Eugene H.
AU - Houghtaling, Penny L.
AU - Soltesz, Edward G.
AU - Johnston, Douglas R.
AU - Mick, Stephanie L.
AU - Navia, José L.
AU - Tong, Michael Zhen Yu
AU - McCurry, Kenneth R.
AU - Akhrass, Rami
AU - Abdallah, Mouin
AU - Pettersson, Gösta B.
AU - Smedira, Nicholas M.
AU - Roselli, Eric E.
AU - Gillinov, A. Marc
AU - Svensson, Lars G.
N1 - Funding Information:
This study was funded in part by the Burdett, Margaret and Eugene Larson Endowed Fund in Cardiovascular Innovation and the Sheikh Hamdan bin Rashid Al Maktoum Distinguished Chair in Thoracic and Cardiovascular Surgery. Dr. Navia holds equity in NaviGate Cardiac Structures. Dr. Tong has received honoraria from Abbott and has been a member of the Advisory Board for Abiomed. Dr. Gillinov has been a consultant for AtriCure, Abbott, Edwards Lifesciences, Medtronic, Cryolife, ClearFlow, and Johnson & Johnson. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Publisher Copyright:
© 2020 American College of Cardiology Foundation
PY - 2020/1/28
Y1 - 2020/1/28
N2 - Background: The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting. Objectives: This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting. Methods: From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality. Results: A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target—77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival. Conclusions: In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.
AB - Background: The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting. Objectives: This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting. Methods: From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality. Results: A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target—77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival. Conclusions: In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.
KW - cardiac surgery
KW - coronary artery bypass grafting
KW - ischemic heart disease
KW - survival
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U2 - 10.1016/j.jacc.2019.11.026
DO - 10.1016/j.jacc.2019.11.026
M3 - Article
C2 - 31976863
AN - SCOPUS:85077649397
SN - 0735-1097
VL - 75
SP - 258
EP - 268
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 3
ER -