Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes.

Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis. This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations. Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; P = 0.99). Outcomes persisted on adjusted analyses. Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings.

Gikandi A ，Stock E ，DeMatt E ，Hirji S ，Awtry J ，Quin JA ，Tolis G Jr ，Biswas K ，Zenati MA ... -  《-》

Value of internal thoracic artery grafting to the left anterior descending coronary artery at coronary reoperation.

The study sought to determine if left internal thoracic artery (LITA) grafting of the left anterior descending (LAD) at reoperative coronary artery bypass grafting (CABG) improves patient outcomes. LITA grafting to the LAD is the gold standard for primary CABG, but its value for reoperative CABG is unknown. From January 1985 to January 2007, reoperative CABG was performed in 3,473 patients who did not receive a LITA during their primary CABG and whose anterior myocardium (LAD) was at risk at reoperation: 2,389 had LITA grafting and 1,084 saphenous vein (SV) grafting to the LAD. Propensity matching (908 matched pairs) was used for balanced comparison of outcomes. Follow-up was continued to 20 years post-operatively, with a mean follow-up of 11 ± 8.2 years. Unadjusted hospital mortality was 2.2% and 6.5% in the LITA and SV groups, respectively (p < 0.001), but 3.1% and 5.6% in propensity-matched groups (p = 0.008). Unadjusted survival at 1, 5, 10, 15, and 20 years was 94%, 82%, 64%, 46%, and 32% for the LITA group, but 88%, 73%, 50%, 32%, and 18% for the SV group (p <.0001), respectively. For propensity-matched groups, both early (p = 0.01) and late survival was greater (p = 0.005) in the LITA group. At 20 years, LITA grafting of the LAD at reoperation resulted in an absolute mortality risk reduction of 6.0% and a hazard ratio of 0.85, with number needed to treat of 16 patients. LITA-to-LAD grafting at reoperation is safe and confers a risk-adjusted survival advantage. When appropriate, a LITA should be used to revascularize the LAD at coronary reoperations.

Sabik JF 3rd ，Raza S ，Blackstone EH ，Houghtaling PL ，Lytle BW ... -  《-》

Bilateral internal thoracic artery grafting: Does graft configuration affect outcome?

Despite evidence that bilateral internal thoracic arteries (ITAs) improve long-term survival after coronary artery bypass grafting (CABG), uptake of this technique remains low. We directly compared bilateral ITA graft configurations and examined long-term outcomes. We reviewed 762 patients who underwent CABG using bilateral ITA grafts at our institution between 1997 and 2014. The outcomes were mortality and a composite revascularization end point defined as need for percutaneous coronary intervention or repeat CABG. Adjusted subgroup analyses were performed using propensity score-adjusted Cox proportional hazards modeling. The cohort was divided into 4 groups: in situ (left ITA [LITA] anastomosed to the left anterior descending artery [LAD] with in situ right ITA [RITA] anastomosed to the left coronary circulation [239 patients]); in situ LITA-LAD and in situ RITA-right coronary circulation (239 patients); in situ RITA-LAD with in situ LITA-left coronary circulation (185 patients); and in situ LITA-LAD with a free RITA as a composite graft with inflow from the LITA or a saphenous vein graft (99 patients). Over a median follow-up of 1128 days, there were 47 deaths, 58 late percutaneous coronary interventions, and 7 repeat CABG procedures. Unadjusted Kaplan-Meier analysis revealed a difference in need for repeat revascularization among the 4 groups (log rank P = .049). However, after statistical adjustment, graft configuration was not an independent predictor of repeat revascularization or death. Bilateral ITA graft configuration has no independent effect on need for repeat revascularization or long-term survival. Therefore, the simplest technique, determined by individual patient characteristics, should be selected.

Magruder JT ，Young A ，Grimm JC ，Conte JV ，Shah AS ，Mandal K ，Sciortino CM ，Zehr KJ ，Cameron DE ，Price J ... -  《-》

Minimally invasive single-vessel left internal mammary to left anterior descending artery bypass grafting improves outcomes over conventional sternotomy: A single-institution retrospective cohort study.

Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally-invasive CABG (MICABG) may reduce perioperative morbidity. Previous results demonstrate improved perioperative outcomes; however, adoption has been limited. The Society of Thoracic Surgeons (STS) database and electronic medical record at a single institution were reviewed for isolated left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between 2011 and 2018. Patients were grouped on the basis of operative approach, comparing sternotomy to non-sternotomy (minimally-invasive). Patient characteristics, perioperative variables, and short- and long-term outcomes were compared. Primary outcomes included mortality and major adverse cardiac events (MACE). Secondary outcomes were morbidity. A total of 42 MICABG and 54 conventional LIMA-LAD procedures were performed with 95.2% of MICABG procedures performed by two surgeons. MICABG were more often elective (83.3 vs 38.9%, P < .001). STS risk scores predicted equitable mortality and morbidity for MICABG dependent on operative indication. MICABG was associated with fewer pulmonary complications (0.0 vs 11.1%, P = .033), in-hospital events (11.9 vs 37.0%, P = .005), and shorter intensive care unit (34.1 vs 66.0 hours, P = .022) and total length of stay (3.7 vs 6.5 days, P = .002). There were no observed strokes, myocardial infarctions, or reoperations. MICABG patients demonstrated reduced thirty-day mortality (0.0 vs 10.9%, P = .036) and improved Kaplan-Meier 5-year (95.2 vs 77.9%, P = .016) and MACE-free survival (89.2 vs 63.9%, P = .010). Minimally-invasive LIMA-LAD CABG demonstrates improved early postoperative morbidity and a long-term mortality benefit. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial when performed by experienced surgeons in the elective setting.

Smith NJ ，Miles B ，Cain MT ，Joyce LD ，Pearson P ，Joyce DL ... -  《-》

Results of the Minimally Invasive Coronary Artery Bypass Grafting Angiographic Patency Study.

Minimally invasive coronary artery bypass grafting is safe and widely applicable, and may be associated with fewer transfusions and infections, and better recovery than standard coronary artery bypass grafting. However, graft patency rates remain unknown. The Minimally Invasive Coronary Artery Bypass Grafting Patency Study prospectively evaluated angiographic graft patency 6 months after minimally invasive coronary artery bypass grafting. In this dual-center study, 91 patients were prospectively enrolled to undergo minimally invasive coronary artery bypass grafting via a 4- to 7-cm left thoracotomy approach. The left internal thoracic artery, the ascending aorta for proximal anastomoses, and all coronary targets were directly accessed without endoscopic or robotic assistance. The study primary outcome was graft patency at 6 months, using 64-slice computed tomography angiography. Secondary outcomes included conversions to sternotomy and major adverse cardiovascular events (Clinical Trial Registration Unique identifier: NCT01334866). The mean age of patients was 64 ± 8 years, the mean ejection fraction was 51% ± 11%, and there were 10 female patients (11%) in the study. Surgeries were performed entirely off-pump in 68 patients (76%). Complete revascularization was achieved in all patients, and the median number of grafts was 3. There was no perioperative mortality, no conversion to sternotomy, and 2 reopenings for bleeding. Transfusion occurred in 24 patients (26%). The median length of hospital stay was 4 days, and all patients were followed to 6 months, with no mortality or major adverse cardiovascular events. Six-month computed tomography angiographic graft patency was 92% for all grafts and 100% for left internal thoracic artery grafts. Minimally invasive coronary artery bypass grafting is safe, feasible, and associated with excellent outcomes and graft patency at 6 months post-surgery.

Ruel M ，Shariff MA ，Lapierre H ，Goyal N ，Dennie C ，Sadel SM ，Sohmer B ，McGinn JT Jr ... -  《-》