Author + information
- Received October 5, 2019
- Accepted November 5, 2019
- Published online January 20, 2020.
- Faisal G. Bakaeen, MDa,∗∗ (, )@FaisalBakaeen,
- Kirthi Ravichandren, MDa,∗,
- Eugene H. Blackstone, MDa,b,
- Penny L. Houghtaling, MSb,
- Edward G. Soltesz, MDa,
- Douglas R. Johnston, MDa,
- Stephanie L. Mick, MDa,
- José L. Navia, MDa,
- Michael Zhen-Yu Tong, MD, MBAa,
- Kenneth R. McCurry, MDa,
- Rami Akhrass, MDa,
- Mouin Abdallah, MDc,
- Gösta B. Pettersson, MD, PhDa,
- Nicholas M. Smedira, MDa,
- Eric E. Roselli, MDa,
- A. Marc Gillinov, MDa and
- Lars G. Svensson, MD, PhDa
- aDepartment of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
- bQuantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
- cCardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
- ↵∗Address for correspondence:
Dr. Faisal G. Bakaeen, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-1, Cleveland, Ohio 44195.
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.
↵∗ Drs. Bakaeen and Ravichandren contributed equally to this work.
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.
- Received October 5, 2019.
- Accepted November 5, 2019.
- 2020 American College of Cardiology Foundation
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