Alexander Iribarne1, Joseph D Schmoker2, David J Malenka2, Bruce J Leavitt2, Jock N McCullough2, Paul W Weldner2, Joseph P DeSimone2, Benjamin M Westbrook2, Reed D Quinn2, John D Klemperer2, Gerald L Sardella2, Robert S Kramer2, Elaine M Olmstead2, Anthony W DiScipio2. 1. From Department of Surgery, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (A.I., D.J.M., J.N.M., J.P.D., E.M.O., A.W.D.); Department of Medicine, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (D.J.M.); Department of Surgery, Section of Cardiac Surgery, University of Vermont Medical Center, Burlington (J.D.S., B.J.L.); Department of Surgery, Section of Cardiac Surgery, Central Maine Medical Center, Lewiston (P.W.W.); Department of Surgery, Section of Cardiac Surgery, Catholic Medical Center, Manchester, NH (B.M.W.); Department of Surgery, Section of Cardiac Surgery, Maine Medical Center, Portland (R.D.Q., R.S.K.); Department of Surgery, Section of Cardiac Surgery, Eastern Maine Medical Center, Bangor (J.D.K.); and Department of Surgery, Section of Cardiac Surgery, Concord Hospital, NH (G.L.S.). alexander.iribarne@hitchcock.org. 2. From Department of Surgery, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (A.I., D.J.M., J.N.M., J.P.D., E.M.O., A.W.D.); Department of Medicine, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (D.J.M.); Department of Surgery, Section of Cardiac Surgery, University of Vermont Medical Center, Burlington (J.D.S., B.J.L.); Department of Surgery, Section of Cardiac Surgery, Central Maine Medical Center, Lewiston (P.W.W.); Department of Surgery, Section of Cardiac Surgery, Catholic Medical Center, Manchester, NH (B.M.W.); Department of Surgery, Section of Cardiac Surgery, Maine Medical Center, Portland (R.D.Q., R.S.K.); Department of Surgery, Section of Cardiac Surgery, Eastern Maine Medical Center, Bangor (J.D.K.); and Department of Surgery, Section of Cardiac Surgery, Concord Hospital, NH (G.L.S.).
Abstract
BACKGROUND: Although previous studies have demonstrated that patients receiving bilateral internal mammary artery (BIMA) conduits during coronary artery bypass grafting have better long-term survival than those receiving a single internal mammary artery (SIMA), data on risk of repeat revascularization are more limited. In this analysis, we compare the timing, frequency, and type of repeat coronary revascularization among patients receiving BIMA and SIMA. METHODS: We conducted a multicenter, retrospective analysis of 47 984 consecutive coronary artery bypass grafting surgeries performed from 1992 to 2014 among 7 medical centers reporting to a prospectively maintained clinical registry. Among the study population, 1482 coronary artery bypass grafting surgeries with BIMA were identified, and 1297 patients receiving BIMA were propensity-matched to 1297 patients receiving SIMA. The primary end point was freedom from repeat coronary revascularization. RESULTS: The median duration of follow-up was 13.2 (IQR, 7.4-17.7) years. Patients were well matched by age, body mass index, major comorbidities, and cardiac function. There was a higher freedom from repeat revascularization among patients receiving BIMA than among patients receiving SIMA (hazard ratio [HR], 0.78 [95% CI, 0.65-0.94]; P=0.009). Among the matched cohort, 19.4% (n=252) of patients receiving SIMA underwent repeat revascularization, whereas this frequency was 15.1% (n=196) among patients receiving BIMA (P=0.004). The majority of repeat revascularization procedures were percutaneous coronary interventions (94.2%), and this did not differ between groups (P=0.274). Groups also did not differ in the ratio of native versus graft vessel percutaneous coronary intervention (P=0.899), or regarding percutaneous coronary intervention target vessels; the most common targets in both groups were the right coronary (P=0.133) and circumflex arteries (P=0.093). In comparison with SIMA, BIMA grafting was associated with a reduction in all-cause mortality at 12 years of follow-up (HR, 0.79 [95% CI, 0.69-0.91]; P=0.001), and there was no difference in in-hospital morbidity. CONCLUSIONS: BIMA grafting was associated with a reduced risk of repeat revascularization and an improvement in long-term survival and should be considered more frequently during coronary artery bypass grafting.
BACKGROUND: Although previous studies have demonstrated that patients receiving bilateral internal mammary artery (BIMA) conduits during coronary artery bypass grafting have better long-term survival than those receiving a single internal mammary artery (SIMA), data on risk of repeat revascularization are more limited. In this analysis, we compare the timing, frequency, and type of repeat coronary revascularization among patients receiving BIMA and SIMA. METHODS: We conducted a multicenter, retrospective analysis of 47 984 consecutive coronary artery bypass grafting surgeries performed from 1992 to 2014 among 7 medical centers reporting to a prospectively maintained clinical registry. Among the study population, 1482 coronary artery bypass grafting surgeries with BIMA were identified, and 1297 patients receiving BIMA were propensity-matched to 1297 patients receiving SIMA. The primary end point was freedom from repeat coronary revascularization. RESULTS: The median duration of follow-up was 13.2 (IQR, 7.4-17.7) years. Patients were well matched by age, body mass index, major comorbidities, and cardiac function. There was a higher freedom from repeat revascularization among patients receiving BIMA than among patients receiving SIMA (hazard ratio [HR], 0.78 [95% CI, 0.65-0.94]; P=0.009). Among the matched cohort, 19.4% (n=252) of patients receiving SIMA underwent repeat revascularization, whereas this frequency was 15.1% (n=196) among patients receiving BIMA (P=0.004). The majority of repeat revascularization procedures were percutaneous coronary interventions (94.2%), and this did not differ between groups (P=0.274). Groups also did not differ in the ratio of native versus graft vessel percutaneous coronary intervention (P=0.899), or regarding percutaneous coronary intervention target vessels; the most common targets in both groups were the right coronary (P=0.133) and circumflex arteries (P=0.093). In comparison with SIMA, BIMA grafting was associated with a reduction in all-cause mortality at 12 years of follow-up (HR, 0.79 [95% CI, 0.69-0.91]; P=0.001), and there was no difference in in-hospital morbidity. CONCLUSIONS:BIMA grafting was associated with a reduced risk of repeat revascularization and an improvement in long-term survival and should be considered more frequently during coronary artery bypass grafting.