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The Journal of Cardiovascular Surgery 1998 February;39(1):57-63

Copyright © 2000 EDIZIONI MINERVA MEDICA

language: English

Long-term survival benefit of internal thoracic artery grafting is negligible in a patient with bad ventricle

Canver C. C., Heisey D. M., Nicholas R. D., Cooler S. D., Kroncke G. M.

From the Section of Cardiothoracic Surgery, William S. Middleton Memorial Veterans Hospital, University of Wisconsin School of Medicine, Madison, Wisconsin


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Background. Although ­the inter­nal tho­rac­ic ­artery (ITA) ­graft is ­well ­known ­for ­its ben­e­fit of enhanc­ing ­patient lon­gev­ity ­after cor­o­nary ­artery ­bypass graft­ing (­CABG), wheth­er ­its super­i­or paten­cy is asso­ciat­ed ­with ­improved ­patient sur­vi­val at ­all lev­els of ­left ven­tric­u­lar func­tion is ­unknown. The pur­pose of ­this ­study ­was to deter­mine wheth­er ­the ­use of ­ITA graft­ing dur­ing ­CABG con­fers ­improved sur­vi­val ben­e­fit to ­patients ­with ­impaired pre­op­er­a­tive ­left ven­tric­u­lar func­tion.
Methods. A ret­ro­spec­tive ­chart ­review ­was per­formed in 966 ­patients ­who ­had under­gone iso­lat­ed pri­mary ­CABG ­between 1984 ­and 1995. The ­study pop­u­la­tion includ­ed 320 ­patients ­with ­only ­venous con­duits (no-­ITA ­group) ­and 646 ­patients ­with at ­least ­one ­ITA con­duit (­ITA ­group). A Cox par­tial like­li­hood ­approach ­was ­used to mod­el ­the instan­ta­ne­ous mor­tal­ity ­risk ­ratios as func­tions of ­ITA ­use ­and pre­op­er­a­tive ejec­tion frac­tion (EF). The for­ward step­wise regres­sion mod­el spe­cif­i­cal­ly exam­ined ­the fol­low­ing poten­tial con­found­ers in ­the ­risk anal­y­ses: ­year of oper­a­tion, ­patient ­age, ­weight, ­body sur­face ­area, ­graft loca­tion, num­ber of ­grafts, per­fu­sion ­time, ische­mia ­time ­and Veterans Administration pre­op­er­a­tive car­diac sur­gi­cal ­risk esti­mates.
Results. Early (30-­day) mor­tal­ity in ­the ­ITA ­group (0.5%) ­was low­er ­than ­the no-­ITA ­group (4.1%) (p= 0.0004). While 91% of ­the ­ITA ­group ­patients ­were ­still ­alive, ­only 70% of ­the no-­ITA ­group ­patients ­were ­long-­term sur­vi­vors (p=0.0001). The ITA ­risk ­ratios ­for ­the increas­ing pro­por­tions of EF ­were ­not ­the ­same. In ­patients ­with E≤0.40, ­the ITA ­risk ­ratio, 2.96, ­was sig­nif­i­cant­ly dif­fer­ent (p=0.0001). It ­was ­only ­for EF >0.46, a sig­nif­i­cant sur­vi­val ben­e­fit ­due to an ITA ­graft ­could be detect­ed. The ­ITA-EF rela­tion­ship ­was ­not con­found­ed by ­the inclu­sion of ­those poten­tial con­found­ing var­i­ables in ­the mod­el.
Conclusions. Patient sur­vi­val ­after ­CABG ­using an ­ITA ­graft ­may be affect­ed by ­the lev­el of pre­op­er­a­tive EF. The inter­nal tho­rac­ic ­artery-spe­cif­ic ­patient sur­vi­val ben­e­fit ­appears to be ­less in a ­patient ­with ­poor ­left ven­tric­u­lar func­tion.

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