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THE JOURNAL OF CARDIOVASCULAR SURGERY

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

lingua: Inglese

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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