Early and Late Outcomes of Single versus Bilateral Internal Thoracic Artery Revascularization for Patients in Critical Condition

Objective: Bilateral internal thoracic artery (BITA) revascularization is considered to be the highest standard of surgical care for the treatment of patients with complex coronary disease. However, the optimal surgical approach for patients presenting to the operation in critical state is indecisive. In our center, left-sided BITA grafting is the preferred method for surgical revascularization, frequently also for high risk patients. In this study we sought to compare the outcome of bilateral vs single ITA revascularization in critical patients.

Methods: We evaluated short- and long-term outcomes of all patients who underwent surgical revascularization in our center during 1996-2011, critical preoperative state was acknowledged briefly with either of the following: preoperative ventricular tachycardia or fibrillation, aborted sudden cardiac death, cardiac massage, need for mechanical ventilation or preoperative insertion intra-aortic balloon counter-pulsation.

Results: In total, 394 critically defined patients with multi-vessel disease underwent CABG during the study period. Of them, 193 underwent SITA while 201 underwent BITA grafting. Those who underwent SITA were more likely to be older, female gender, suffer from recent MI, left main disease and had a higher logistic euroscore ranks.

No statistically significant difference was observed between the SITA and BITA groups in 30-day mortality (13.0% vs. 8.5%, p=0.148) or in other early outcomes. Long-term survival (median follow up of 17.4 years IQR 13.5-20) was significantly better in the BITA group (median 9.31+/- 0.9 vs 14.4 +/- 1.1 years, p=0.001). Propensity score matching (132 matched pairs) yielded similar improved long-term outcomes for the BITA group, while in multivariable analysis BITA revascularization was found to be a predictor for improved survival with a HR of 0.431 (95%CI 0.24-0.77) p=0.004.

Conclusions: This study demonstrated long term clinical benefit for BITA revascularization in patients presenting for surgical revascularization in critical pre-operative state.