Should Diabetes Be a Contraindication to Bilateral Internal Mammary Artery Grafting?

Iribarne, Alexander; Westbrook, Benjamin M.; Malenka, David J.; Schmoker, Joseph D.; McCullough, Jock N.; Leavitt, Bruce J.; Weldner, Paul W.; DeSimone, Joseph; Kramer, Robert S.; Quinn, Reed D.; Olmstead, Elaine M.; Klemperer, John D.; Sardella, Gerald L.; Ross, Cathy S.; DiScipio, Anthony W.

doi:10.1016/j.athoracsur.2017.08.054

Cited by 20 publications

(16 citation statements)

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“…In contrast to our findings of higher mortality in the diabetic BIMA population (versus LIMA), Gansera and colleagues [7] identified significantly lower rates of operative mortality (3.1% vs 4.7%) in diabetic BIMA (versus single internal mammary artery) patients [17]. Furthermore, multiple previous studies have demonstrated similar rates of operative mortality and significantly reduced hazard for longterm mortality among diabetic patients who received BIMA versus single internal mammary artery grafts [18][19][20]. However, all of these previous studies were retrospective and limited to a single institution or to a regional collaborative.…”

Section: Commentcontrasting

confidence: 76%

Bilateral Internal Mammary Artery Use in Diabetic Patients: Friend or Foe?

Crawford

Zhou

Fraser

et al. 2018

The Annals of Thoracic Surgery

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Section: Commentcontrasting

confidence: 76%

Bilateral Internal Mammary Artery Use in Diabetic Patients: Friend or Foe?

Crawford

Zhou

Fraser

et al. 2018

The Annals of Thoracic Surgery

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“…But they speculate that there is evidence that late outcome of surgical revascularization is improved when at least two arterial grafts are used and conclude that every patient should receive arterial grafts. In a PS-matched analysis among diabetic patients with a median duration of followup of 9.3 years, 23 patients who received a BIMA also had significantly improved long-term survival when compared with SIMA patients. Our data do not support these earlier results in diabetic patients.…”

Section: Discussionmentioning

confidence: 97%

Off-pump Revascularization with Bilateral versus Single Mammary Arteries—A Propensity Score-Matched Analysis

Puehler

Zittermann

Dia³

et al. 2019

Thorac Cardiovasc Surg

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Background Coronary artery bypass grafting is the first-line therapy for severe multivessel coronary artery disease. We aimed to investigate the clinical outcome in patients undergoing isolated off-pump surgery with the single or bilateral internal mammary artery (SIMA or BIMA) approach. Methods We performed a propensity score-matched analysis in 1,852 consecutive patients, aged 50 to 70 years, who underwent myocardial revascularization at our institution between July 2009 and August 2016. Primary end point was the probability of survival. Results Mean follow-up was 36.3 (range: 0.1–89.6) months. The probability of survival in the SIMA and BIMA groups was 98.6 and 99.0% at year 1, 92.0 and 92.5% at year 5, and 85.6 and 81.6% at year 7, respectively, with a hazard ratio (HR) of mortality for the BIMA group versus the SIMA group of 0.98 (95% confidence interval[CI]: 0.64–1.52; p = 0.94). There was evidence for interaction between diabetes and study group on mortality risk (HR = 2.59, 95% CI: 1.07–6.23; p = 0.034). Freedom from mediastinitis/wound infection was higher in the SIMA group than in the BIMA group (99.5 and 96.9%, respectively; HR of an event = 6.39, 95% CI: 2.88–14.18; p < 0.001). The corresponding values in the subgroups of diabetic patients were 98.6 and 90.9%, respectively (HR = 6.45, 95% CI: 2.24–18.58; p = 0.001). Mediastinitis/wound infection was associated with increased mortality risk (HR = 2.96, 95% CI: 1.29–6.78; p = 0.010). Conclusion Overall, our data indicate similar probability of survival up to a maximum follow-up of 7 years by off-pump surgery with the SIMA or BIMA approach. However, in diabetic patients, the clinical outcome indicates caution regarding the use of the BIMA approach.

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“…Several studies have shown the superiority of arterial grafts over venous grafts in terms of long-term survival, need of repeated revascularization, and graft failure [28,29,31,32] without impact on in-hospital mortality [33]. But in our practice, and for a long time, we considered diabetes as an absolute contraindication to BITA harvesting because of the "inevitable and frightening" mediastinitis.…”

Section: Discussionmentioning

confidence: 98%

“…However, BITA was indicated in the univariate analysis but was not significant in multivariate analysis as an independent predictor of mediastinitis. Even if several recent publications [28,29] claimed that BITA use has not been associated with an increased risk of mediastinitis compared to SITA, the debate remains; Taggart et al [30] had published the 5-year results of ART investigation and found that BITA was significantly associated with higher rate of both sternal wound complications and sternal reconstructions without benefit of survival or freedom from adverse events at 5 years. However, it seems that the risk can be lowered if graft harvesting was made by skeletonized fashion with meticulous attention to preserve sternal blood flow [31,32].…”

Section: Discussionmentioning

confidence: 99%

Coronary artery bypass surgery in type 2 diabetic patients: predictors of mortality and morbidity

et al. 2019

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Background: Coronary artery bypass grafting has been widely admitted in the therapeutic arsenal of coronary artery disease in diabetics with low morbi-mortality. However, it requires special management which may be challenging in low-volume centers especially in African countries. We aimed to analyze the outcome of coronary artery bypass graft in our diabetic population and define predictors of adverse events. Patients and methods: We retrospectively enrolled 529 consecutive diabetic patients (type 2) who underwent onpump coronary artery bypass grafting at our institution between January 2000 and June 2018. The mean age was 61.1 ± 8.3 years with 4.04 as sex ratio (M/F) and 2.95 as mean EuroSCORE II. History of acute myocardial infarction, left main coronary artery stenosis, and three-vessel disease was present in respectively 58%, 26.1%, and 72.2% of patients. The average number of bypass was 2.4 ± 0.8. Duration of cardiopulmonary bypass and aortic crossclamping were respectively 124.8 ± 43.5 and 79.7 ± 32.9 min. Results: In-hospital mortality was 5.9% (n = 31) and the late mortality was 6.9% (n = 32). Duration of artificial ventilation, ICU stay, and postoperative stay were respectively 7 h, 44 h, and 13 days. Postoperative complications were myocardial infarction, superficial wound infection, mediastinitis, and low cardiac output syndrome in respectively 9.1%, 25.5%, 3.8%, and 12.7% of patients. Multivariable logistic regression analysis revealed that left ventricular ejection fraction < 40% (OR = 1.88; 95% CI 1.30-2.47; p = 0.03), poor perioperative glycemic control (OR = 1.53; 95% CI 1.12-2.38; p = 0.014), intra-aortic balloon pump insertion (OR = 2.29; 95% CI 1.47-3.10; p < 0.001), and postoperative cardiac complications (OR = 2.01; 95% CI 1.23-2.78; p < 0.001) were predictors of in-hospital mortality. Predictors of mediastinitis were obesity (OR = 5.86; 95% CI 1.43-23.95; p = 0.014), inotropic drugs use (OR = 8.14; 95% CI 1.57-42.34; p = 0.013), chest reopening for bleeding (OR = 4.01; 95% CI 0.62-25.85; p = 0.014), and blood transfusion (OR = 7.56; 95% CI 1.09-52.76; p = 0.041). Follow-up was 86.1% complete, with a mean follow-up of 63.5 ± 48.3 months (1-192 months), and cumulative survival at 5, 10, and 15 years was respectively 95.5 ± 1.1%, 86.3 ± 2.9%, and 76.9 ± 6.9%. Conclusion: Even in low-volume centers in developing areas, coronary artery bypass surgery is an effective therapy for coronary artery disease in diabetic patients despite a relative high morbidity and mortality.

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Should Diabetes Be a Contraindication to Bilateral Internal Mammary Artery Grafting?

Abstract: Among diabetics undergoing CABG, use of BIMA grafting does not result in increased in-hospital morbidity or mortality and confers a long-term survival advantage when compared with SIMA grafting. Thus, diabetic patients should be considered for BIMA grafting more frequently.

Cited by 20 publications

References 38 publications

Bilateral Internal Mammary Artery Use in Diabetic Patients: Friend or Foe?

Bilateral Internal Mammary Artery Use in Diabetic Patients: Friend or Foe?

Off-pump Revascularization with Bilateral versus Single Mammary Arteries—A Propensity Score-Matched Analysis

Coronary artery bypass surgery in type 2 diabetic patients: predictors of mortality and morbidity

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