Aventura Medical Center, Aventura, FL, USA.
J Thorac Cardiovasc Surg. 2012 Apr;143(4):844-853.e4. doi: 10.1016/j.jtcvs.2011.12.026. Epub 2012 Jan 14.
Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied.
Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm.
There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001).
Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered.
冠状动脉旁路移植术中使用双侧内乳动脉（BITA）搭桥已被证明可改善长期生存率。然而，在高风险患者中使用这种技术仍存在顾虑。射血分数（EF）降低的患者手术风险更高，长期生存率降低。我们研究了在 EF 降低的大量患者中广泛应用 BITA 技术时，与单根内乳动脉（SITA）搭桥相比，BITA 的围手术期和长期结果。
1972 年 2 月至 1994 年 5 月，连续 4537 例 EF 记录的患者接受了 SITA（2340 例）或 BITA（2197 例）搭桥。前瞻性收集的临床数据将 EF 明确归类为小于 0.30（组 I；n=233）、0.30 至 0.50（组 II；n=1256）或大于 0.50（组 III；n=3048）。采用多变量分析确定手术和晚期死亡率的相关因素。使用倾向评分进行最优匹配，创建匹配的 SITA 和 BITA 队列：组 I，SITA 和 BITA，n=87 例；组 II，SITA 和 BITA，n=448 例；组 III，SITA 和 BITA，n=1137 例。通过对数秩算法测试生存分布的均等性。
匹配的 SITA 和 BITA 组之间的手术死亡率没有差异（组 I：SITA 与 BITA，10.3%与 6.9%，P=0.418；组 II：4.7%与 4.5%，P=0.873；组 III：3.2%与 2.0%，P=0.086）。逻辑回归分析显示，SITA 与 BITA 不是手术死亡率的预测因素。在术后任何并发症（包括胸骨伤口感染）的无并发症发生率方面，匹配的 SITA 和 BITA 组之间没有差异。在组 II 和 III 中，使用 BITA 搭桥可显著提高晚期生存率（10 年和 20 年生存率，SITA 与 BITA 在组 II 中的比较：57.7%±0.3%和 19%±2.5%与 62.0%±2.3%和 33.1%±3.4%，P=0.016；在组 III 中的比较：67.1%±1.4%和 35.8%±1.7%与 74.6%±1.3%和 38.1%±2.1%，P=0.012）。同样，在 Cox 回归中，在组 II（P<0.007）和 III（P<0.001）中，SITA 与 BITA 的选择也是晚期死亡率的显著预测因素。
在倾向性匹配的患者中，广泛应用 BITA 与 SITA 搭桥相比，可提高长期生存率，且不会增加 EF 正常和降低患者的手术死亡率或发病率。应认真考虑扩大 BITA 搭桥的应用。
