Loberman Dan, Pevni Dmitry, Mohr Rephael, Paz Yosef, Nesher Nahum, Midlij Mohamad Khaled, Ben-Gal Yanai
Division of Cardiac Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
Department of Cardiothoracic Surgery, Faculty of Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.
J Am Heart Assoc. 2017 Jul 21;6(7):e005951. doi: 10.1161/JAHA.117.005951.
Bilateral internal thoracic artery grafting (BITA) is associated with improved survival. However, surgeons do not commonly use BITA in patients after myocardial infarction (MI) because survival is good with single internal thoracic artery grafting (SITA). We aimed to compare the outcomes of BITA with those of SITA and other approaches in patients with multivessel disease after recent MI.
In total, 938 patients with recent MI (<3 months) who underwent BITA between 1996 and 2011 were compared with 682 who underwent SITA. SITA patients were older and more likely to have comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure, peripheral vascular disease), to be female, and to have had a previous MI. Acute MI and 3-vessel disease were more prevalent in the BITA group. Operative mortality of BITA patients was lower (3.0% versus 5.8%, =0.01), and sternal infections and strokes were similar. Median follow-up was 15.21 years (range: 0-21.25 years). Survival of BITA patients was better (70.3% versus 52.5%, <0.001). Propensity score matching was used to account for differences in preoperative characteristics between groups. Overall, 551 matched pairs had similar preoperative characteristics. BITA was a predictor of better survival in the matched groups (hazard ratio: 0.679; =0.002; Cox model). Adjusted survival of emergency BITA and SITA patients was similar (hazard ratio: 0.883; =0.447); however, in the nonemergency group, BITA was a predictor of better survival (hazard ratio: 0.790; =0.009; Cox model).
This study suggests that survival is better with BITA compared with SITA in nonemergency cases after recent MI, with proper patient selection.
双侧胸廓内动脉移植术（BITA）与生存率提高相关。然而，由于单支胸廓内动脉移植术（SITA）的生存率良好，外科医生在心肌梗死（MI）患者中并不常用BITA。我们旨在比较近期MI后多支血管病变患者中BITA与SITA及其他方法的疗效。
总共将1996年至2011年间接受BITA的938例近期MI（<3个月）患者与682例接受SITA的患者进行比较。SITA患者年龄更大，更可能有合并症（糖尿病、慢性阻塞性肺疾病、慢性肾衰竭、外周血管疾病），女性患者更多，且既往有MI。BITA组急性MI和三支血管病变更为常见。BITA患者的手术死亡率较低（3.0%对5.8%，P=0.01），胸骨感染和中风情况相似。中位随访时间为15.21年（范围：0至21.25年）。BITA患者的生存率更高（70.3%对52.5%，P<0.001）。采用倾向评分匹配法来解释组间术前特征的差异。总体而言，551对匹配患者具有相似的术前特征。在匹配组中，BITA是生存率更高的预测因素（风险比：0.679；P=0.002；Cox模型）。急诊BITA和SITA患者的调整后生存率相似（风险比：0.883；P=0.447）；然而，在非急诊组中，BITA是生存率更高的预测因素（风险比：0.790；P=0.009；Cox模型）。
本研究表明，在近期MI后的非急诊病例中，经过适当的患者选择，BITA的生存率优于SITA。
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