From Department of Surgery, Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (A.I., D.J.M., J.N.M., J.P.D., E.M.O., A.W.D.); Department of Medicine, Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (D.J.M.); Department of Surgery, Section of Cardiac Surgery, University of Vermont Medical Center, Burlington (J.D.S., B.J.L.); Department of Surgery, Section of Cardiac Surgery, Central Maine Medical Center, Lewiston (P.W.W.); Department of Surgery, Section of Cardiac Surgery, Catholic Medical Center, Manchester, NH (B.M.W.); Department of Surgery, Section of Cardiac Surgery, Maine Medical Center, Portland (R.D.Q., R.S.K.); Department of Surgery, Section of Cardiac Surgery, Eastern Maine Medical Center, Bangor (J.D.K.); and Department of Surgery, Section of Cardiac Surgery, Concord Hospital, NH (G.L.S.).
Circulation. 2017 Oct 31;136(18):1676-1685. doi: 10.1161/CIRCULATIONAHA.117.027405.
Although previous studies have demonstrated that patients receiving bilateral internal mammary artery (BIMA) conduits during coronary artery bypass grafting have better long-term survival than those receiving a single internal mammary artery (SIMA), data on risk of repeat revascularization are more limited. In this analysis, we compare the timing, frequency, and type of repeat coronary revascularization among patients receiving BIMA and SIMA.
We conducted a multicenter, retrospective analysis of 47 984 consecutive coronary artery bypass grafting surgeries performed from 1992 to 2014 among 7 medical centers reporting to a prospectively maintained clinical registry. Among the study population, 1482 coronary artery bypass grafting surgeries with BIMA were identified, and 1297 patients receiving BIMA were propensity-matched to 1297 patients receiving SIMA. The primary end point was freedom from repeat coronary revascularization.
The median duration of follow-up was 13.2 (IQR, 7.4-17.7) years. Patients were well matched by age, body mass index, major comorbidities, and cardiac function. There was a higher freedom from repeat revascularization among patients receiving BIMA than among patients receiving SIMA (hazard ratio [HR], 0.78 [95% CI, 0.65-0.94]; =0.009). Among the matched cohort, 19.4% (n=252) of patients receiving SIMA underwent repeat revascularization, whereas this frequency was 15.1% (n=196) among patients receiving BIMA (=0.004). The majority of repeat revascularization procedures were percutaneous coronary interventions (94.2%), and this did not differ between groups (=0.274). Groups also did not differ in the ratio of native versus graft vessel percutaneous coronary intervention (=0.899), or regarding percutaneous coronary intervention target vessels; the most common targets in both groups were the right coronary (=0.133) and circumflex arteries (=0.093). In comparison with SIMA, BIMA grafting was associated with a reduction in all-cause mortality at 12 years of follow-up (HR, 0.79 [95% CI, 0.69-0.91]; =0.001), and there was no difference in in-hospital morbidity.
BIMA grafting was associated with a reduced risk of repeat revascularization and an improvement in long-term survival and should be considered more frequently during coronary artery bypass grafting.
虽然先前的研究表明，接受双侧内乳动脉（BIMA）桥接的冠状动脉旁路移植术患者的长期生存率优于接受单根内乳动脉（SIMA）桥接的患者，但关于再次血运重建风险的数据则更为有限。在本分析中，我们比较了接受 BIMA 和 SIMA 治疗的患者再次血运重建的时间、频率和类型。
我们对 7 家医疗中心在 1992 年至 2014 年间进行的 47984 例连续冠状动脉旁路移植术进行了多中心回顾性分析，并向一个前瞻性维护的临床注册中心报告。在研究人群中，确定了 1482 例接受 BIMA 的冠状动脉旁路移植术，并且将 1297 例接受 BIMA 的患者与 1297 例接受 SIMA 的患者进行倾向匹配。主要终点是无再次血运重建。
中位随访时间为 13.2（IQR，7.4-17.7）年。患者在年龄、体重指数、主要合并症和心功能方面匹配良好。接受 BIMA 的患者无再次血运重建的比例高于接受 SIMA 的患者（风险比[HR]，0.78[95%CI，0.65-0.94]；=0.009）。在匹配队列中，19.4%（n=252）的接受 SIMA 的患者接受了再次血运重建，而接受 BIMA 的患者这一比例为 15.1%（n=196）（=0.004）。大多数再次血运重建手术是经皮冠状动脉介入治疗（94.2%），两组之间无差异（=0.274）。两组之间经皮冠状动脉介入治疗的靶血管之间也没有差异；两组最常见的靶血管均为右冠状动脉（=0.133）和回旋支动脉（=0.093）。与 SIMA 相比，BIMA 移植与 12 年随访时全因死亡率降低相关（HR，0.79[95%CI，0.69-0.91]；=0.001），且院内发病率无差异。
BIMA 移植与再次血运重建风险降低以及长期生存率提高相关，在冠状动脉旁路移植术中应更频繁地考虑。
