Sequential composite BIMA grafting for 3v-CAD: factors that predict successful outcome of the one-inflow and two-inflow revascularization techniques

• Published in: General thoracic and cardiovascular surgery Vol. 72; no. 10; pp. 656 - 667
• Main Authors: Andrási, Terézia B., Glück, Alannah C., Talipov, Ildar, Volevski, Lachezar, Vasiloi, Ion
• Format: Journal Article
• Language: English
• Published: Singapore Springer Nature Singapore 01.10.2024; Springer Nature B.V
• Subjects: Aged; Angina pectoris; Cardiac Surgery; Cardiology; Cardiovascular disease; Coronary Angiography; Coronary Artery Bypass - adverse effects; Coronary Artery Bypass - methods; Coronary Artery Bypass - mortality; Coronary Artery Disease - mortality; Coronary Artery Disease - surgery; Coronary vessels; Delirium; Female; Heart attacks; Hospitals; Humans; Hypertension; Ischemia; Kaplan-Meier Estimate; Male; Mammary Arteries - surgery; Mammary Arteries - transplantation; Medical imaging; Medicine; Medicine & Public Health; Middle Aged; Mortality; Original; Original Article; Patients; Proportional Hazards Models; Retrospective Studies; Risk Factors; Surgeons; Surgical Oncology; Thoracic Surgery; Time Factors; Treatment Outcome; Weaning; Operative technique; BIMA T-Graft; Surgical revascularization; Two-inflow; MACCE; Triple-vessel coronary artery disease; Functional mitral valve regurgitation
• ISSN: 1863-6705; 1863-6713; 1863-6713
• DOI: 10.1007/s11748-024-02022-0

Objective The effect of one-inflow and two-inflow coronary surgical revascularization techniques inclosing skeletonized double mammary artery (BIMA) as T-graft on outcome is studied. Methods Early ad mid-term outcome of complete BIMA revascularization (C-T-BIMA) versus left-sided BIMA with right-sided aorto-coronary bypass (L-T-BIMA + R-CABG) is quantified and analyzed by multivariate logistic regression, Cox-regression, and Kaplan–Meier analysis in a series of 204 consecutive patients treated for triple-vessel coronary disease (3v-CAD). Results The L-T-BIMA + R-CABG technique ( n  = 104) enables higher number of total (4.02 ± 0.87 vs. 3.71 ± 0.69, p  = 0.015) and right-sided (1.21 ± 0.43 vs. 1.02 ± 0.32, p  = 0.001) coronary anastomoses, improves total bypass flow (125.88 ± 92.41 vs. 82.50 ± 49.26 ml, p  < 0.0001) and bypass flow/anastomosis (31.83 ± 23.9 vs.22.77 ± 14.23, p  = 0.001), and enhances completeness of revascularization (84% vs.69%, p  = 0.014) compared to C-T-BIMA strategy ( n  = 100), respectively. Although the incidence of MACCE was comparable in the two groups (8% vs.1.2%, p  = 0.055), the progression of functional mitral regurgitation (FMR) was significantly lower after L-T-BIMA + R-CABG, then after C-T-BIMA (47% vs.64%, p  = 0.017). The use of C-T-BIMA-technique (HR = 4.2, p  = 0.01) and preoperative RCA occlusion (HR = 3.006, p  = 0.023) predicted FMR progression, whereas L-T-Graft + R-CABG technique protected against it (X 2  = 14.04, p  < 0.0001) independent of the anatomic and clinical complexity (Syntax score I: HR = 16.2, p  = 0.156, Syntax score II: HR = 1.901, p  = 0.751), of early- (0.96% vs.2%, p  = 0.617) and mid-term mortality (5.8% vs.4%, p  = 0.748) when compared to C-T-BIMA, respectively. Conclusions The two-inflow coronary revascularization by L-T-BIMA + R-CABG better protects against FMR progression without increasing MACCE and mortality. Older patients with RCA occlusion and reduced LV-EF benefit most from the two-inflow L-T-BIMA + R-CABG technique. Younger 3v-CAD patients with normal LV-EF can preferentially be managed with the one-inflow C-T-BIMA; however, long-term outcome remains to be revealed.