Abstract
Background
Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting in women. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender.
Methods
Of 786 consecutive women with multivessel coronary disease who underwent isolated coronary bypass surgery at the authors’ institution from 1999 throughout 2014, 477 (60.7%; mean age: 70 ± 7.7 years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models.
Results
There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2 ± 6.1%); glomerular filtration rate < 50 ml/min was an independent risk factor (p = 0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index >35 kg/m 2 (p = 0.0094), diabetes (p = 0.005), non-elective surgical priority (p = 0.0087) and multiple blood transfusions (p = 0.016). The mean follow-up was 6.8 ± 4.5 years. The non-parametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1–79.1], 59.5 (95% CI: 55.9–63.1) and 91.9% (95% CI: 90.1–93.7), respectively. Preoperative congestive heart failure (p = 0.04) and left main coronary artery disease (p = 0.0095) were predictors of major adverse cardiac and cerebrovascular events.
Conclusions
BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes.
Highlights
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Increased risk of complications prevents liberal use of bilateral internal thoracic artery (BITA) grafting in women.
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Outcomes of 477 women who underwent routine BITA grafting were reviewed retrospectively.
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There were 19 (4%) hospital deaths; glomerular filtration rate < 50 ml/min was an independent risk factor.
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The 13-year freedom from cardiac/cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization was 76.1, 59.5 and 91.9%, respectively.
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After routine BITA grafting, the increased rates of early complications in women do not prevent excellent late outcomes.
1
Introduction
In coronary artery bypass graft (CABG) surgery as well as in every cardiac operation, female gender is a predictor of poor early and late outcomes. In almost all scoring systems specifically designed to predict the operative risk after cardiac surgery, female gender is among the risk factors for hospital, or 30-day mortality . In almost all studies reporting immediate postoperative complications and long-term outcomes after CABG surgery, the results are worst in women .
In the last decade, the use of bilateral internal thoracic artery (BITA) grafting for myocardial revascularization has proven to be useful to improve long-term survival , even for high-risk patients such as dialysis or insulin-dependent patients . However, the use of BITA grafting is limited, and sometimes discouraged in women because of concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI) . Consequently, outcomes of routine BITA grafting remain largely unexplored in female gender. This disparity in BITA use by sex should be addressed in the interest of expanding the benefits of BITA grafting to more large number of patients.
The present authors have reviewed retrospectively their 16-year experience in routine use of BITA grafting in women. The aims of the study were to report immediate and long-term results and perform a risk factor analysis for poor outcomes.
2
Patients and methods
From January 1999 to December 2014, 786 consecutive women with multivessel coronary artery disease had isolated CABG surgery with at least one internal thoracic artery (ITA) graft at the authors’ institution; in 477 (60.7%) cases, BITA grafts were used for myocardial revascularization of the antero-septal and postero-lateral cardiac walls (left-sided revascularization). The baseline characteristics and risk profiles of these BITA patients are listed in Table 1 . The expected operative risk for each patient was calculated according to the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) .
| Characteristic | n = 477 |
|---|---|
| Age, years | 70 ± 7.8 (66–76) |
| <60 | 53 (11.1) |
| 60–69 | 136 (28.5) |
| 70–79 | 254 (53.2) |
| >80 | 34 (7.1) |
| Hypertension | 373 (78.2) |
| Former smoker | 52 (10.9) |
| Current smoker | 10 (2.1) |
| BMI, kg/m 2 | 26.7 ± 4.3 (23.6–29.3) |
| >30 | 91 (19.1) |
| >35 | 20 (4.2) |
| Diabetes on insulin | 49 (10.3) |
| Diabetes on hypoglycemic agent | 96 (20.1) |
| Serum glucose >200 mg/dl | 29 (6.1) |
| Serum hemoglobin, g/l | 12.2 ± 1.3 (11.3–13) |
| <12 | 207 (43.4) |
| Poor mobility b | 6 (1.3) |
| Chronic lung disease b | 23 (4.8) |
| GFR c , ml/min | 60.2 ± 24.5 (47.7–73) |
| 50–85 b | 271 (56.8) |
| <50 b | 137 (28.7) |
| Chronic dialysis | 10 (2.1) |
| Extracardiac arteriopathy b | 123 (25.8) |
| Atrial fibrillation | 10 (2.1) |
| Congestive heart failure | 44 (9.2) |
| Unstable angina | 245 (51.4) |
| Recent myocardial infarction b | 117 (24.5) |
| Coronary artery disease | |
| Left main | 159 (33.3) |
| Two-vessel | 56 (11.7) |
| Three-vessel | 344 (72.1) |
| LVEF, % | 56.8 ± 10 (52–60) |
| 30–50 b | 100 (21) |
| 20–30 b | 3 (0.6) |
| <20 b | 3 (0.6) |
| Previous PCI | 11 (2.3) |
| Previous CABG surgery (SVGs alone) | 2 (0.4) |
| Critical state b | 39 (8.2) |
| Use of IABP | 13 (2.7) |
| Surgical priority b | |
| Elective | 150 (31.4) |
| Urgent | 322 (67.5) |
| Emergency | 5 (1) |
| Expected operative risk (by EuroSCORE II d ), % | 5.2 ± 6.1 (1.9–6.2) |
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