Sequential Composite BIMA Grafting for 3v-CAD: Factors Tat Predict Successful Outcome of the One-inflow and Two-inflow Revascularization Techniques

Background: The effect of one-inflow and two-inflow coronary surgical revascularization techniques featuring skeletonized double mammary artery (BIMA) as T-graft on outcome is studied.

Methods: Early postoperative and mid-term outcome of complete T-graft BIMA revascularization (C-T-BIMA) versus left-sided T-graft BIMA with right-sided aorto-coronary bypass (L-T-BIMA+R-CABG) is 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 and improves total bypass flow (125.88 ± 92.41 vs. 82.50 ± 49.26 mL, p < 0.0001), bypass flow/anastomosis (31.83 ± 23.9 vs.22.77 ± 14.23, p = 0.001) and completeness of revascularization (84% vs. 69%, p = 0.014) compared with C-T-BIMA strategy (n = 100), respectively.

The C-T-BIMA strategy (HR=4.2, p = 0.01) and preoperative presence of RCA-occlusion (HR=3.006, p = 0.023) are relevant risk factors fort he progression of the functional mitral regurgitation (FMR), while L-T-Graft+R-CABG technique protects against FMR-progression (X2= 14.04, p < 0.0001) independent of the preoperative anatomic complexity (Syntax-score I: HR=16.2, p = 0.156), of comorbidities (Syntax-score II: HR=1.901, p = 0.751; Euroscore-II: HR=0.00, p = 0.680), and without enhancing MACCE at 30-days (0.02% vs. 0.08%, p = 0.055), early mortality (0.96% vs. 2%, p = 0.617) and mortality at 5-years (5.8% vs. 4%, p = 0.748) when compared with C-T-BIMA, respectively.

Conclusion: When treating 3v-CAD, two-inflow coronary revascularization such as the L-T-BIMA+R-CABG technique, leads to improved completeness of revascularization and attenuates the postoperative progression of FMR independently of Syntax-scores and without increasing the risk for MACCE.

Older patients with increased SS II score, reduces LV-EF and suffering from RCA-occlusion benefit most from the two-inflow L-T-BIMA+R-CABG technique.

Younger 3v-CAD-patients with normal LV-EF might be preferentially managed with the one-inflow C-T-BIMA surgery, however additional research is needed to detect exact patient-subsets who would benefit from this one-inflow technique also on the long-term.

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Artikel online veröffentlicht:
13. Februar 2024