Off-Pump Bilateral Versus Single Skeletonized Internal Thoracic Artery Grafting in High-Risk Patients

Abstract

Background— We compared the outcomes in propensity score-matched high-risk patients (European System for Cardiac Operative Risk Evaluation [EuroSCORE] ≥5) undergoing off-pump coronary artery bypass graft surgery using bilateral or single skeletonized internal thoracic artery (ITA). Methods and Results— Of 794 consecutive patients undergoing isolated coronary artery bypass graft surgery (788 by the off-pump technique without emergent conversion to cardiopulmonary bypass), the 536 who had a EuroSCORE ≥5 and underwent off-pump skeletonized single (n=236) or bilateral (n=300) ITA were retrospectively analyzed after excluding the 6 who were transferred to our hospital after receiving percutaneous cardiopulmonary support, the 45 who had only 1 target in the left-side coronary area, and the 207 with EuroSCORE <5. A total of 235 pairs were matched using propensity scores calculated from 7 preoperative factors (C statistic, 0.65). The rate of postoperative complications was similar between the groups. The mean observation period was 3.2 years. The 5-year estimated survival rate free from overall death and cardiac event in patients receiving bilateral versus single ITA grafting was 85.8±5.5% versus 74.8±4.9% ( P =0.002) and 87.4±4.6% versus 66.1±5.7% ( P =0.001), respectively. In multivariate Cox proportional hazard models, bilateral ITA grafting was significantly associated with a lower risk of overall death (hazard ratio, 0.56; 95% CI, 0.32 to 0.87; P =0.009) and cardiac event (hazard ratio, 0.40; 95% CI, 0.24 to 0.69; P =0.001). Conclusions— In high-risk patients, off-pump skeletonized left-sided bilateral in situ ITA grafting is associated with lower risk of overall death and cardiac event than single ITA grafting without increased operative risk.