HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tomaso Bottio Giulio Rizzoli Gino Gerosa Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bottio, T. Articles by Gerosa, G. Search for Related Content PubMed Articles by Bottio, T. Articles by Gerosa, G. Related Collections Coronary disease

Letters to the Editor

Total arterial revascularization, conventional coronary artery bypass surgery, and age cut-off for the loss of benefit from bilateral internal thoracic artery grafting

Department of Cardiovascular Surgery, University of Padua Medical School, Padua, Italy

Received 15 August 2008; accepted 20 October 2008.

^_* Corresponding author. Address: Istituto di Chirurgia Cardiovascolare, Via Giustiniani, 2, 35100 Padova, Italy. Tel.: +39 049 8212408; fax: +39 049 82212409. (Email: tbottio{at}gmail.com).

Key Words: Myocardial revascularization • Total arterial revascularization • Age cut-off for bilateral ITA grafting

We have a concern regarding the report by Mohammadi et al. [1]. In their study 10,954 patients who underwent myocardial revascularization were retrospectively analyzed. Among these 9566 patients received a single internal thoracic artery (ITA) and 1388 patients received a double ITA. Long-term survival and overall impact of ITA use on cardiac-related death were studied. The authors concluded that the survival benefit due to BITA use is lost after the age of 60. What is the true clinical relevance of these results? Since BITA harvesting has been found to increase operation time, postoperative bleeding and sternal wound complications [2], according to the conclusions of this paper, the total arterial revascularization strategy should be discussed for patients between 60 and 65 years, and stopped for the elderly.

We maintain that the following issues should be pointed out. It is unclear how many y- or t-configurations have been used to manage BITA and how RITA graft (inflow from subclavian artery or free-graft from aorta) has been managed. Additionally, it would be interesting to know if the radial artery has been used and how this graft has been managed.

Furthermore we would like to add personal considerations to explain our surgical strategy on elderly patients. A shift from saphenous vein grafts to ITA occurred more than two decades ago. Recently, several studies suggested that multiple ITA grafts might provide an excellent graft patency and fewer incidences of late cardiac events [3–5].

We analyzed our population undergoing BITA plus radial artery revascularization (01/01/2004–30/06/2008). It is composed of 140 patients (mean age 66 ± 9.3) who received a BITA grafting (BITA are skeletonized without injury to pleural space); among these, 60 patients received an additional arterial graft (radial artery; 30% endoscopic harvesting). The majority (94%) underwent composite y-grafting (sequential grafting in 16%). Never has the arterial graft been anastomosed to the ascending aorta. Respectively, 18% of patients were suffering from COPD, 9% insulin dependent and 25% tablets dependent diabetes, 23.3% had impaired ejection-fraction (EF < 50%), 25% had peripheral-vascular-disease, 28% had cerebro-vascular-disease, and finally 24% were on NYHA-class III–IV. Four patients died (2.8%), 4.5% needed a sternal re-wiring, 0.7% suffered from stroke, 3% underwent surgical-revision for bleeding, and finally 1.5% needed a thoracentesis. Median TnI value was 3.57 ng/dl (0.02–190). At 4-year follow-up by internal institute analysis we concluded that the total arterial revascularization-technique (TAR) when compared to conventional-CABG, also in the elderly, guarantees a greater in-hospital and short-term satisfaction, as well as a long-term survival and freedom from recurrent angina and related need for re-revascularization. Besides all that, we speculate that the TAR y-grafting technique should be the preferred method for cardiac revascularization also in older patients, offering the most physiological myocardial-flow (lower TnI value). The possibility to avoid side clamping of the aorta reducing peripheral and cerebral embolization, is absolutely important for patients with aortic sclerosis and/or diabetes. Additionally, such a procedure offers a faster patient rehabilitation avoiding the most problematic healing of leg-wounds typical for diabetic patients. Finally, the endoscopic radial artery harvesting favors further qualitative and esthetic advantages (better and faster healing of arm wounds).

Footnotes

The authors of the original paper [1] were invited to reply to this Letter to the Editor but they did not respond.

References

1. Mohammadi S, Dagenais F, Doyle D, Mathieu P, Baillot R, Charbonneau E, Perron J, Voisine P. Age cut-off for the loss of benefit from bilateral internal thoracic artery grafting. Eur J Cardiothorac Surg 2008;33(6):977-982.[Abstract/Free Full Text]
2. Damgaard S, Lund JT, Lilleør NB, Perko MJ, Sander K, Dimo B, Jensen MB, Madsen JK, Kelbaek H, Steinbrüchel DA. Comparable three months’ outcome of total arterial revascularization versus conventional coronary surgery: Copenhagen Arterial Revascularization Randomized Patency and Outcome trial. J Thorac Cardiovasc Surg 2008;135:1069-1075.[Abstract/Free Full Text]
3. Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC. Influence of the internal mammary artery graft on 10-year survival and other cardiac events. N Eng J Med 1986;314:1-9.[Abstract]
4. Rankin JS, Tuttle RH, Wechsler AS, Teichmann TL, Glower DD, Califf RM. Techniques and benefits of multiple internal mammary artery bypass at 20 years of follow-up. Ann Thorac Surg 2007;83:1008-1015.[Abstract/Free Full Text]
5. Muneretto C, Bisleri G, Negri A, Manfredi J, Metra M, Nodari S, Culot L, Dei Cas L. Total arterial myocardial revascularization with composite grafts improves results of coronary surgery in elderly: a prospective randomized comparison with conventional coronary artery bypass surgery. Circulation 2003;108:II29-II33.[Medline]

This article has been cited by other articles:

				A. M. Abolhoda and G. D. Wirth Reply to Terzi et al. Whole or split latissimus dorsi muscle for intrathoracic transposition Eur. J. Cardiothorac. Surg., January 1, 2009; 35(1): 190 - 190. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tomaso Bottio Giulio Rizzoli Gino Gerosa Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bottio, T. Articles by Gerosa, G. Search for Related Content PubMed Articles by Bottio, T. Articles by Gerosa, G. Related Collections Coronary disease