Bilateral internal thoracic artery grafting improves long-term survival in patients with reduced ejection fraction: A propensity-matched study with 30-year follow-up

Objective The optimal surgical approach for critically ill patients with complex coronary disease remains uncertain. We compared outcomes of bilateral internal thoracic artery (BITA) versus single ITA (SITA) revascularization in critical patients. Methods We evaluated 394 consecutive critical patients with multi-vessel disease who underwent CABG during 1996–2001. Outcomes measured were early mortality, strokes, myocardial-infarctions, sternal infections, revisions for bleeding, and late survival. The critical preoperative state was acknowledged concisely by one or more of the following: preoperative ventricular tachycardia/fibrillation, aborted sudden cardiac death, or the need for mechanical ventilation or for preoperative insertion of intra-aortic-balloon counter-pulsation. Results During the study period, 193 of our patients who underwent SITA and 201 who underwent BITA were in critical condition. The SITA group was older (mean 68.0 vs. 63.3 years, p = 0.001) and higher proportions were females (28.5% vs. 18.9% p = 0.025), after recent-MI (69.9% vs. 57.2% p = 0.009) and with left-main disease (38.3% vs. 49.3% p = .029); the median logistic EuroSCORE was higher (0.2898 vs. 0.1597, p<0.001). No statistically significant differences were observed between the SITA and BITA groups in 30-day mortality; and in rates of early CVA, MI and sternal infections (13.0% vs. 8.5%, p = 0.148; 4.1% vs. 6.0%, p = 0.49; 6.7% vs. 4.5%, p = 0.32 and 2.1% vs. 2.5%, p>0.99, respectively). Long-term survival (median follow-up of 15 years, interquartile-range: 13.57–15) was better in the BITA group (median 14.39 vs. 9.31± 0.9 years, p = 0.001). Propensity-score matching (132 matched pairs) also yielded similar early outcomes and improved long-term survival (median follow-up of 15 years, interquartile-range: 13.56–15) for the BITA group (median 12.49±1.71 vs. 7.63±0.99 years, p = 0.002). In multivariable analysis, BITA revascularization was found to be a predictor for improved survival (hazard-ratio of 0.419, 95%CI 0.23–0.76, p = 0.004). Conclusions This study demonstrated long-term survival benefit for BITA revascularization in patients in a critical pre-operative state who presented for surgical revascularization.

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Long-term outcomes in patients with critical limb ischemia and heart failure with preserved or reduced ejection fraction

Vascular Medicine ◽

10.1177/1358863x17714153 ◽

2017 ◽

Vol 22 (4) ◽

pp. 307-315 ◽

Cited By ~ 6

Author(s):

Kavita B Khaira ◽

Ellen Brinza ◽

Gagan D Singh ◽

Ezra A Amsterdam ◽

Stephen W Waldo ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Left Ventricular ◽

Term Survival ◽

Long Term Survival ◽

Reduced Ejection Fraction ◽

History Of

The impact of heart failure (HF) on long-term survival in patients with critical limb ischemia (CLI) has not been well described. Outcomes stratified by left ventricular ejection fraction (EF) are also unknown. A single center retrospective chart review was performed for patients who underwent treatment for CLI from 2006 to 2013. Baseline demographics, procedural data and outcomes were analyzed. HF diagnosis was based on appropriate signs and symptoms as well as results of non-invasive testing. Among 381 CLI patients, 120 (31%) had a history of HF and 261 (69%) had no history of heart failure (no-HF). Within the HF group, 74 (62%) had HF with preserved ejection fraction (HFpEF) and 46 (38%) had HF with reduced ejection fraction (HFrEF). The average EF for those with no-HF, HFpEF and HFrEF were 59±13% vs 56±9% vs 30±9%, respectively. The likelihood of having concomitant coronary artery disease (CAD) was lowest in the no-HF group (43%), higher in the HFpEF group (70%) and highest in the HFrEF group (83%) ( p=0.001). Five-year survival was on average twofold higher in the no-HF group (43%) compared to both the HFpEF (19%, p=0.001) and HFrEF groups (24%, p=0.001). Long-term survival rates did not differ between the two HF groups ( p=0.50). There was no difference in 5-year freedom from major amputation or freedom from major adverse limb events between the no-HF, HFpEF and HFrEF groups, respectively. Overall, the combination of CLI and HF is associated with poor 5-year survival, independent of the degree of left ventricular systolic dysfunction.

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