bita grafting: when to do it (when to not do it ) joseph f. sabik, md chairman and professor of...
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BITA Grafting: When to do it (when to not do it )
Joseph F. Sabik, MDChairman and Professor of Surgery
Department of Thoracic and Cardiovascular Surgery
Sheik Hamdam Bin Rashid Al Maktoum Distinguished Chair
Cleveland Clinic Lerner College of Medicine
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Two Internal Thoracic Artery Grafts are Better Than One
Lytle et al. / J Thorac Cardiovasc Surg 1999
5
4
3
2
1
0 Reo
per
atio
n (
%/y
ear)
0 2
100
80
60
40
20
0
Su
rviv
al %
4 6 8 10 12
Survival
Reoperation
BITA n=1089SITA n=4147
P < 0.001
Years After CABG
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StudyPatients 10,124
Intervention Primary isolated CABG
Setting Single center Time period 1971 to 1989
Mean F/U 16.5 years
Endpoint Survival
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Survival Difference
-20 -10 0 10 20 30 40 50
100
80
60
40
20
0Difference at 20 Years
%
SITAbenefit
BITAbenefit
% < StatedDifference
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
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Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
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Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
![Page 8: BITA Grafting: When to do it (when to not do it ) Joseph F. Sabik, MD Chairman and Professor of Surgery Department of Thoracic and Cardiovascular Surgery](https://reader033.vdocuments.mx/reader033/viewer/2022051416/56649e3f5503460f94b2f9b4/html5/thumbnails/8.jpg)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
![Page 9: BITA Grafting: When to do it (when to not do it ) Joseph F. Sabik, MD Chairman and Professor of Surgery Department of Thoracic and Cardiovascular Surgery](https://reader033.vdocuments.mx/reader033/viewer/2022051416/56649e3f5503460f94b2f9b4/html5/thumbnails/9.jpg)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
![Page 10: BITA Grafting: When to do it (when to not do it ) Joseph F. Sabik, MD Chairman and Professor of Surgery Department of Thoracic and Cardiovascular Surgery](https://reader033.vdocuments.mx/reader033/viewer/2022051416/56649e3f5503460f94b2f9b4/html5/thumbnails/10.jpg)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
![Page 11: BITA Grafting: When to do it (when to not do it ) Joseph F. Sabik, MD Chairman and Professor of Surgery Department of Thoracic and Cardiovascular Surgery](https://reader033.vdocuments.mx/reader033/viewer/2022051416/56649e3f5503460f94b2f9b4/html5/thumbnails/11.jpg)
0 5
100
80
60
40
0
Years
%
10 15 20
Survival
BITASITA
Age30
50
70
20
“Ideal” Profile
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
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Survival
BITA (LVF normal/mild)SITA (LVF normal/mild)BITA (mod/sev LVF)SITA (mod/sev LVF)
0 5Years
%
10 15 20Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
100
80
60
40
0
20
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Survival
0 5Years
%
10 15 20
BITASITA
Age
30
50
70
LV Dysfunction
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
100
80
60
40
0
20
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0 5Years
%
10 15 20
BITASITA
Age
3050
70
Survival
Non-Cardiac Morbidity
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
100
80
60
40
0
20
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0 5Years
%
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
10 15 20
BITA
SITA
Survival
Age 30, 50, 70
LV Dysfunction +Non-Cardiac Morbidity
100
80
60
40
0
20
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Survival Difference
Δ%
Age
5
10
15
20Follow-up12
8
4
0
-440 50 60 70 80
Lytle, Ann Thorac Surg, 2004
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Diabetics
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StudyPatients 11,922 diabetics
Intervention Primary isolated CABG
Setting Single center
Time period 1972 to 2011
Follow-up 104,516 patient-years
Endpoints Hospital outcomes
Long-term mortality
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20
40
60
80
100
0 5 10 15 20
%
Years
BITA
SITA
P<.0001
Survival
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Survival: Adjusted
1.5
Off-pump
Late Risk of Death1.00.67
BITA
IR
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1.0 1.50.67
Resp.failure
Reop for bleeding
Deep SWI
Favors BITA Favors SITA
Hospital Outcomes Adjusted
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Risk of DSWI
1.5
PAD
Deep SWI0.67
Medically treated DM
Female
2.0 2.5
MI
1.0
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5
10
15
20 25 30 35 40
%
BMI
Effect of BMI on DSWI Risk
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5
10
15
20 25 30 35 40
DSWI Risk Factors
BMI
% Female & BITA
Male & BITA
Medically treated diabetic MI
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Woman
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Patients
1/1972 to 1/2011
n = 57,943
Primary Isolated CABG
Men (81%)n = 46,934
Women (19%)n = 11,009
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%
Years
Men
Women
0 5 10 15 20 25 30
100
80
60
40
0
20
Survival
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0 5 10 15 20 25 30
%
Years
BITA
SITA
No ITA
Men
Survival100
80
60
40
0
20
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0 5 10 15 20 25 30
%
Years
Survival
BITA
No ITA
SITA
Women100
80
60
40
0
20
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Survival
CR
SITA
BITA
0.5 0.8 1.251.0Hazard Ratio
WomanMan
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Summary
• Almost all patients benefit from BITA
- Most get 10% increase in survival at 10 yrs
- LV dysfunction and non-cardiac co-morbidities derive less benefit