Cabg indications, conduits and results

coronary artery bypass grafting indications , conduits , results .recent articles and studies

1. CABG- Indications, Conduits & Results

2. glossary evolution of CABG CABG indications Conduits of CABG Post operative results Trials of CAD

3. evolution of CABG

4. AIMS of CABG Relieve symptoms Improve survival

5. GUIDELINES Clinical guidelines on myocardial revascularization by: ACC/ AHA STS European Society of Cardiology/ European Association for Cardio thoracic Surgery Heart Team approach- Class I recommendation in determining treatment strategy and selection of appropriate revascularization procedure by ACC/AHA & ESC/EACTS

6. Heart Team- ACC/ AHA Definition A multidisciplinary team composed of an interventional cardiologist and a cardiac surgeon who jointly review the patient’s medical condition and coronary anatomy, determine that PCI and/or CABG are technically feasible and reasonable, and discusses revascularization options with the patient before a treatment strategy is selected.

7. Indications- Ischemic Heart Disease Asymptomatic CAD Stable angina Acute coronary syndromes Unstable angina NSTEMI STEMI Concomitant open heart surgeries

8. Class I & Iia indications from 2011 AHA/ACC guidelines for cabg

9. Lv dysfunction and heart failure Cabg is indicated in patients with lvef < 50% & > 35% (class Iia ) Lvef <35% (class Iib ) Stitch trial Subjects : 1212 patients with lvef <35% 2 groups: medical therapy alone and medical therapy plus CABG Median follow up 56 months Bonow RO, Maurer G, Lee KL, et al: Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med 364:1617–1625, 2011 .

10. Life threatening Ventricular Arrhythmias CABG more effective in treating ventricular fibrillation than ventricular tachycardia, as the latter originates from myocardial scar formation Particularly useful in the setting of exercise-induced ventricular arrhythmias Suppresses ventricular arrhythmias in the setting of left main or triple vessel disease. Autschbach R, Falk V, Gonska BD, et al: The effect of coronary bypass graft surgery for the prevention of sudden cardiac death: recurrent episodes after ICD implantation and review of literature. Pacing Clin Electrophysiol 17:552–558, 1994. Daoud EG, Niebauer M, Kou WH, et al: Incidence of implantable defibrillator discharges after coronary revascularization in survivors of ischemic sudden cardiac death. Am Heart J 130:277– 280, 1995 .

11. Hybrid Coronary Revascularization Recommendations Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI). Lack of suitable graft conduits. Unfavourable LAD artery for PCI (excessive vessel tortuosity or chronic total occlusion).

12. The Peculiar Indian Younger age at presentation Higher rates of three vessel disease Diffuse involvement Distal disease, higher prevalence of bifurcation disease Escalating prevalence of Type II Diabetes Mellitus,CKD ,HTN Short stature Smaller coronary vessels Strong family history Cherian, J Coron Heart Dis 2017, 1:1

13. Though guidelines exist….. Decision making should be based on Clinical presentation Severity of Angina Extent of Ischemia Response to Medical Therapy Extent of anatomical disease by angiography

14. Conduits

15. Graft choice: desirable features Length sufficient to reach the target artery Internal diameter 2-3mm Diameter match with native coronary artery, ratio 1:1 to 2:1 Wall thickness<1mm Free from atheroma, calcification or fibrosis Pedicled (in-situ)grafts Cumulative patency > 80% at 10 years

16. Presentations limiting arterial grafting Unstable angina Acute evolving myocardial infarct Cardiogenic shock Emergent or urgent surgery after failed ptca Concomitant cardiac operations such as repair of a ruptured ventricular septum

17. Patient factors limiting extensive arterial grafting Age : >80 years Reduced life span: malignancy Diabetes mellitus (increased sternal morbidity) Obesity: bmi >30kg/m2 Lung function: forced expiratory volume per sec < 1lit Renal function: serum creatinine > 1.3mg/dl Coagulopathy or platelet dysfunction Urgent or emergent presentation

18. Conduit options Arterial venous Internal Thoracic Great Saphenous Radial short saphenous Right gastro epiploic upper limb veins (cephalic & basilic) Inferior Epigastric Gastroduodenal synthetic Left gastric EPTfe Dacron Biological prosthesis Tissue engineered grafts Synthetic biomaterials and polyurethanes

19. Differences in biological characteristics between arterial & venous grafts Functional endothelium (EDRF, NO) Internal thoracic artery (ITA) releases more NO than the radial artery (RA) at both basal and stimulated levels. Further, the ITA has a greater bradykinin-stimulated release of EDRF than the RA does. Pressure differences Veins less susceptible to spasm and less affected to competitive flow & auto regulation

20. Internal thoracic artery

21. ita - histology Muscular media: 6-12 elastic lamellae Internal elastic lamina with fenestrations- prevents ingress of smooth muscle Less of smooth muscle- less spasm More expression of NO ITA is a “live” graft

22. contraindications u/l or B/l ita’s Pre existing or iatrogenic damage Poor flow from severe spasm or dissection Ipsilateral subclavian stenosis Demonstrated involvement of ITA in providing collateral supply to the lower extremity Mediastinal irradiation Emergency CABG with cardiogenic shock b/l ita’s Emergency operations Insulin dependent Diabetes Mellitus Obesity Severe COPD Oral or i.v glucocorticoid therapy

23. Radial artery

24. contraindications Inadequate collateral supply (+ Allens test) More prone to spasm in the presence of significant competitive flow, hence no Radial grafts for coronary artery with < 70% stenosis. Recent radial artery catheterization Raynaud’s disease Musicians Old patients with high prevalence of Radial artery atherosclerosis Ongoing hemodialysis

25. Right Gastroepiploic artery

26. Indications GEA grafts commonly used when the ITA grafts do not reach the posterior surface of the heart or when conventional conduits are not available. contraindications The only absolute contraindication to use of the right gastroepiploic artery is previous complete or partial gastrectomy. Coronary artery lesions with < 70% stenosis Pitfalls Pancreatitis, diaphgramatic hernia and graft kinking.

27. Great Saphenous Vein

28. Fate of a vein graft

29. Vein Harvest techniques

30. ACC/ AHA Recommendations (2011) Class I If possible, the LIMA should be used to bypass the LAD when bypass of the LAD is indicated Class IIa The RIMA is probably indicated to bypass the LAD artery when the LIMA is unavailable or unsuitable as a bypass conduit When anatomically & clinically suitable, use of a second IMA to graft the left circumflex or right coronary artery (when critically stenosed and perfusing LV myocardium) is reasonable to improve the likelihood of survival and to decrease reintervention. An arterial graft should not be used to bypass the right coronary artery with less than a critical stenosis (<90%)

31. Reported conduit patency in CABG

32. RESULTS

33. Morbidity- post operative bleeding Reexploration - 2% to 6% of CABG cases & 4.5 fold higher risk of mortality Predisposing factors advanced age, lower body weight, preoperative cardiogenic shock, anemia, renal dysfunction (especially dialysis-dependent patients), poor nutritional status, recent thrombolytic therapy, emergency cases, repeat operations, and longer CPB times. Karthik S, Grayson AD, McCarron EE, et al: Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 78:527–534, discussion 534, 2004.

34. Strategies to prevent excessive bleeding meticulous surgical technique and hemostasis, prevention or reversal of intraoperative hemodilution, prompt reversal of hypothermia, detection and treatment of residual heparin effect with protamine, blood pressure control, administration of antifibrinolytics, and the use of recombinant activated factor VIIa in severe situations

35. Perioperative Myocardial Infarction Perioperative MI occurs in 2% to 10% of first time CABG cases. Insertion of an IABP may be required to minimize myocardial ischemia. Diagnostic criteria CK-Mb & troponin-I levels > x5 times the upper normal limit New q-waves New lbbb pattern, new rwma on tee Thielmann M, Massoudy P, Schmermund A, et al: Diagnostic discrimination between graft-related and non-graft-related perioperative myocardial infarction with cardiac troponin I after coronary artery bypass surgery. Eur Heart J 26:2440–2447, 2005.

36. Graft-related problems Improper harvesting kinking and overstretching of the grafts, acute occlusion, technical anastomotic stenosis, or conduit spasm Causes related to the native circulation inadequate myocardial protection, incomplete revascularization, coronary embolization Yau JM, Alexander JH, Hafley G, et al: Impact of perioperative myocardial infarction on angiographic and clinical outcomes following coronary artery bypass grafting (from project of ex-vivo vein graft engineering via transfection [prevent] iv). Am J Cardiol 102:546–551, 2008.

37. Neurologic Events Type 1 deficits, which represent major, focal neurologic deficits, stupor, and coma type 2 Delirium- 3% to 50% of patients Transient disturbance of cognitive function with an incidence of 30% to 80% at discharge & 20% - 40% six months to 1 year after surgery Eagle KA, Guyton RA, Davidoff R, et al: ACC/AHA guidelines for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the 1991 guidelines for coronary artery bypass graft surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 34:1262–1347, 1999.

38. Type I deficits are associated with up to 25% risk of mortality. Incidence of stroke post CABG-1.4% to 3.8% Stroke post CABG- mortality of up to 17%, with early (<24 hours) strokes with a threefold higher risk of dying. Filsoufi F, Rahmanian PB, Castillo JG, et al: Incidence, topography, predictors and long-term survival after stroke in patients undergoing coronary artery bypass grafting. Ann Thorac Surg 85:862–870, 2008.

39. Post operative renal dysfunction 7- 8% cases after CABG Mortality: 0.9 to 19% & 63% in those requiring hemodialysis Mangano cm, diamondstone LS, ramsay JG, et al: renal dysfunction after myocardial revascularization: risk factors, adverse outcomes, and hospital resource utilization. The multicenter study of perioperative ischemia research group. Ann intern med 128:194–203, 1998

40. Atrial Fibrillation 20% to 40% incidence- peak incidence on the second & third postoperative days Transient & return to sinus rhythm within 2 to 3 days of treatment Bramer S, van straten AH, soliman hamad MA, et al: the impact of new-onset postoperative atrial fibrillation on mortality after coronary artery bypass grafting. Ann thorac surg 90:443–449, 2010.

41. Treatment options Correction of electrolyte imbalances, acidosis Correction of hypoxia Synchronized cardioversion, if hemodynamics stable Amiodarone, beta blockers, digoxin. Anticoagulation if AF persists for more than 48 hours

42. Sternal wound infections (SWIs) Superficial (SSWI) & deep DSWI requires the presence of one of the following: positive culture from mediastinal fluid or tissue; observable mediastinitis during surgery; presence of chest pain, sternal instability, or high-grade fever; and either purulent drainage from the mediastinum or positive blood cultures DSWIs commonly require reexploration and débridement of necrotic tissue in the operating room with some cases requiring early vascularized muscle flap coverage

43. Incidence of SSWI- 0.47% to 8.0% & a mortality rate of 0.5% to 9.1% Incidence of DSWI- 0.22% to 1.97% & a mortality rate of 1.0% to 36% Staphylococcus aureus & coagulase negative staphylococci Toumpoulis IK, Anagnostopoulos CE, Derose JJ, Jr, et al: The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting. Chest 127:464–471, 2005. Cayci C, Russo M, Cheema FH, et al: Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis. Ann Plast Surg 61:294–301, 2008

44. Trials

45. Evidence Medical therapy versus surgical revascularization trials PTCA versus CABG trials Stent (bare metal or drug eluting) versus CABG trials Single vs bilateral ITA trials On-pump vs off pump Cabg trials

46. Medical versus CABG trials Veterans Administration Cooperative study(VA) European Coronary Surgery survey (ECSS) Coronary Artery Surgery survey (CASS) STItCH (Surgical Treatment for Ischemic Heart Failure) trial

47. VA STUDY ECSS CASS Years 1972-74 1973- 76 1975-79 Female (%) 10 Mean age (years) 51 50 51 Class III- IV angina 60% 42% 0% TVD 50% 56% 51% Patients randomized 686 768 780 Patients with ITA grafts 5% 14% 16% LV function excluded Marked enlargement <50% EF < 35% EF Graft patency 70% / 12 months 90% /9 months 82% /18 months In hospital mortality (surgical) 5.8 % 3.3 % 1.4 % Cross over M S 38 % 36 % 37 % Improved survival 5 years Surgery Medical therapy 45 17 75 60 63 38

48. Results Subgroups benefitted from CABG LMCA disease TVD/DVD with proximal LAD disease Impaired LV Function Strong positive stress test

49. ?L Benefits of CABG on survival, symptoms, & post infarction mortality - transient & lasted fewer than 11 years Benefits began to diminish after 5 years, when graft closure accelerated Low-risk patients (good prognosis with medical therapy) derived no survival benefit with surgical therapy at any time during the follow-up period Surgery didn’t reduce the incidence of MI or sudden death

50. 10-year follow-up results- patients with LV dysfunction exhibit long-term benefit from initial strategy of surgical treatment Patients with mild stable angina & normal left ventricular function randomized to initial medical treatment (with option for later surgery if symptoms progress) have survival equivalent to those patients randomized to initial surgery

51. PTCA versus CABG: BARI trial

52. No of subjects: 611 medical therapy alone, PCI (6 weeks after randomization) and CABG (12 weeks after randomization) Patients with angiographically documented proximal multivessel coronary stenosis of more than 70% by visual assessment & documented ischemia were considered for inclusion Predefined primary end points were the incidence of total mortality, Q-wave MI, or refractory angina that required revascularization for patients in any of the 3 treatment groups

53. Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial

54. Study Design: Randomized Parallel Stratified Patients Enrolled: 1,800 897 to CABG 903 to DES-PCI. About 25.1% were diabetic, with 33% having evidence of prior myocardial infarction. The total SYNTAX score was similar between the CABG and PCI arms (29.1 vs. 28.4, p = 0.19) Mean Follow-Up: 1, 3, 5, and 10 years Mean Patient Age: 65.1 years Mean Ejection Fraction : Only about 2% had an ejection fraction of <30%.

55. Patient Populations: De novo coronary artery disease Coronary anatomy suitable for both CABG and PCI. Primary Endpoints: MACCE (all-cause mortality, stroke, MI, or repeat revascularization) at 1, 3, 5, and 10 years. Secondary Endpoints: Death, MI, CVA, Death MI, or cerebrovascular accident. Drug/Procedures Used: All patients in the PCI arm received TAXUS (paclitaxel-eluting) stents, whereas all patients in the CABG arm underwent on- or off-pump bypass.

56. Syntax 1 score Synytax score <22: low grade 22-32: intermediate lesions >32: high grade lesions

57. Results at 1 year follow up incidence of (MACCE) was lower in the CABG arm compared with PCI (12.4% vs. 17.8%, p = 0.002), and did not meet the prespecified noninferiority threshold for PCI. reduction in the incidence of repeat revascularization in the CABG arm compared with PCI (5.9% vs. 13.5%, p < 0.001). incidence of cerebrovascular accident was significantly higher in the CABG arm (2.2% vs. 0.6%, p = 0.003) incidence of symptomatic graft occlusion and stent thrombosis was similar between the two arms (3.4% vs. 3.3%, p = 0.89

58. Lt main disease & diabetic patients LM disease patients, the overall 12-month MACCE event rate was lower with CABG (13.7% vs. 15.8%) patients with LM only (8.5% vs. 7.1%) and LM + 1-VD (13.2% vs. 7.5%) seemed to do slightly better with PCI. patients with diabetes had lower 12month MACCE event rates with CABG than with PCI (14.2% vs. 26.0%, p = 0.0025)

59. Results at 5 year follow up incidence of the primary endpoint of MACCE was still lower in the CABG arm as compared with the PCI arm (26.9% vs. 37.3%, p < 0.0001). Reductions were also noted in the incidence of repeat revascularization (13.7% vs. 25.9%, p < 0.0001). incidence of stent thrombosis or graft occlusion was similar (4.0% vs. 5.5%). CABG was superior to PCI for CV (5.8% vs. 9.6%, p = 0.008) and cardiac (5.3% vs. 9.0%, p = 0.003) mortality

60. Lt main disease patients MACCE rates at 5 years were similar between PCI and CABG (36.9% vs. 31.0%, p = 0.12). higher rates of stroke with CABG (1.5% vs. 4.3%, p = 0.03) and higher rates of repeat revascularization with PCI (26.7% vs. 15.5%, p< 0.01). overall 3-VD subset, MACCE rates at 5 years were higher in the PCI arm compared with CABG (37.5% vs. 24.2%, p < 0.001)

61. Results at 10 year follow up All-cause mortality for PCI vs. CABG: 25.6% vs. 29.4%, p = 0.11. Left main subset: 29.7% vs. 31.9%, p = 0.43. Three-vessel disease subset: 21.9% vs. 29.2%, p = 0.007, especially among patients with a high SYNTAX score. Diabetes patients: 36.6% vs. 39.4%, p = 0.45. Cost effectiveness Total procedure costs were lower in the CABG arm compared with PCI ($8,504 vs. $11,919) due to a large number of stents required(mean 4.6). However, overall hospitalization costs were higher in the CABG arm ($33,190 vs. $23,154; Δ = $10,036; p < 0.001).

62. Syntax ii trail Type of study: multicenter, single-arm trial Study population: de novo 3VD who were candidates for revascularization. SYNTAX score II. interaction between clinical variables and the anatomical SYNTAX score I clinical variables: age, renal function (creatinine clearance), left ventricle ejection fraction, left main involvement, sex, presence of chronic obstructive pulmonary disease and of peripheral vascular disease.

63. State of the art PCI Modolo R, Collet C, Onuma Y, Serruys PW. SYNTAX II and SYNTAX III trials: what is the take home message for surgeons? Ann Cardiothorac Surg 2018;7(4):470482. doi : 10.21037/acs.2018.07.02

64. Physiologically guided intervention evaluating the functional severity of a stenosis in the coronary artery to determine the need for revascularization using parameters like fractional flow reserve (FFR): Pressure difference across a coronary artery stenosis which is an absolute number, an ffr of 0.80 means a given stenosis causes a 20% drop in pressure across stenosis or instantaneous wave-free ratio ( iFR ): instantaneous diastolic pressure gradient between the aorta and the pressure distal to the stenosis

65. Results at 1year follow up Patients undergoing state-of-the-art PCI experienced less MACce (10.6% vs. 17.4%; HR 0.58, 95% CI: 0.39–0.85, P=0.006) compared with the equipoise PCI arm of SYNTAX I. rate of stent thrombosis, which was lower with the SYNTAX II approach (HR 0.26, 95% CI: 0.07–0.97, P=0.045). analysis comparing SYNTAX II PCI patients vs. CABG for multivessel disease patients showed no difference between the groups with regards to Macce [10.6% vs. 11.2%; HR 0.91 (95% CI: 0.59–1.14), P=0.684, respectively]

66. Syntax iii trial Results: treatment decision making between CABG and PCI based on coronary CTA is in in almost perfect agreement with the decision derived from conventional coronary angiography in patients with left main or 3VD Support the potential role of non-invasive imaging with coronary CTA for treatment decision making and planning

67. Trial of Everolimus -Eluting Stents or Bypass Surgery for Coronary Disease (Best trial) Study design: randomized noninferiority, multinational trial from south east asia . Study population: 1776 patients with multivessel coronary artery disease to PCI with everolimus -eluting stents or to CABG. Primary end point: composite of death, myocardial infarction, or target-vessel revascularization at 2 years after randomization. Park SJ, Ahn JM, Kim YH, Park DW, Yun SC, Lee JY, Kang SJ, Lee SW, Lee CW, Park SW, Choo SJ. Trial of everolimus -eluting stents or bypass surgery for coronary disease. New England Journal of Medicine. 2015 Mar 26;372(13):1204-12.

68. Results primary end point had occurred in 11.0% of the patients in the PCI group and in 7.9% of those in the CABG group (P = 0.32 for noninferiority). follow-up (median, 4.6 years), the primary end point had occurred in 15.3% of the patients in the PCI group and in 10.6% of those in the CABG group (hazard ratio, 1.47; 95% CI, 1.01 to 2.13; P = 0.04). rates of any repeat revascularization and spontaneous myocardial infarction were significantly higher after PCI than after CABG.

69. Randomized Trial of Stents versus Bypass Surgery for Left Main Coronary Artery Disease (Precombat study) Study design: prospective, randomized trial conducted Study population: 600 patients with unprotected left main coronary artery stenosis randomly assigned to undergo PCI with a sirolimus-eluting stent (n=300) or CABG (n=300). Primary end point: major adverse cardiac or cerebrovascular event (MACCE: a composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) Ahn J-M, Roh J-H, Kim Y-H, Park D-W, Yun S-C, Lee PH, Chang M, Park HW, Lee S-W, Lee CW, Park S-W, Choo SJ, Chung C, Lee J, Lim D-S, Rha S-W, Lee S-G, Gwon H-C, Kim H-S, Chae I-H, Jang Y, Jeong M-H, Tahk S-J, Seung KB, Park S-J, Randomized Trial of Stents versus Bypass Surgery for Left Main Coronary Artery Disease: Five-Year Outcomes of the PRECOMBAT Study, Journal of the American College of Cardiology (2015), doi : 10.1016/ j.jacc.2015.03.033.

70. Results at 5 year follow up MACCE occurred in 52 patients in the PCI group and 42 patients in the CABG group (cumulative event rates of 17.5% and 14.3%; hazard ratio [HR], 1.27; p=0.26). The two groups did not differ significantly in terms of death from any cause, myocardial infarction, or stroke as well as their composite (8.4% and 9.6%; HR, 0.89; p=0.66). Ischemia-driven target vessel revascularization occurred more frequently in the PCI group than in the CABG group (11.4% and 5.5%; HR, 2.11; p=0.012).

71. Percutaneous Coronary Intervention Versus Coronary Bypass Surgery in United States Veterans With Diabetes (VA-CARDS) trial Study design: prospective multicenter study Study population: 198 eligible patients with diabetes with severe coronary artery disease of which 97 were randomly assigned to CABG & 101 were assigned to PCI with drug-eluting stents followed for at least 2 years. Primary outcome: composite of nonfatal myocardial infarction or death. Kamalesh M, Sharp TG, Tang XC, Shunk K, Ward HB, Walsh J, King S, Colling C, Moritz T, Stroupe K, Reda D. Percutaneous coronary intervention versus coronary bypass surgery in United States veterans with diabetes. Journal of the American College of Cardiology. 2013 Feb 26;61(8):808-16.

72. Results at 2 year follow up all-cause mortality was 5.0% for CABG and 21% for PCI (hazard ratio: 0.30; 95% confidence interval: 0.11 to 0.80) while the risk for nonfatal myocardial infarction was 15% for CABG and 6.2% for PCI (hazard ratio: 3.32; 95% confidence interval: 1.07 to 10.30).

73. Coronary artery revascularization in diabetes (Cardia) trial Study design: randomized controlled double arm non inferiority trial Study population: 510 diabetic patients with multivessel or complex single-vessel coronary disease from 24 centers were randomized to PCI with sirolimus des’s or CABG. Primary end point: composite rate of death, MI, stroke, all-cause mortality & repeat revascularization Kapur A, Hall RJ, Malik IS, Qureshi AC, Butts J, de Belder M, Baumbach A, Angelini G, de Belder A, Oldroyd KG, Flather M. Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients: 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial. Journal of the American College of Cardiology. 2010 Feb 2;55(5):432-40.

74. Results at 1 year follow up the composite rate of death, MI, and stroke was 10.5% in the CABG group and 13.0% in the PCI group (p =0.39) rates of death, MI, stroke, or repeat revascularization were 11.3% and 19.3% (p =0.02), respectively. Conclusion The CARDia trial is the first randomized trial of coronary revascularization in diabetic patients, but the 1-year results did not show that PCI is noninferior to CABG. longer-term follow-up and data from other trials will be needed to provide a more precise comparison of the efficacy of these 2 revascularization strategies

75. Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) Trial

76. ARTERIAL REVASCULARISATION TRIAL (ART) RANDOMIZED CONTOL TRIAL, Taggart DP et al. 28 cardiac surgical centers in 7 countries. 3102 patients, 1554 were randomly assigned to SIMA group & 1548 to the BIMA group. planned follow-up of 10 years recently published an interim analysis of their results with 5 years of follow-up in 2016. Taggart DP, Altman DG, Gray AM, Lees B, Gerry S, Benedetto U, Flather M. Randomized trial of bilateral versus single internal-thoracic-artery grafts. New England Journal of Medicine. 2016 Dec 29;375(26):2540-9 .

77. Results after 5 year follow up Death rate was 8.7% in the BIMA group vs 8.4% in the SIMA group (HR , 1.04; P = 0.77), and the rate of the composite of death from any cause, MI, or stroke was 12.2% and 12.7%, respectively (hazard ratio, 0.96; P = 0.69). Rate of sternal wound complication was 3.5% in the BIMA group versus 1.9% in the SIMA group (P = 0.005), and the rate of sternal reconstruction was 1.9% versus 0.6% (P = 0.002).

78. Veterans Affairs Randomized On/Off Bypass (ROOBY) Trial Study design: controlled, single-blinded, randomized trial. Study population: 2203 patients randomized to off-pump versus on-pump CABG. Follow-up angiography was obtained in 685 off-pump (62%) and 685 on-pump (62%) patients. Results: Off-pump CABG resulted in lower patency rates than on-pump CABG for arterial conduits (85.8% versus 91.4%; P=0.003) and saphenous vein grafts (72.7% versus 80.4%; P=0.001). Hattler B, Messenger JC, Shroyer AL, Collins JF, Haugen SJ, Garcia JA, Baltz JH, Cleveland Jr JC, Novitzky D, Grover FL. Off-Pump coronary artery bypass surgery is associated with worse arterial and saphenous vein graft patency and less effective revascularization: Results from the Veterans Affairs Randomized On/Off Bypass (ROOBY) trial. Circulation. 2012 Jun 12;125(23):2827-35.

79. Fewer off-pump patients were effectively revascularized (50.1% versus 63.9% on-pump; P=0.001). The 1-year adverse cardiac event rate was 16.4% in patients with ineffective revascularization versus 5.9% in patients with effective revascularization (P=0.001).

80. Effects of Off-Pump and On-Pump Coronary-Artery Bypass Grafting at 1 Year (coronary trial) Study design: randomized controlled trial Study population: 4752 patients with coronary artery disease who were scheduled to undergo CABG and randomly assigned them to undergo the procedure off-pump or on-pump. Results: 1 year, there was no significant difference in the rate of the primary composite outcome of death, myocardial infarction, stroke, or new renal failure between off-pump and on-pump CABG (12.1% and 13.3%, respectively; hazard ratio with off-pump CABG, 0.91; 95% confidence interval P = 0.24). Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, Straka Z, Piegas LS, Akar AR, Jain AR, Noiseux N. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. New England Journal of Medicine. 2013 Mar 28;368(13):1179-88.

81. The rate of repeat coronary revascularization at 1 year was 1.4% in the off-pump group and 0.8% in the on-pump group (hazard ratio, 1.66; 95% CI, 0.95 to 2.89; P = 0.07). no significant differences between the two groups at 1 year in measures of quality of life or neurocognitive function.

82. Take home message based on current evidence CABG remains the best revascularization strategy in MVD, conferring reduced mortality and repeat revascularization risk. The absolute risk increases in stroke associated with CABG does not outweigh the benefit in the long-term survival achievable with this technique of revascularization

83. Thank you