Late results of first myocardial revascularization in multiple vessel disease:: single versus bilateral internal mammary artery with or without saphenous vein grafts

Objective(s): We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVGs), if compared to the use of single IMA and SVG(s), increases the quality of the results of coronary bypass grafting in patients younger than 75 years who undergo first myocardial revascularization. Methods: From September 1986 to December 1999, 1602 patients younger than 75 years underwent first myocardial revascularization using left internal mammary (LIMA) to left anterior descending (LAD) and SVG(s) (n = 576) or BIMA (one IMA on the LAD) with or without SVG(s) (n = 1026). Propensity score analysis was used to select 1140 patients with the same preoperative and operative characteristics. Thirty day outcome was evaluated as well as 10-year freedom from death by any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area (GA), redo/PTCA, redo/PTCA in a GA, target cardiac events (death from cardiac cause, AMI in a GA, redo/PTCA in a GA), and any event. Follow-up ranged from 3.5 to 16.8 years (mean 7.3 +/- 4.8 years). Results: Thirty day mortality was 2.8% in Group LIMA and 2.1% in Group BIMA, P n.s.; incidence of major complications was, respectively, 7.0 versus 5.4%, P n.s. Group BIMA showed better 10-year freedom from cardiac death (96.5 +/- 0.8 versus 91.3 +/- 1.4, P = 0.0288), AMI (98.0 +/- 0.6 versus 94.3 +/- 1.2, P = 0.0180), AMI in a GA (98.4 +/- 0.6 versus 94.7 +/- 1.1, P = 0.0057) and target cardiac events (93.9 +/- 1.1 versus 86.3 +/- 1.8, P = 0.0388). Cox analysis confirmed that LIMA + SV(s) was an independent risk factor from lower freedom from cardiac death, AMI, AMI in a GA and cardiac events. Conclusions: As freedom from cardiac events is a main target of any revascularization procedure, we think that, when a patient undergoes a first coronary surgery and is younger than 75 years, BIMA grafting should not be denied, especially if his life expectancy is higher than 10 years. (C) 2004 Elsevier B.V. All rights reserved.