Bilateral internal thoracic artery grafting concomitant with other cardiac operations ― Insights from a European multicenter retrospective study on 1,123 consecutive patients ―

Background: The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain unproven. Methods and Results: Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III-IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/ cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/ cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively. Conclusions: BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.