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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
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
StudyPatients 10,124
Intervention Primary isolated CABG
Setting Single center Time period 1971 to 1989
Mean F/U 16.5 years
Endpoint Survival
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)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients
Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)
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)
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
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
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
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
Survival Difference
Δ%
Age
5
10
15
20Follow-up12
8
4
0
-440 50 60 70 80
Lytle, Ann Thorac Surg, 2004
Diabetics
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
20
40
60
80
100
0 5 10 15 20
%
Years
BITA
SITA
P<.0001
Survival
Survival: Adjusted
1.5
Off-pump
Late Risk of Death1.00.67
BITA
IR
1.0 1.50.67
Resp.failure
Reop for bleeding
Deep SWI
Favors BITA Favors SITA
Hospital Outcomes Adjusted
Risk of DSWI
1.5
PAD
Deep SWI0.67
Medically treated DM
Female
2.0 2.5
MI
1.0
5
10
15
20 25 30 35 40
%
BMI
Effect of BMI on DSWI Risk
5
10
15
20 25 30 35 40
DSWI Risk Factors
BMI
% Female & BITA
Male & BITA
Medically treated diabetic MI
Woman
Patients
1/1972 to 1/2011
n = 57,943
Primary Isolated CABG
Men (81%)n = 46,934
Women (19%)n = 11,009
%
Years
Men
Women
0 5 10 15 20 25 30
100
80
60
40
0
20
Survival
0 5 10 15 20 25 30
%
Years
BITA
SITA
No ITA
Men
Survival100
80
60
40
0
20
0 5 10 15 20 25 30
%
Years
Survival
BITA
No ITA
SITA
Women100
80
60
40
0
20
Survival
CR
SITA
BITA
0.5 0.8 1.251.0Hazard Ratio
WomanMan
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