Off-pump Coronary Artery Bypass Surgery with Bilateral Internal Thoracic Arteries: the Leipzig Experience

Background: Contrasting results of recent randomized controlled trials (RCTs) comparing off-pump and on-pump coronary artery bypass graft (CABG) surgery, as well as the lack of evidence for any survival benefit of bilateral internal thoracic artery (ITA) grafting over single ITA use, has intensified the debate about the role of the off-pump technique and bilateral ITA use in CABG surgery. We therefore investigated our 15-year experience in off-pump CABG with bilateral ITA grafting and evaluated temporal trends in preoperative characteristics and postoperative outcomes.

Methods: Demographic, intra-operative, and outcome data of 1,199 consecutive patients undergoing off-pump CABG with bilateral ITA grafting was prospectively collected in a computerized database. Patients who underwent on-pump cardiac procedures and other extra-cardiac procedures were excluded from this study. Assessment of changes in perioperative characteristics and parameters with time was performed by dividing the whole cohort into three groups (2003-2007, 2008-2012, and 2013-2017) based on the year of surgery.

Results: The overall 30-day mortality was 0.6%, with no differences observed between the three time cohorts (0.6%, 0.7%, 0.5%; P=0.8). The perioperative stroke rate for whole cohort was 0.6% and demonstrated a significant reduction in the last two time cohorts (1%, 0.5%, 0.5%; P<0.0001). The overall incidence of deep sternal wound infections was 0.7%, but was marginally higher in the last time-cohort (0.6%, 0.5%, 0.9%; P=0.7). Overall survival for the entire cohort was 92.9%±1% and 78.9%±4% at 5 and 10 years follow-up, respectively. Older age at surgery and presence of peripheral vascular disease were the only predictors of late mortality.

Conclusions: Off-pump CABG with bilateral skeletonized ITAs is a safe operation and is associated with a low mortality and morbidity, which can be maintained in high volume center unit over a long period of time. The long-term survival of patients undergoing such an operation is excellent.