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