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Coronary Artery Disease: HELP
Articles by Thomas A. Schwann
Based on 31 articles published since 2010
(Why 31 articles?)
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Between 2010 and 2020, Thomas Schwann wrote the following 31 articles about Coronary Artery Disease.
 
+ Citations + Abstracts
Pages: 1 · 2
1 Review Technical Aspects of the Use of the Radial Artery in Coronary Artery Bypass Surgery. 2019

Gaudino, Mario / Fremes, Stephen / Schwann, Thomas A / Tatoulis, James / Wingo, Matthew / Tranbaugh, Robert F. ·Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York. Electronic address: mfg9004@med.cornell.edu. · Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada. · Department of Cardiothoracic Surgery, University of Toledo, Toledo, Ohio; Department of Cardiothoracic Surgery, University of Massachusetts - Baystate, Springfield, Massachusetts. · Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia. · Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York. ·Ann Thorac Surg · Pubmed #30552888.

ABSTRACT: BACKGROUND: The radial artery has been used for coronary artery bypass surgery for more than 25 years. The recent confirmation of the clinical benefits associated with the use of the artery is likely to drive a new interest toward this conduit in the next few years. METHODS: A group of surgeons with extensive experience in the systematic use of the radial artery summarize here the key technical aspects of the use of the conduit for coronary bypass operations. RESULTS: Preoperative evaluation of the ulnar collateral circulation and attention to the characteristics of the target vessel are keys for the successful use of the radial artery. Open or endoscopic harvesting can be used, preferentially with the aid of the harmonic scalpel. The use of vasodilatory and antispastic protocols is probably important but poorly supported by the current evidence. The radial artery can be used for multiple grafting strategies with a variable degree of technical complexity. CONCLUSIONS: With attention to few technical key points, the radial artery is a versatile conduit that can be easily introduced in the everyday practice of coronary artery bypass surgery.

2 Review Off-Pump Coronary Artery Bypass Grafting: 30 Years of Debate. 2018

Gaudino, Mario / Angelini, Gianni D / Antoniades, Charalambos / Bakaeen, Faisal / Benedetto, Umberto / Calafiore, Antonio M / Di Franco, Antonino / Di Mauro, Michele / Fremes, Stephen E / Girardi, Leonard N / Glineur, David / Grau, Juan / He, Guo-Wei / Patrono, Carlo / Puskas, John D / Ruel, Marc / Schwann, Thomas A / Tam, Derrick Y / Tatoulis, James / Tranbaugh, Robert / Vallely, Michael / Zenati, Marco A / Mack, Michael / Taggart, David P / Anonymous6640966. ·1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York City NY. · 2 Bristol Heart Institute University of Bristol United Kingdom. · 3 University of Oxford United Kingdom. · 4 Cleveland Clinic Cleveland OH. · 5 Cardiac Surgery Pope John Paul II Foundation Campobasso Italy. · 6 Cardiovascular Disease Institute University of L'Aquila Italy. · 7 Schulich Heart Centre Sunnybrook Health Science University of Toronto Canada. · 8 Division of Cardiac Surgery Ottawa Heart Institute Ottawa Canada. · 9 TEDA International Cardiovascular Hospital Chinese Academy of Medical Sciences & Peking Union Medical College Tianjin China. · 10 Department of Pharmacology Catholic University School of Medicine Rome Italy. · 11 Department of Cardiovascular Surgery Icahn School of Medicine at Mount Sinai New York City NY. · 12 University of Ottawa Heart Institute Ottawa Canada. · 13 University of Toledo College of Medicine Toledo OH. · 14 Department of Surgery University of Melbourne Parkville Australia. · 15 Sydney Medical School The University of Sydney Australia. · 16 Harvard Medical School Boston MA. · 17 The Heart Hospital Baylor Plano Plano TX. ·J Am Heart Assoc · Pubmed #30369328.

ABSTRACT: -- No abstract --

3 Review Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol. 2017

Gaudino, Mario / Alexander, John H / Bakaeen, Faisal G / Ballman, Karla / Barili, Fabio / Calafiore, Antonio Maria / Davierwala, Piroze / Goldman, Steven / Kappetein, Peter / Lorusso, Roberto / Mylotte, Darren / Pagano, Domenico / Ruel, Marc / Schwann, Thomas / Suma, Hisayoshi / Taggart, David P / Tranbaugh, Robert F / Fremes, Stephen. ·Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA. · Duke Clinical Research Institute, Duke Health, Durham, NC, USA. · Cleveland Clinic Foundation, Cleveland, OH, USA. · Department of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA. · Department of Cardiovascular Surgery, S. Croce e Carle Hospital, Cuneo, Italy. · Fondazione Giovanni Paolo II, Campobasso, Italy. · Herzzentrum Leipzig, Leipzig, Germany. · Department of Medicine, University of Arizona, Tucson, AZ, USA. · Thoraxcenter, Erasmus MC, Rotterdam, Netherlands. · Maastricht University Medical Centre, Maastricht, Netherlands. · Galway University Hospitals, Galway, Ireland. · University Hospital Birmingham, Birmingham, UK. · University of Ottawa Heart Institute, Ottawa, ON, Canada. · The University of Toledo, Toledo, OH, USA. · Suma Heart Clinic, Tokyo, Japan. · University of Oxford, Oxford, UK. · Sunnybrook Health Science, University of Toronto, Toronto, ON, Canada. ·Eur J Cardiothorac Surg · Pubmed #29059371.

ABSTRACT: SUMMARY: The primary hypothesis of the ROMA trial is that in patients undergoing primary isolated non-emergent coronary artery bypass grafting, the use of 2 or more arterial grafts compared with a single arterial graft (SAG) is associated with a reduction in the composite outcome of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary hypothesis is that in these patients, the use of 2 or more arterial grafts compared with a SAG is associated with improved survival. The ROMA trial is a prospective, unblinded, randomized event-driven multicentre trial comprising at least 4300 subjects. Patients younger than 70 years with left main and/or multivessel disease will be randomized to a SAG or multiple arterial grafts to the left coronary system in a 1:1 fashion. Permuted block randomization stratified by the centre and the type of second arterial graft will be used. The primary outcome will be a composite of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary outcome will be all-cause mortality. The primary safety outcome will be a composite of death from any cause, any stroke and any myocardial infarction. In all patients, 1 internal thoracic artery will be anastomosed to the left anterior descending coronary artery. For patients randomized to the SAG group, saphenous vein grafts will be used for all non-left anterior descending target vessels. For patients randomized to the multiple arterial graft group, the main target vessel of the lateral wall will be grafted with either a radial artery or a second internal thoracic artery. Additional grafts for the multiple arterial graft group can be saphenous veins or supplemental arterial conduits. To detect a 20% relative reduction in the primary outcome, with 90% power at 5% alpha and assuming a time-to-event analysis, the sample size must include 845 events (and 3650 patients). To detect a 20% relative reduction in the secondary outcome, with 80% power at 5% alpha, the sample size must include 631 events (and 3650 patients). To be conservative, the sample size will be set at 4300 patients. The primary outcome will be tested according to the intention-to-treat principle. The primary analysis will be a Cox proportional hazards regression model, with the treatment arm included as a covariate. If non-proportional hazards are observed, alternatives to Cox proportional hazards regression will be explored.

4 Article Analyse the evidence, generate new evidence and apply the evidence: cardiac surgery is not only about cutting and sewing. 2020

Gaudino, Mario / Schwann, Thomas / Puskas, John / Kolh, Philippe. ·Department of Cardiothoracic Surgery, Cornell University, New York, NY, USA. · Department of Cardiothoracic Surgery, University of Massachusetts-Baystate, Springfield, MA, USA. · Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA. · Department of Biomedical and Preclinical Sciences, University of Liège, Liège, Belgium. ·Eur J Cardiothorac Surg · Pubmed #31435673.

ABSTRACT: -- No abstract --

5 Article Radial Artery Versus Right Internal Thoracic Artery Versus Saphenous Vein as the Second Conduit for Coronary Artery Bypass Surgery: A Network Meta-Analysis of Clinical Outcomes. 2019

Gaudino, Mario / Lorusso, Roberto / Rahouma, Mohamed / Abouarab, Ahmed / Tam, Derrick Y / Spadaccio, Cristiano / Saint-Hilary, Gaëlle / Leonard, Jeremy / Iannaccone, Mario / D'Ascenzo, Fabrizio / Di Franco, Antonino / Soletti, Giovanni / Kamel, Mohamed K / Lau, Christopher / Girardi, Leonard N / Schwann, Thomas A / Benedetto, Umberto / Taggart, David P / Fremes, Stephen E. ·1 Department of Cardio-Thoracic Surgery Weill Cornell Medicine New York NY. · 2 Department of Cardio-Thoracic Surgery Heart & Vascular Centre Maastricht University Medical Hospital and CARIM (Cardiovascular Research Institute Maastricht) Maastricht The Netherlands. · 3 Schulich Heart Centre Sunnybrook Health Science University of Toronto Canada. · 4 Department of Cardiothoracic Surgery Golden Jubilee National Hospital Glasgow United Kingdom. · 5 Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom. · 6 Department of Matematical Sciences Politecnico di Torino Turin Italy. · 7 Department of Cardiology "Città della Scienza e della Salute" University of Turin Italy. · 8 University of Toledo Medical Center Toledo OH. · 9 School of Clinical Sciences Bristol Heart Institute University of Bristol United Kingdom. · 10 University of Oxford United Kingdom. ·J Am Heart Assoc · Pubmed #30636525.

ABSTRACT: Background There remains uncertainty regarding the second-best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the radial artery ( RA ), right internal thoracic artery ( RITA ), and saphenous vein ( SV ). No network meta-analysis has compared these 3 strategies. Methods and Results MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA , SV , and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all-cause long-term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection ( DSWI ). Pairwise and network meta-analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included ( RA , 16 201, SV , 112 018, RITA, 21 683). At NMA , the use of SV was associated with higher long-term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI , 1.12-1.34) and RITA (incidence rate ratio, 1.26; 95% CI , 1.17-1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI , 0.55-0.91). There were no differences for any outcome between RITA and RA , although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI , 0.92-2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used. Conclusions The use of the RA or the RITA is associated with a similar and statistically significant long-term clinical benefit compared with the SV . There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.

6 Article The Incremental Value of Three or More Arterial Grafts in CABG: The Effect of Native Vessel Disease. 2018

Schwann, Thomas A / El Hage Sleiman, Abdul Karim M / Yammine, Maroun B / Tranbaugh, Robert F / Engoren, Milo / Bonnell, Mark R / Habib, Robert H. ·Department of Surgery, University of Toledo, Toledo, Ohio; Department of Surgery, Mercy Saint Vincent Medical Center, Toledo, Ohio. Electronic address: thomas.schwann@utoledo.edu. · Scholars in Health Research Program, American University of Beirut, Beirut, Lebanon. · Department of Surgery, Weill Cornell Medicine, New York, New York. · Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan. · Department of Surgery, University of Toledo, Toledo, Ohio. · The Society of Thoracic Surgeons Research Center, Chicago, Illinois. ·Ann Thorac Surg · Pubmed #30244703.

ABSTRACT: BACKGROUND: We investigated whether extended arterial grafting with three or more arterial grafts in patients with a left internal thoracic artery to left anterior descending artery graft improves survival in coronary artery bypass graft surgery patients and whether its effects will depend on the extent of coronary artery disease; specifically three-vessel disease (3VD) versus two-vessel disease (2VD). METHODS: Fifteen-year mortality was analyzed in 11,931 patients with multivessel disease and primary isolated left internal thoracic artery to left anterior descending artery coronary artery bypass graft surgery with 2 or more grafts. Patients were aged 64.3 ± 10.5 years; 3,484 (29.2%) were women; 2,532 (21.2%) had 2VD and 9,399 (78.8%) had 3VD. Patients were grouped into one single-artery group (n = 6,782, 56.9%; reference group), and two multiple artery groups: two arteries (n = 3,678, 30.8%) and three arteries (n = 1,471, 12.3%). Long-term survival was compared by Kaplan-Meier estimates. Risk-adjusted mortality hazard ratio (HR) with 95% confidence interval (CI) were derived by covariate adjusted Cox regression to quantify multiple artery effects versus one artery in the overall cohort and separately among patients with 2VD and 3VD. RESULTS: Radial artery (94%) and right internal thoracic artery (6%) conduits were used for additional arterial grafts. For the entire multivessel cohort, increasing number of arterial grafts was associated with incrementally improved 15-year survival (two arteries HR 0.85, 95% CI: 0.78 to 0.92; three arteries HR 0.75, 95% CI: 0.65 to 0.85). The three arteries versus two arteries comparison was consistent, even if not significant (HR 0.89, 95% CI: 0.77 to 1.03). The benefits derived from additional arterial grafts were more pronounced in case of 3VD (two arteries HR 0.84 95% CI: 0.76 to 0.92; three arteries HR 0.73, 95% CI: 0.63 to 0.84), without survival benefit with 2VD. CONCLUSIONS: Our results support the use of extended arterial grafting to maximize long-term coronary artery bypass graft surgery patient survival, especially for 3VD patients.

7 Article The effect of completeness of revascularization during CABG with single versus multiple arterial grafts. 2018

Schwann, Thomas A / Yammine, Maroun B / El-Hage-Sleiman, Abdul-Karim M / Engoren, Milo C / Bonnell, Mark R / Habib, Robert H. ·College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio. · Mercy Saint Vincent Medical Center, Toledo, Ohio. · Department of Internal Medicine, Outcomes Research Unit, Vascular Medicine Program, American University of Beirut, Beirut, Lebanon. · Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan. · Society of Thoracic Surgery Research Center, Chicago, Illinois. ·J Card Surg · Pubmed #30216551.

ABSTRACT: INTRODUCTION: Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG). METHODS: We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression. RESULTS: Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17]). CONCLUSIONS: Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG.

8 Article Evidence and temporality of the obesity paradox in coronary bypass surgery: an analysis of cause-specific mortality. 2018

Schwann, Thomas A / Ramia, Paul S / Engoren, Milo C / Bonnell, Mark R / Goodwin, Matthew / Monroe, Ian / Habib, Robert H. ·Department of Surgery, University of Toledo, Toledo, OH, USA. · Vascular Medicine Program, Faculty of Medicine, American University of Beirut, Beirut, Lebanon. · Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA. · The Society of Thoracic Surgeons Research Center, Chicago, IL, USA. ·Eur J Cardiothorac Surg · Pubmed #29868854.

ABSTRACT: OBJECTIVES: We evaluated the presence of an 'obesity paradox' in coronary artery bypass grafting (CABG) patients, determined its time course and ascertained whether it is associated with improved cardiovascular (CV) survival versus non-CV survival. METHODS: A retrospective analysis of 3 prospectively collected databases was conducted. A fifteen-year Kaplan-Meier analysis in 7091 CABG patients was performed and repeated in 5 body mass index [BMI (kg/m2)] cohorts [Normal (18.5-24.99 kg/m2), Overweight (25-29.99 kg/m2), Obese I (30-34.99 kg/m2), Obese II (35-39.99 kg/m2) and Obese III (≥40 kg/m2)]. Mortality hazard ratios {HR [95% confidence interval (CI)]} were derived using comprehensive multivariable competing risk Cox regression, accounting for BMI categories for overall (0-15), Early (0-1), Intermediate (1-8) and Late (8-15) postoperative years, to relax the proportional hazards assumption. The regression was repeated using BMI as a continuous variable. Mortality was classified into any, CV and non-CV. RESULTS: Obese patients were younger with more comorbidities. Fifteen-year survival was improved in the Overweight and Obese I groups (P < 0.001). Adjusted 15-year mortality was reduced in the Overweight [HR (95% CI) = 0.88 (0.79-0.98)] and Obese I [HR = 0.88 (0.78-0.99)] groups driven by improved CV and non-CV survival. This trend was noted in the early (Overweight) and intermediate postoperative periods (Overweight and Obese I) with no significance in the late period. Higher mortality in the Obese III [HR = 1.28 (1.06-1.55)] group was driven by a decreased CV survival. Using BMI as a continuous variable, a BMI of 29 kg/m2 was associated with optimal survival. CONCLUSIONS: We identified a protective partial obesity paradox in the early and intermediate postoperative periods among Overweight and mildly obese (Obese I) patients with improved CV and non-CV survival. The morbidly obese (the Obese III group) had higher early and late CV mortality.

9 Article Use Rate and Outcome in Bilateral Internal Thoracic Artery Grafting: Insights From a Systematic Review and Meta-Analysis. 2018

Gaudino, Mario / Bakaeen, Faisal / Benedetto, Umberto / Rahouma, Mohamed / Di Franco, Antonino / Tam, Derrick Y / Iannaccone, Mario / Schwann, Thomas A / Habib, Robert / Ruel, Marc / Puskas, John D / Sabik, Joseph / Girardi, Leonard N / Taggart, David P / Fremes, Stephen E. ·Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY mfg9004@med.cornell.edu. · Cleveland Clinic, Cleveland, OH. · Bristol Heart Institute, School of Clinical Sciences, University of Bristol, United Kingdom. · Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY. · Schulich Heart Centre, Sunnybrook Health Science, University of Toronto, Ontario, Canada. · Città della Scienza e della Salute, Department of Cardiology, University of Turin, Torino, Italy. · University of Toledo Medical Center, Toledo, OH. · The Society of Thoracic Surgeons Research Center, Chicago, IL. · Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada. · Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY. · University Hospitals Cleveland Medical Center, Cleveland, OH. · University of Oxford, United Kingdom. ·J Am Heart Assoc · Pubmed #29773579.

ABSTRACT: BACKGROUND: This meta-analysis was designed to assess whether center experience affects the short- and long-term results and the relative benefits of bilateral internal thoracic artery grafting (BITA) for coronary artery bypass grafting. METHODS AND RESULTS: MEDLINE and EMBASE were searched to identify all articles reporting the outcome of BITA in patients undergoing coronary artery bypass grafting. The BITA center experience was gauged according to the percentage use of BITA in the institutional overall coronary artery bypass grafting population (%BITA). The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality, perioperative myocardial infarction, perioperative stroke, deep sternal wound infections (DSWIs), and major postoperative adverse event. The rates of the primary and secondary outcomes were calculated after adjusting for %BITA. Primary and secondary outcomes were also compared between the BITA and the single internal thoracic artery arms in the adjusted studies. Meta-regression was used to evaluate the effect of %BITA on the primary and secondary outcomes. Thirty-four studies (27 894 patients undergoing BITA) were included. In the pooled analysis, the incidence rate for long-term mortality was 2.83% (95% confidence interval, 2.21%-3.61%). %BITA was significantly and inversely associated with long-term mortality and the rate of DSWI. In the pairwise comparison, %BITA was significantly and inversely associated with the risk of long-term mortality and DSWI in the group undergoing BITA. CONCLUSIONS: BITA series with higher %BITA report significantly lower long-term mortality and DSWI rate as well as higher long-term survival advantage and lower relative risk of DSWI in their BITA cohort. These findings suggest that a specific volume-outcome relationship exists for BITA grafting.

10 Article Effectiveness of radial artery-based multiarterial coronary artery bypass grafting: Role of body habitus. 2018

Schwann, Thomas A / Ramia, Paul S / Habib, Joseph R / Engoren, Milo C / Bonnell, Mark R / Habib, Robert H. ·Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; Mercy Saint Vincent Medical Center, Toledo, Ohio. Electronic address: Thomas.schwann@utoledo.edu. · Department of Internal Medicine, Outcomes Research Unit, American University of Beirut, Beirut, Lebanon. · Department of Anesthesiology, University of Michigan, Ann Arbor, Mich. · Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio. · Society of Thoracic Surgeons Research Center, Chicago, Ill. ·J Thorac Cardiovasc Surg · Pubmed #29615332.

ABSTRACT: BACKGROUND: The multiarterial grafting survival advantage noted in the overall population undergoing coronary artery bypass grafting is not well defined in the obese. We investigated the early to late survival effects of the radial artery in left internal thoracic artery-based multiarterial bypass grafting (radial artery-multiarterial bypass grafting) versus single arterial bypass grafting (left internal thoracic artery-single arterial bypass grafting) in obese patients. METHODS: We analyzed 15-year Kaplan-Meier survival in 6102 patients receiving primary, left internal thoracic artery-based coronary artery bypass grafting with 2 or more grafts divided into body mass index groups: nonobese (<30 kg/m RESULTS: Radial artery-multiarterial bypass grafting was more frequently used in obese patients who were younger (62 ± 10 years; mild/morbid: 45.4%/54.4% radial artery-multiarterial bypass grafting) compared with nonobese patients (66 ± 10 years; 37.4% radial artery-multiarterial bypass grafting). Unadjusted 15-year survival was significantly better for radial artery-multiarterial bypass grafting in all body mass index groups. Multivariate analysis showed a survival benefit of radial artery-multiarterial bypass grafting over the entire 0- to 15-year study period in the all-obese cohort (HR, 0.85; 95% CI, 0.74-0.98) and was more pronounced in the mildly obese (HR, 0.79; 95% CI, 0.66-0.96) versus morbidly obese (HR, 0.88; 95% CI, 0.69-1.13). The radial artery-multiarterial bypass grafting survival benefit was realized between 0.5 and 5 years postoperatively and was comparable for all-obese (HR, 0.69; 95% CI, 0.51-0.94) and nonobese (HR, 0.68; 95% CI, 0.52-0.88) groups. Propensity score matching was confirmatory. CONCLUSIONS: Radial artery-multiarterial bypass grafting confers a long-term survival advantage in both obese and nonobese patients.

11 Article Operative Outcomes of Multiple-Arterial Versus Single-Arterial Coronary Bypass Grafting. 2018

Schwann, Thomas A / Habib, Robert H / Wallace, Amelia / Shahian, David M / O'Brien, Sean / Jacobs, Jeffery P / Puskas, John D / Kurlansky, Paul A / Engoren, Milo C / Tranbaugh, Robert F / Bonnell, Mark R. ·Department of Surgery, University of Toledo, Toledo, Ohio. Electronic address: thomas.schwann@utoledo.edu. · The Society of Thoracic Surgeons Research Center, Chicago, Illinois. · Duke Clinical Research Institute, Duke University, Durham, North Carolina. · Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. · Department of Surgery, Johns Hopkins University, Baltimore, Maryland. · Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York. · Department of Surgery, Columbia University, New York, New York. · Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan. · Department of Surgery, Weill Cornell Medical College, New York, New York. · Department of Surgery, University of Toledo, Toledo, Ohio. ·Ann Thorac Surg · Pubmed #29453002.

ABSTRACT: BACKGROUND: More than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe. METHODS: We analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (n = 73,054) and RA-MABG (n = 97,623) vs SABG (n = 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate. RESULTS: SABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p < 0.001) and RA-MABG (1.19%, p < 0.001). DSWI was higher among BITA-MABG (1.08%, p < 0.001) and similar for RA-MABG (0.71%, p = 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; p = 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p < 0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; p = 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; p = 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (<5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p < 0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; p = 0.049) BITA use. CONCLUSIONS: MABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage.

12 Article Incremental Value of Increasing Number of Arterial Grafts: The Effect of Diabetes Mellitus. 2018

Schwann, Thomas A / El Hage Sleiman, Abdul Karim M / Yammine, Maroun B / Tranbaugh, Robert F / Engoren, Milo / Bonnell, Mark R / Habib, Robert H. ·Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio; Department of Surgery, Mercy Saint Vincent Medical Center, Toledo, Ohio. Electronic address: thomas.schwann@utoledo.edu. · Department of Internal Medicine, Outcomes Research Unit, American University of Beirut, Beirut, Lebanon; Scholars in Health Research Program, American University of Beirut, Beirut, Lebanon. · Department of Surgery, Weill Cornell Medical College, New York, New York. · Department of Surgery, Mercy Saint Vincent Medical Center, Toledo, Ohio; Department of Anesthesiology, University of Michigan Medical Center, Ann Arbor, Michigan. · Department of Surgery, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio. · The Society of Thoracic Surgeons Research Center, Chicago Illinois. ·Ann Thorac Surg · Pubmed #29408243.

ABSTRACT: BACKGROUND: Multiarterial coronary grafting with two arterial grafts leads to improved survival compared with conventional single artery based on left internal thoracic artery to left anterior descending artery and saphenous vein grafts. We investigated whether extending arterial grafting to three or more arterial grafts further improves survival, and whether such a benefit is modified by diabetes mellitus. METHODS: We analyzed 15-year coronary artery bypass graft surgery mortality data in 11,931 patients (age 64.3 ± 10.5 years; 3,484 women [29.2%]; 4,377 [36.7%] with diabetes mellitus) derived from three US institutions (1994 to 2011). All underwent primary isolated left internal thoracic artery to left anterior descending artery grafting with at least two grafts: one artery (n = 6,782; 56.9%); two arteries (n = 3,678; 30.8%); or three or more arteries (n = 1,471; 12.3%). Long-term survival was estimated by Kaplan-Meier methods. Propensity score matching and comprehensive covariate adjustment (Cox regression) were used to derive long-term risk-adjusted hazard ratio (HR) with 95% confidence interval (CI) for increasing number of arterial grafts in the overall cohort and for diabetes and no-diabetes cohorts. RESULTS: Radial artery (94%) and right internal thoracic artery (6%) were used as additional arterial grafts. Multivariate analysis in all patients showed that diabetes was associated with decreased survival (HR 1.43, 95% CI: 1.34 to 53), whereas increasing number of arterial grafts was associated with decreased mortality (one artery HR 1.0 [reference]; two arteries HR 0.87, 95% CI: 0.80 to 0.95; and three arteries HR 0.83, 95% CI: 0.72 to 0.95). Pairwise comparisons also showed an incremental benefit of additional arterial grafts: two arteries versus one artery, HR 0.89 (95% CI: 0.80 to 0.98); and three arteries versus one artery, HR 0.80 (95% CI: 0.68 to 0.94). A three-artery versus two-artery survival advantage trend was also noted, but was not significant in either the overall study cohort (HR 0.90, 95% CI: 0.75 to 1.07), the diabetes cohort (HR 0.79, 95% CI: 0.60 to 1.03), or the no-diabetes cohort (HR 01.00, 95% CI: 0.79 to 1.26). Among diabetes patients, the survival advantage of two arteries versus one artery was modest (HR 0.96, 95% CI: 0.72 to 1.11), whereas it was significant for three arteries versus one artery (HR 0.74, 95% CI: 0.58 to 0.96). Analyses of propensity matched subcohorts were also consistent. CONCLUSIONS: Increasing number of arterial grafts improves long-term survival and supports extended use of arterial grafts in coronary artery bypass graft surgery, irrespective of diabetes status.

13 Article Worldwide Trends in Multi-arterial Coronary Artery Bypass Grafting Surgery 2004-2014: A Tale of 2 Continents. 2017

Schwann, Thomas A / Tatoulis, James / Puskas, John / Bonnell, Mark / Taggart, David / Kurlansky, Paul / Jacobs, Jeffery P / Thourani, Vinod H / O'Brien, Sean / Wallace, Amelia / Engoren, Milo C / Tranbaugh, Robert F / Habib, Robert H. ·Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio; Department of Surgery, Mercy Saint Vincent Medical Center, Toledo, Ohio. Electronic address: thomas.schwann@utoledo.edu. · Department of Surgery, University of Melbourne, Parkville, Australia. · Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York. · Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio. · Department of Cardiovascular Surgery, University of Oxford, Oxford, UK. · Department of Surgery, Columbia University, New York, New York. · Department of Surgery, Johns Hopkins University, Baltimore, Maryland. · Department of Surgery, Emory University, Atlanta, Georgia. · Duke Clinical Research Center, Duke University, Durham, North Carolina. · Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan. · St. Vincent Department of Surgery, Weill Cornell Medical College, New York, New York. · Society of Thoracic Surgeons Research Center, Chicago, Illinois. ·Semin Thorac Cardiovasc Surg · Pubmed #29195570.

ABSTRACT: Recent evidence shows that multi-arterial coronary artery bypass grafting (MABG) based on bilateral internal thoracic (BITA) or left internal thoracic (LITA) and radial artery (RA) improves long-term outcomes compared with single arterial coronary artery bypass grafting (SABG) (LITA + saphenous vein graft). How this evidence affected the worldwide use of MABG, if at all, is not well defined. Accordingly, we report 10-year temporal trends of MABG utilization from 2 continents. A study population of 1,683,434 non-emergent, primary, isolated LITA-based coronary artery bypass grafting (CABG) (≥2 grafts) patients was derived from the Society of Thoracic Surgeons (STS) (1,307,528 (79.5%) of 1,644,388 isolated CABG; total 1179 centers) and the Australia New Zealand Cardiothoracic (ANZ) Databases (34,213 (87%) of 39,046 isolated CABG; 24 centers) between 2004 and 2014. Patients were excluded based on the following: (1) no LITA, (2) if arterial grafts were other than RA or ITA, or (3) if grafting data were missing. The 3 MABG groups were LITA + RA, BITA, and BITA + RA, each with or without supplemental vein grafts. Grafting trends and their associated patient demographics were analyzed. SABG (89.3% STS, 51.4% ANZ) was the most common grafting strategy. MABG was most frequently accomplished by LITA + RA: (STS: 6.1%; ANZ: 42.6%), followed by BITA: (STS: 4.1%; ANZ: 4.3%), while ≥3 (BITA + RA) was rare in the STS (0.5%), but more common in ANZ (5.9%). In the STS, between 2004 and 2014, SABG rates systematically increased from 85.2% to 91.7%, BITA grafting was essentially unchanged from 3.6% to 4.3%, while RA use decreased systematically from 10.5% to 3.7%. In the ANZ, SABG rates increased from 17.3% to 51.4%, BITA grafting decreased from 6.3% to 3.6%, while RA grafting decreased from 65.8% to 39.0%. Compared with SABG patients, BITA patients were younger (STS: median age 59 vs 66, P < 0.001; ANZ: mean age 62 vs 68, P < 0.001), predominately male (STS: 84% vs 73%, P < 0.001; ANZ: 86% vs 79%, P < 0.001), less obese (body mass index >30 kg/m

14 Article First and second generation DESs reduce diabetes adverse effect on mortality and re-intervention in multivessel coronary disease: 9-Year analysis. 2017

Badour, Sanaa A / Dimitrova, Kamellia R / Kanei, Yumiko / Tranbaugh, Robert F / Hajjar, Mark M / Kabour, Ameer / Schwann, Thomas A / Alam, Samir / Badr, Kamal / Habib, Robert H. ·Department of Internal Medicine, Vascular Medicine Program and Outcomes Research Unit, American University of Beirut, Lebanon. · Divisions of Cardiology, Mount Sinai Beth Israel Medical Center, New York, NY, USA. · Cardiothoracic Surgery, Mount Sinai Beth Israel Medical Center, New York, NY, USA. · Division of Cardiology, Mercy Saint Vincent Medical Center, Toledo, OH, USA. · Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA. · Department of Internal Medicine, Vascular Medicine Program and Outcomes Research Unit, American University of Beirut, Lebanon. Electronic address: rh106@aub.edu.lb. ·Cardiovasc Revasc Med · Pubmed #28314676.

ABSTRACT: BACKGROUND/PURPOSE: Diabetes portends an increased risk of adverse early and late outcomes in patients undergoing PCI. In this study, we aimed to investigate if the adverse effect of diabetes mellitus (DM) on early and late PCI outcomes is reduced with drug-eluting (DES) compared to bare-metal (BMS) stents. METHODS/MATERIALS: We reviewed the Mount Sinai Beth Israel Hospital first PCI experience for multivessel coronary artery disease (CAD, 1998-2009). Patients were excluded if they had single-vessel CAD, emergency, no stent, prior bypass graft or myocardial infarction <24h. Diabetes-effect was derived from 9-year all-cause mortality and re-intervention risk-adjusted hazard ratios [AHR (95% confidence intervals)] for DES (N=2679; 48% three-vessel; 39% DM) and BMS (N=2651; 40% three-vessel; 33% DM) and then stratified based on stent (DES/BMS) and vessel disease (two/three). RESULTS: Diabetes-effect on mortality was lower for DES (AHR CONCLUSIONS: Our analysis of a large real-world PCI series indicates that diabetes is associated with worse 9-year mortality irrespective of stent type, albeit this is mitigated to varying degrees with DES, particularly in DES2 and in case of 2-vessel disease. A complementary stent-effect analysis confirmed DES-to-BMS and DES2-to-DES1 superiority in both diabetics and non-diabetics.

15 Article Coronary Artery Bypass Graft Surgery Using the Radial Artery, Right Internal Thoracic Artery, or Saphenous Vein as the Second Conduit. 2017

Tranbaugh, Robert F / Schwann, Thomas A / Swistel, Daniel G / Dimitrova, Kamellia R / Al-Shaar, Laila / Hoffman, Darryl M / Geller, Charles M / Engoren, Milo / Balaram, Sandhya K / Puskas, John D / Habib, Robert H. ·Department of Cardiovascular Surgery, Mount Sinai Beth Israel, New York, New York. Electronic address: rft9008@med.cornell.edu. · Division of Cardiothoracic Surgery, University of Toledo Medical Center, Toledo, Ohio. · Division of Cardiothoracic Surgery, Mount Sinai St. Luke's, New York, New York. · Department of Cardiovascular Surgery, Mount Sinai Beth Israel, New York, New York. · Outcomes Research Unit and Vascular Medicine Program, American University of Beirut Medical Center, Beirut, Lebanon. · Division of Anesthesia, Mercy Saint Vincent Medical Center, Toledo, Ohio. ·Ann Thorac Surg · Pubmed #28215422.

ABSTRACT: BACKGROUND: It is not clear whether radial artery (RA), right internal thoracic artery (RITA), or saphenous vein (SV) is the preferred second bypass graft during coronary artery bypass graft surgery using the left internal thoracic artery (LITA) in patients aged less or greater than 70 years. METHODS: Late survival data were collected for 13,324 consecutive, isolated, primary coronary artery bypass graft surgery patients from three hospitals. Cox regression analysis was performed on all patients grouped by age. RESULTS: Adjusted Cox regression showed overall better RA versus SV survival (hazard ratio [HR] 0.82, p < 0.001) and no difference in RITA versus SV survival (HR 0.95, p = 0.35). However, the survival benefit of RA versus SV was seen only in patients aged less than 70 years (HR 0.77, p < 0.001); and RITA patients aged less than 70 years also had a survival benefit compared with SV (HR 0.86, p = 0.03). There was no difference in survival for RA versus RITA across all ages. CONCLUSIONS: For patients aged less than 70 years, the optimal grafting strategy is using either RA or RITA as the second preferred graft. In patients aged 70 years or more, RA and RITA grafting should be used selectively. Multiple arterial grafting using either RA or RITA should be more widely utilized during coronary artery bypass graft surgery for patients less than 70 years of age.

16 Article Effects of Blood Transfusion on Cause-Specific Late Mortality After Coronary Artery Bypass Grafting-Less Is More. 2016

Schwann, Thomas A / Habib, Joseph R / Khalifeh, Jawad M / Nauffal, Victor / Bonnell, Mark / Clancy, Christopher / Engoren, Milo C / Habib, Robert H. ·Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio; Mercy Saint Vincent Medical Center, Toledo, Ohio. · Department of Internal Medicine, Outcomes Research Unit and Vascular Medicine Program, American University of Beirut, Beirut, Lebanon. · Department of Internal Medicine, Outcomes Research Unit and Vascular Medicine Program, American University of Beirut, Beirut, Lebanon; Department of Medicine, Johns Hopkins Medical Institutes, Baltimore, Maryland. · Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio. · Mercy Saint Vincent Medical Center, Toledo, Ohio; Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan. · Department of Internal Medicine, Outcomes Research Unit and Vascular Medicine Program, American University of Beirut, Beirut, Lebanon. Electronic address: rh106@aub.edu.lb. ·Ann Thorac Surg · Pubmed #27344276.

ABSTRACT: BACKGROUND: Red blood cell transfusion after coronary artery bypass graft surgery has been associated with increased late all-cause death. Yet, whether this association is, first, independent of the packed red blood cells and perioperative morbidity association, and second, of a cardiac versus noncardiac etiology remains unknown. METHODS: We analyzed patients undergoing coronary artery bypass graft surgery at two Ohio hospitals (n = 6,947) from 1994 to 2007. Salvage operations and patients with preoperative renal failure were excluded. Long-term outcomes and leading cause of death (cardiac, noncardiac, all cause) were derived from the US Social Security Death Index and later from Ohio Department of Health Death Index. Fifteen-year mortality cumulative incidence functions were compared for transfusion groups (yes, n = 2,540; no, n = 4,806) overall, and then stratified based on perioperative complications status (yes, n = 2,638; no, n = 4,708). Comprehensive, 32 covariates, risk-adjusted transfusion effects were estimated by competing risk regression. Results were confirmed by propensity score adjusted analysis. RESULTS: Perioperative transfusions and complications occurred in 33.9% and 35.2% of patients, respectively. In all, 3,108 deaths (48.1%) have been documented (median time to death, 7.43 years). Both transfusion rates (25.6% versus 49.1%, p < 0.001) and deaths (58.2% versus 38.5%, p < 0.001) were more frequent among complications patients. Red blood cells transfusion increased intermediate to late mortality risk overall (15-year adjusted hazard ratio [AHR] 1.21, 95% confidence interval [CI]: 1.11 to 1.31), and for complications (AHR 1.24, 95% CI: 1.11 to 1.39) and no complications (AHR 1.16, 95% CI: 1.03 to 1.31). The increased mortality was true for cardiac and noncardiac etiologies (AHR 1.19, 95% CI: 1.03 to 1.36, and AHR 1.14, 95% CI: 1.01 to 1.29, respectively). Red blood cell transfusion increased mostly cardiac deaths (AHR 1.38, 95% CI: 1.14 to 1.66) among the complications group, and noncardiac mortality (AHR 1.24, 95% CI: 1.05 to 1.47) for the no complications group. A parallel propensity matched sensitivity analysis confirmed these findings. CONCLUSIONS: Perioperative red blood cells transfusion is associated with significant adverse late death effects among both complicated patients and noncomplicated patients, principally seen between 0 and 5 years postoperatively, and is driven by both increased cardiovascular and noncardiovascular mortality. Further studies are needed to elucidate the mechanisms behind these findings, including their potential dose dependence.

17 Article Equipoise between radial artery and right internal thoracic artery as the second arterial conduit in left internal thoracic artery-based coronary artery bypass graft surgery: a multi-institutional study†. 2016

Schwann, Thomas A / Hashim, Sabet W / Badour, Sanaa / Obeid, Mounir / Engoren, Milo / Tranbaugh, Robert F / Bonnell, Mark R / Habib, Robert H. ·University of Toledo Medical Center, Toledo, OH, USA Mercy St. Vincent Medical Center, Toledo, OH, USA thomas.schwann@utoledo.edu. · Yale University School of Medicine, New Haven, CT, USA. · American University of Beirut, Beirut, Lebanon. · University of Michigan, Ann Arbor, MI, USA. · Mount Sinai Beth Israel Medical Center, New York, NY, USA. · University of Toledo Medical Center, Toledo, OH, USA. ·Eur J Cardiothorac Surg · Pubmed #25762396.

ABSTRACT: OBJECTIVES: Multiple arterial coronary artery grafting (MABG) improves long-term survival compared with single arterial CABG (SABG), yet the best second arterial conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second arterial graft were compared with SABG. METHODS: Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts. RESULTS: Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively. CONCLUSIONS: RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery.

18 Article CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting. 2015

Habib, Robert H / Dimitrova, Kamellia R / Badour, Sanaa A / Yammine, Maroun B / El-Hage-Sleiman, Abdul-Karim M / Hoffman, Darryl M / Geller, Charles M / Schwann, Thomas A / Tranbaugh, Robert F. ·Department of Internal Medicine, American University of Beirut, Beirut, Lebanon; Outcomes Research Unit, American University of Beirut, Beirut, Lebanon; Vascular Medicine Program, American University of Beirut, Beirut, Lebanon. Electronic address: rh106@aub.edu.lb. · Department of Cardiovascular Surgery, Mount Sinai Beth Israel Medical Center, New York, New York. · Outcomes Research Unit, American University of Beirut, Beirut, Lebanon. · Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio. · Department of Cardiovascular Surgery, Mount Sinai Beth Israel Medical Center, New York, New York. Electronic address: rtranbau@chpnet.org. ·J Am Coll Cardiol · Pubmed #26403338.

ABSTRACT: BACKGROUND: Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES). OBJECTIVES: This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG). METHODS: We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts. RESULTS: BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001). CONCLUSIONS: Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.

19 Article Multi Versus Single Arterial Coronary Bypass Graft Surgery Across the Ejection Fraction Spectrum. 2015

Schwann, Thomas A / Al-Shaar, Laila / Tranbaugh, Robert F / Dimitrova, Kamellia R / Hoffman, Darryl M / Geller, Charles M / Engoren, Milo C / Bonnell, Mark R / Habib, Robert H. ·Department of Surgery, University of Toledo Medical Center, Toledo, Ohio. · Vascular Medicine Program, American University of Beirut, Beirut, Lebanon. · Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan. · Mercy Saint Vincent Medical Center, Toledo, Ohio; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon. · Vascular Medicine Program, American University of Beirut, Beirut, Lebanon; Department of Surgery, Mount Sinai Beth Israel Medical Center, New York, New York. Electronic address: rh106@aub.edu.lb. ·Ann Thorac Surg · Pubmed #26116479.

ABSTRACT: BACKGROUND: Left internal thoracic artery (LITA) and radial artery (RA) multi-arterial CABG (MABG) is generally associated with improved long-term survival compared with traditional LITA and saphenous vein single arterial CABG (SABG). We examined the hypothesis that this multi-arterial survival advantage persists irrespective of left ventricular ejection fraction (LVEF). METHODS: We retrospectively analyzed the primary, non-salvage multi-graft CABG experience (n = 11,261; 64.4 ± 10.4 years, 70.4% men) from 2 institutions (1995 to 2011). Risk-adjusted 15-year survival was pairwise compared for the MABG versus SABG grafting approaches within 3 LVEF subcohorts (>0.50, n = 4,833 [44% MABG]; 0.36 to 0.50, n = 4,465 [39% MABG]; and ≤ 0.35, n = 1,963 [35% MABG]) using propensity-matched and covariate adjusted Cox regression (all patients) comparisons. RESULTS: Propensity matching yielded 1,317 (LVEF > 0.50), 1,179 (LVEF, 0.36 to 0.50), and 470 (LVEF ≤ 0.35) well-matched grafting method pairs. Acute perioperative mortality was equivalent between MABG and SABG within each LVEF group, but increased with decreasing LVEF. MABG was uniformly associated with better 15-year survival compared with SABG for all LVEF categories. The associated matched-adjusted hazard ratios (95% confidence intervals) were consistent across EF groups at 0.79 (0.68 to 0.93), 0.80 (0.69 to 0.93), and 0.82 (0.66 to 1.0), respectively. Covariate adjusted HR in all patients concurred with matched results. CONCLUSIONS: MABG results in significantly enhanced long-term survival compared with LITA/SVG SABG regardless of the degree of LV dysfunction. These results favor MABG as the therapy of choice in patients with LV dysfunction.

20 Article Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease. 2015

Nauffal, Victor / Schwann, Thomas A / Yammine, Maroun B / El-Hage-Sleiman, Abdul-Karim M / El Zein, Mohamad H / Kabour, Ameer / Engoren, Milo C / Habib, Robert H. ·Department of Internal Medicine, Outcomes Research Unit and Scholars in Health Research Program, American University of Beirut, Beirut, Lebanon; Department of Medicine, Johns Hopkins Medical Institutes, Baltimore, Md. · Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio. · Department of Surgery, Brigham and Women's Hospital, Boston, Mass. · Department of Internal Medicine, Outcomes Research Unit and Scholars in Health Research Program, American University of Beirut, Beirut, Lebanon. · Department of Medicine, Johns Hopkins Medical Institutes, Baltimore, Md. · Division of Cardiology, Mercy Saint Vincent Medical Center, Toledo, Ohio. · Department of Anesthesia, University of Michigan, Ann Arbor, Mich. · Department of Internal Medicine, Outcomes Research Unit and Scholars in Health Research Program, American University of Beirut, Beirut, Lebanon. Electronic address: rh106@aub.edu.lb. ·J Thorac Cardiovasc Surg · Pubmed #25772280.

ABSTRACT: OBJECTIVE: Recent studies have indicated that coronary artery bypass grafting (CABG) outcomes in patients with prior stents are suboptimal. We aimed to study the impact of prior percutaneous coronary intervention (PCI) with stenting (PCI-S) on late CABG mortality in diabetic patients with triple-vessel disease. METHODS: We reviewed the primary nonemergency CABG experience from a single U.S. institution (n = 7005; 1996-2007, Toledo, Ohio). Diabetics with triple-vessel disease (n = 1583) were identified and divided into 2 groups: (1) prior PCI-S (n = 202); and (2) no prior PCI (No-PCI [n = 1381]). Hierarchic Cox proportional hazards models were used to assess the effect of prior PCI-S on 5-year mortality after CABG. A propensity score for PCI-S and No-PCI patients was derived using a nonparsimonious logistic regression and used to generate a 1:1 (PCI-S to No-PCI) matched cohort. RESULTS: In model 1, after adjusting for preoperative clinical characteristics, medications, off-pump surgery, and isolated CABG surgery status, prior PCI-S was associated with a 39% increased risk of mortality (hazard ratio [HR] = 1.39, with 95% confidence interval [CI; 1.02, 1.90]; P = .04). Further adjustment for date of surgery (model 2) (HR = 1.39, with 95% CI [1.02, 1.91]; P = .04) or operative parameters (model 3) (HR = 1.38, with 95% CI [1.01, 1.88]; P = .046) did not alter the association. The 1:1 matched-cohort analysis confirmed the increased risk associated with PCI-S (HR = 1.61, with 95% CI [1.03, 2.51]; P = .037). CONCLUSIONS: Patients who have both diabetes and triple-vessel disease, and have undergone prior PCI-S, have poorer long-term outcomes after CABG compared with those who have had no prior PCI-S.

21 Article Time-varying survival benefit of radial artery versus vein grafting: a multiinstitutional analysis. 2014

Schwann, Thomas A / Tranbaugh, Robert F / Dimitrova, Kamellia R / Engoren, Milo C / Kabour, Ameer / Hoffman, Darryl M / Geller, Charles M / Ko, Wilson / Habib, Robert H. ·Department of Surgery, University of Toledo Medical Center, Toledo, Ohio; Mercy Saint Vincent Medical Center, Toledo, Ohio. · Beth Israel Medical Center, New York, New York. · Mercy Saint Vincent Medical Center, Toledo, Ohio; Anesthesiology, University of Michigan, Ann Arbor, Michigan. · Mercy Saint Vincent Medical Center, Toledo, Ohio. · Department of Internal Medicine and Outcomes Research Unit, American University of Beirut, Beirut, Lebanon. Electronic address: rh106@aub.edu.lb. ·Ann Thorac Surg · Pubmed #24360093.

ABSTRACT: BACKGROUND: A survival benefit of radial artery use versus saphenous vein grafting in coronary artery bypass grafting (CABG) has been reported. We aimed to elucidate the relative radial artery survival benefit as a function of time after surgery from two independent CABG series. METHODS: We compared 0- to 15-year survival with radial artery versus saphenous vein grafting in isolated, nonsalvage primary CABG with left internal thoracic artery to left anterior descending from two institutions: Ohio (radial artery [n=2,361; 61 years]; saphenous vein [n=2,547; 67 years]), and New York (radial artery [n=1,970; 58 years]; saphenous vein [n=2,974; 69 years]). Separate multivariate radial artery-use propensity models based on demographic, preoperative factors, intraoperative variables, and completeness of revascularization data were computed and used to derive propensity- and sex-matched CABG cohorts (1,799 [Ohio] and 995 [New York] pairs). A three-phase (early and late) mortality model was fit to Kaplan-Meier mortality estimates and used to derive relative radial artery versus saphenous vein hazard functions. RESULTS: Radial artery use patterns and patient risk profiles differed substantially for New York and Ohio, with the New York radial artery cohort significantly younger and more male. Within-institution matched graft-type cohorts were well matched. Cumulative mortality was significantly better for radial artery at both institutions (p < 0.001 both). All mortality-time data were well described by the three-phase model, and the derived relative hazard functions were qualitatively and quantitatively similar for New York and Ohio, exhibiting maximal benefit between 0.5 and 5 years. CONCLUSIONS: Despite substantial differences in radial artery use patterns during a 15-year period, our analysis in large propensity-matched radial artery and saphenous vein cohorts yielded remarkably similar, time-varying radial artery to saphenous vein survival benefit at both institutions. These converging findings based on two independent patient series extend currently available objective evidence in support of a radial artery survival advantage in CABG.

22 Article Use of genetic programming, logistic regression, and artificial neural nets to predict readmission after coronary artery bypass surgery. 2013

Engoren, Milo / Habib, Robert H / Dooner, John J / Schwann, Thomas A. ·Department of Anesthesiology, University of Michigan, Ann Arbor, MI 48109-5861, USA. engorenm@med.umich.edu ·J Clin Monit Comput · Pubmed #23504197.

ABSTRACT: As many as 14 % of patients undergoing coronary artery bypass surgery are readmitted within 30 days. Readmission is usually the result of morbidity and may lead to death. The purpose of this study is to develop and compare statistical and genetic programming models to predict readmission. Patients were divided into separate Construction and Validation populations. Using 88 variables, logistic regression, genetic programs, and artificial neural nets were used to develop predictive models. Models were first constructed and tested on the Construction populations, then validated on the Validation population. Areas under the receiver operator characteristic curves (AU ROC) were used to compare the models. Two hundred and two patients (7.6 %) in the 2,644 patient Construction group and 216 (8.0 %) of the 2,711 patient Validation group were re-admitted within 30 days of CABG surgery. Logistic regression predicted readmission with AU ROC = .675 ± .021 in the Construction group. Genetic programs significantly improved the accuracy, AU ROC = .767 ± .001, p < .001). Artificial neural nets were less accurate with AU ROC = 0.597 ± .001 in the Construction group. Predictive accuracy of all three techniques fell in the Validation group. However, the accuracy of genetic programming (AU ROC = .654 ± .001) was still trivially but statistically non-significantly better than that of the logistic regression (AU ROC = .644 ± .020, p = .61). Genetic programming and logistic regression provide alternative methods to predict readmission that are similarly accurate.

23 Article Late effects of radial artery vs saphenous vein grafting for multivessel coronary bypass surgery in diabetics: a propensity-matched analysis. 2013

Schwann, Thomas A / Al-Shaar, Laila / Engoren, Milo / Habib, Robert H. ·Department of Surgery, University of Toledo, College of Medicine, Toledo, OH, USA. ·Eur J Cardiothorac Surg · Pubmed #23428573.

ABSTRACT: OBJECTIVES: To determine whether the use of the radial artery (RA) vs the saphenous vein (SV) as the second grafting conduit with the internal thoracic artery (ITA) confers a late-survival advantage in diabetes mellitus (DM). METHODS: We reviewed our 1996-2007 DM coronary artery bypass grafting (CABG) experience. Study patients (N = 2281) included all primary, non-salvage multigraft CABG discharged alive and receiving ≥1 ITA graft. Bilateral ITA, ITA-only grafts or concomitant valve/aortic surgery patients were excluded. A non-parsimonious, RA use propensity model (42 variables) was derived excluding five factors [gender, vessel disease, insulin, renal failure and left ventricular (LV) dysfunction] that were always strictly matched for all pairs. Greedy matching resulted in well-matched ITA/RA and ITA/SV cohorts (N = 578 each). The late follow-up was truncated at 16 years, and survival comparisons were done by Kaplan-Meier analysis. RESULTS: RA grafting was used in 933 (41%) DM patients and was more frequent for non-insulin (513/1348; 49.1%) compared with insulin (271/784; 34.6%) dependent patients. Relatively fewer insulin ITA/RA (169; 62%) could be matched vs non-insulin (469; 71%). Late survival was significantly better for ITA/RA overall [hazard ratio, HR (95% confidence interval) = 0.78 (0.65-0.95); P = 0.012], but this was primarily due to the non-insulin sub-cohort [HR = 0.72 (0.56-0.91); P = 0.007] as opposed to no effect for insulin [HR = 0.92 (0.68-1.26); P = 0.61]. Sub-cohort analysis revealed a significant ITA/RA survival advantage in males, preserved LV function and three-vessel disease. No sub-cohorts were associated with superior ITA/SV survival. CONCLUSION: Our analysis indicated that RA grafting confers a significant late-survival advantage and, thus, supports its liberal use in DM patients undergoing multivessel CABG.

24 Article Late effects of radial artery versus saphenous vein grafting in patients aged 70 years or older. 2012

Habib, Robert H / Schwann, Thomas A / Engoren, Milo. ·Department of Internal Medicine, American University of Beirut, Beirut, Lebanon. rh106@aub.edu.lb ·Ann Thorac Surg · Pubmed #22771490.

ABSTRACT: BACKGROUND: We aimed to determine whether the reported late survival benefit of radial artery (RA) versus saphenous vein (SV) grafting in the general coronary artery bypass graft surgery (CABG) population is maintained in elderly patients aged 70 years or older. METHODS: We reviewed our 1996 to 2007 experience in 2,120 elderly patients (RA, n = 607; SV, n = 1,513) who underwent primary, nonsalvage CABG with multiple completed grafts including at least one internal thoracic artery (ITA) graft. Patients were excluded in case of single-vessel disease, bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery. Kaplan-Meier 12-year survival estimates were compared for 1-to-1 matched ITA/RA and ITA/SV cohorts based on a nonparsimonious RA use propensity model (48 variables). RESULTS: The ITA/RA and ITA/SV cohorts (both, aged 75 ± 4yrs and 3.5 ± 0.8 grafts) were well matched and had identical operative mortality (2.3%; 11 of 480 each). Late survival was superior ITA/RA versus ITA/SV (p < 0.001), estimated at 85.1% versus 70.6% and 70.9% versus 50.5% for 5 and 10 years, respectively. Late survival risk ratios (95% confidence interval) for RA versus SV grafting was 0.47 (0.36 to 0.61), and the relative SV to RA death hazard was greater than 1 between 1 and 144 months. CONCLUSIONS: The late survival results suggest that elderly (≥70 years) primary multivessel CABG patients benefit substantially when RA is used as the second conduit in combination with ITA. Indeed, compared with previously published comparisons including all age groups, the derived risk ratio indicates that the benefit for the elderly may exceed that for younger patients in the initial decade after CABG. Use of RA should not be avoided in the elderly.

25 Article Comparison of late coronary artery bypass graft survival effects of radial artery versus saphenous vein grafting in male and female patients. 2012

Schwann, Thomas A / Engoren, Milo / Bonnell, Mark / Clancy, Christopher / Habib, Robert H. ·Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio. ·Ann Thorac Surg · Pubmed #22771486.

ABSTRACT: BACKGROUND: This study aimed to compare the survival benefit derived from using radial artery (RA) as a second arterial conduit in combination with internal thoracic artery (ITA), as opposed to ITA plus saphenous vein (SV) in men and women. METHODS: We reviewed the 1996 to 2007 primary, nonsalvage coronary artery bypass graft surgery (CABG) experience at Mercy Saint Vincent Medical Center (n = 6,384; 69% men, 31% women). Study subjects had two or more completed grafts including one ITA graft. Patients with bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery were excluded. Separate sex nonparsimonious propensity models for RA grafting based on 47 preoperative and intraoperative factors were used to identify matched ITA/RA and ITA/SV cohorts. Kaplan-Meier and Cox regression analyses were then applied to assess sex-specific 12-year survival risk ratios of RA versus SV grafting. RESULTS: Patient variables for the RA and SV cohorts were well-matched in both men (n = 1,416 each; median age 62 years) and women (n = 567 each; median age 66 years). Thirty-day mortality was similar for ITA/RA versus ITA/SV in men (1.3% versus 1.2%; p = 1.0) and women (1.4% versus 1.9%; p = 0.664). Late mortality (1 to 144 months) was significantly better for ITA/RA in men (risk ratio 0.65, 95% confidence interval: 0.54 to 0.79; p < 0.001) and women (risk ratio 0.75, 95% confidence interval: 0.57 to 0.99; p = 0.045). CONCLUSIONS: Late survival results suggest that male and female CABG patients benefit appreciably from use of RA as a second arterial conduit in combination with ITA. Yet, the late survival advantage derived from RA use was relatively less for women. This sex variance in benefit likely reflects differences in risk profiles of male and female CABG patients.

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