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Effect of surgical timing and the use of Bilateral Internal thoracic artery grafting on outcome of patients after acute MI?
Nachum Nesher1, Dan Loberman2, Rephael Mohr1, Demitri Pevni1, Mohamed Medleg1, Amir Kramer1, Zachi Aizer1, Yossi Paz1, Yanai Ben-Gal1.
1Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 2Brigham and Women's Hospital, Boston, MA, USA.

OBJECTIVE:
The long time required to get myocardial infarction (MI) patients to surgery, and the efficiency of primary Per-Cutaneous Interventions( PCI) and fibrinolysis in restoring myocardial blood supply have resulted in less common use of coronary artery bypass grafting (CABG) as first line reperfusion strategy for patients with acute MI The purpose of this study is to compare early and long-term outcome of CABG for acute MI patients, according to time interval between hospital admission and surgery and the use of bilateral internal thoracic (BITA) grafting
METHODS:
Eight hundred ninety one multi- vessel coronary disease patients underwent CABG after acute MI (<7 days) between 1996 and 2010. They were stratified according to timing of surgery: 336 were operated within 24 hours of symptoms onset (emergency group) while 555 between 1-7 days (Non- emergency group).
RESULTS:
Emergency patients were older, less often female or diabetics and more likely to have unstable angina, EF<30%, preoperative critical state, and left main disease. They were less likely to undergo BITA grafting and more likely to have their surgery performed after PCI. Operative mortality (9.2% vs. 2.2%, p<0.001) and occurrence of peri-operative MI ( 5.4% vs.1.1%, p<0.001)were higher in the emergency group .Sternal wound infection (3% Vs 1.8%)and strokes(3,9% vs. 2.5% ) were not significantly different between groups Mean follow-up was 12.9 + 2.2 years. Kaplan Meier 10 years survival of BITA patients was better in both groups (66.4% vs.49.9.9% [p=0.004] in the Emergency group and 73.9% vs. 52.9%[ p<0.001] in the Non -Emergency group p=0.004.) After adjustment for propensity score, operative timing and assignment to BITA were not predictors of improved long term survival, however the interaction of BITA grafting and Non-Emergency operation was associated with improved survival .Thus, Non - Emergent patients undergoing BITA grafting have significantly better survival. (HR 1.256 p=0.038.)
CONCLUSIONS:
This study shows better early outcome for Acute MI patients operated on later than 24 hours after symptoms onset This improved early outcome is associated with better long-term survival when CABG is performed using BITA grafting.


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