Satya Shanbhag Waikato Cardiothoracic Unit ART Trial Satya Shanbhag Waikato Cardiothoracic Unit

Introduction Use of BITA/BIMA graft for CABG has till now shown good long term benefit Pooled data show that BITA grafts decrease mortality by 20% at 10 years compared to single LIMA grafts BIMA grafts not widely adopted: difficult, cause increased sternal events and benefit not fully known through randomised studies

Methods Patients randomly assigned to undergo LIMA or BIMA graft (June 2004 –Dec 2007) Study in 28 cardiac centers in 7 countries F/U period up to 10 years (5 yrs interim analysis) Primary Outcome: Death from any cause in 10 yrs Secondary Outcome: Composite of death from any cause, MI and Stroke

Methods Statistics: Kaplan Meier with log rank correction, Cox proportional hazard model for HR Pre-specified sub group analysis for: age (<70 and >70), DM (yes/no), radial artery graft( yes/no), EF (<50% and >50%) and number of grafts (<3 and >3).

Author Conclusions The study is an interim analysis (at 5 yrs) of the ART trial At 5yrs no difference in primary and composite outcomes between the two group Higher sternal complication in the BIMA group

Study strengths Well conducted multi institutional randomised study The study met the required number of patients Some amount of blinding performed for selection Published in a reputed journal

Study weakness Interim analysis only- no definitive conclusion can be drawn The graft configuration not standardised 25% of patients >70 yr old underwent complex BIMA grafts The trial may not find significance because 16.4% of BIMA patients did not get the graft.

Study weakness Sternal complication high due to 49% BIMA having pedicled grafts Doubtful lateral wall revascularisation due to 49%pedicled BIMA More than 20% of LIMA patients received supplemental radial artery graft- shown to be better than single graft (possible equivalent to BIMA)

What are the evidence/guidelines?

What are the evidence/guidelines?

LIMA vs BIMA

RIMA vs Radial

CABG: long term graft patency

Conclusions BIMA and total arterial graft has its own use and advantages These should be offered for the ideal candidate patients Radial artery graft offers an alternative to RIMA and is as effective Further randomised studies required with long term f/u