1. Satya Shanbhag Waikato Cardiothoracic Unit
ART Trial
Satya Shanbhag
Waikato Cardiothoracic Unit

3. 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

4. Methods
Patients randomly assigned to undergo LIMA or BIMA graft (June –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

5. 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).

13. 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

14. 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

15. 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.

16. 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)

17. What are the evidence/guidelines?

18. What are the evidence/guidelines?

19. LIMA vs BIMA

22. RIMA vs Radial

23. CABG: long term graft patency

24. 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