1. BITA Grafting: When to do it (when to not do it ) Joseph F. Sabik, MD Chairman and Professor of Surgery Department of Thoracic and Cardiovascular Surgery Sheik Hamdam Bin Rashid Al Maktoum Distinguished Chair Cleveland Clinic Lerner College of Medicine Joseph F. Sabik, MD Chairman and Professor of Surgery Department of Thoracic and Cardiovascular Surgery Sheik Hamdam Bin Rashid Al Maktoum Distinguished Chair Cleveland Clinic Lerner College of Medicine

2. Two Internal Thoracic Artery Grafts are Better Than One Lytle et al. / J Thorac Cardiovasc Surg 1999 5 4 3 2 1 0 Reoperation (%/year) 02 100 80 60 40 20 0 Survival % 4681012 Survival Reoperation BITA n=1089 SITA n=4147 P < 0.001 Years After CABG

4. Study Patients10,124 InterventionPrimary isolated CABG Setting Single center Time period 1971 to 1989 Mean F/U16.5 years Endpoint Survival

5. Survival Difference -20-1001020304050 100 80 60 40 20 0 Difference at 20 Years % SITAbenefit BITAbenefit % < Stated Difference Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)

6. Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)

7. Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)

8. Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)

9. Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)

10. Incremental Risk Factors for Death in 1152 Matched Pairs of BITA and SITA Patients Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)

11. 05 100 80 60 40 0 Years % 101520 Survival BITA SITA Age 30 50 70 20 “Ideal” Profile Lytle et al. / (Ann Thorac Surg 2004;78:2005–14)

12. Survival BITA (LVF normal/mild) SITA (LVF normal/mild) BITA (mod/sev LVF) SITA (mod/sev LVF) 05 Years % 101520 Lytle et al. / (Ann Thorac Surg 2004;78:2005–14) 100 80 60 40 0 20

13. Survival 05 Years % 101520 BITA SITA Age 30 50 70 LV Dysfunction Lytle et al. / (Ann Thorac Surg 2004;78:2005–14) 100 80 60 40 0 20

14. 05 Years % 101520 BITA SITA Age 30 50 70 Survival Non-Cardiac Morbidity Lytle et al. / (Ann Thorac Surg 2004;78:2005–14) 100 80 60 40 0 20

15. 05 Years % 101520 BITA SITA Survival Age 30, 50, 70 LV Dysfunction + Non-Cardiac Morbidity 100 80 60 40 0 20

16. Survival Difference Δ%Δ% Age 5 10 15 20 Follow-up 12 8 4 0 -4 4050607080 Lytle, Ann Thorac Surg, 2004

17. DiabeticsDiabetics

18. Study Patients11,922 diabetics InterventionPrimary isolated CABG Setting Single center Time period 1972 to 2011 Follow-up 104,516 patient-years Endpoints Hospital outcomes Long-term mortality

19. % Years BITA SITA P<.0001 Survival

20. Survival: Adjusted 1.5 Off-pump Late Risk of Death 1.00.67 BITA IR

21. 1.01.5 0.67 Resp. failure Reop for bleeding Deep SWI Favors BITAFavors SITA Hospital Outcomes Adjusted

22. Risk of DSWI Risk of DSWI 1.5 PAD Deep SWI 0.67 Medically treated DM Female 2.02.5 MI 1.0

23. % BMI Effect of BMI on DSWI Risk

24. DSWI Risk Factors BMI % Female & BITA Male & BITA Medically treated diabetic MI

25. WomanWoman

26. Patients 1/1972 to 1/2011 n = 57,943 Primary Isolated CABG Men (81%) n = 46,934 Women (19%) n = 11,009

27. % Years Men Women 051015202530 100 80 60 40 0 20 Survival

28. 051015202530 % Years BITA SITA No ITA Men Survival 100 80 60 40 0 20

29. 051015202530 % Years Survival BITA No ITA SITA Women 100 80 60 40 0 20

30. Survival CR SITA BITA 0.50.81.251.0 Hazard Ratio Woman Man

31. SummarySummary Almost all patients benefit from BITA 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 Almost all patients benefit from BITA 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