Hospital Volume and Outcome after Bilateral Internal Mammary Artery Grafting


  • Andrea Perrotti Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
  • Daniel Reichart Hamburg University Heart Center, Hamburg, Germany
  • Giuseppe Gatti Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
  • Giuseppe Faggian Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
  • Francesco Onorati Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
  • Marisa De Feo Division of Cardiac Surgery, Universita degli Studi della Campania Luigi Vanvitelli, Caserta, Italy
  • Sidney Chocron, MD Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
  • Magnus Dalén Department of Molecular Medicine and Surgery, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  • Giuseppe Santarpino Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany and Città di Lecce Hospital GVM Care&Research, Lecce, Italy
  • Antonino S. Rubino Centro Clinico-Diagnostico “G.B. Morgagni”, Centro Cuore, Pedara, Italy
  • Daniele Maselli Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
  • Riccardo Gherli Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
  • Antonio Salsano Division of Cardiac Surgery, University of Genoa, Genoa, Italy
  • Francesco Nicolini Division of Cardiac Surgery, University of Parma, Parma, Italy
  • Marco Zanobini Department of Cardiac Surgery, Centro Cardiologico - Fondazione Monzino IRCCS, University of Milan, Milan, Italy
  • Karl Bounader Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
  • Stefano Rosato National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
  • Tuomas Tauriainen Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
  • Tatu Juvonen Heart Center, Helsinki University Hospital, Finland
  • Giovanni Mariscalco Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
  • Vito G. Ruggieri Division of Cardiac Surgery, Reims University Hospital, Reims, France; 20Heart Center, Turku University Hospital, and Department of Surgery, University of Turku, Turku, Finland
  • Fausto Biancari Heart Center, Turku University Hospital, and Department of Surgery, University of Turku, Turku, Finland



Coronary artery bypass grafting, bilateral, internal mammary artery, sternal wound infection


Background: Bilateral internal mammary artery (BIMA) grafting largely is underutilized in patients undergoing coronary artery bypass grafting (CABG), partly because of the perceived increased complexity of
the procedure.

Aims: In this study, we evaluated whether BIMA grafting can safely be performed also in centers, where this revascularization strategy infrequently is adopted.

Methods: Out of 6,783 patients from the prospective multicenter E-CABG study, who underwent isolated non-
emergent CABG from January 2015 to December 2016, 2,457 underwent BIMA grafting and their outcome was evaluated in this analysis.

Results: The mean number of BIMA grafting per center was 82 cases/year and hospitals were defined as high or low volume, according to this cutoff value. Six hospitals were considered as centers with a high volume of BIMA grafting (no. of procedures ranging from 120 to 267/year; overall: 2,156; prevalence: 62.2%) and nine hospitals as centers with a low volume of BIMA grafting (no. of procedures ranging from 2 to 39/year; overall: 301; prevalence: 9.1%). Multilevel mixed-effects regression analysis showed that the low- and high-volume cohorts had similar outcomes. Propensity score one-to-one matching analysis of 292 pairs showed that the low-volume cohort had a significantly shorter intensive care unit stay (2.2 ± 2.3 versus 2.9 ± 4.8 days, P = .020). The rates of in-hospital death (1.0% versus 0.3%, P = .625), deep sternal wound infection/mediastinitis (3.8% versus 3.1%, P = .824), and 1-year survival (98.1% versus 99.7%, P = .180) as well as other outcomes were similar between the high- and
low-volume cohorts.

Conclusions: BIMA grafting can be safely performed also in centers in which this revascularization strategy is infrequently performed.


Benedetto U, Lau C, Caputo M, Kim L, Feldman DN, Ohmes LB, et al. 2018. Comparison of outcomes for off-pump versus on-pump coronary artery bypass grafting in low-volume and high-volume centers and by low-volume and high-volume surgeons. Am J Cardiol 121:552-557.

Benussi B, Gatti G, Gripshi F, Biondi F, Porcari A, Ruggiero D, et al. 2019. Clinical Validation of a Coronary Surgery Technique That Minimizes Aortic Manipulation. Ann Thorac Surg 107:1166-1173.

Biancari F, Ruggieri VG, Perrotti A, Svenarud P, Dalén M, Onorati F, et al. 2015. European multicenter study on coronary artery bypass grafting (E-CABG registry): study protocol for a prospective clinical registry and proposal of classification of postoperative complications. J Cardiothorac Surg 10:90.

Dalén M, Ivert T, Holzmann MJ, Sartipy U. 2014. Bilateral versus single internal mammary coronary artery bypass grafting in Sweden from 1997-2008. PLoS One 9:e86929.

Dorman MJ, Kurlansky PA, Traad EA, Galbut DL, Zucker M, Ebra G. 2012. Bilateral internal mammary artery grafting enhances survival in diabetic patients. A 30-year follow-up propensity-score matched cohorts. Circulation 126:2935-2942.

Garatti A, Castelvecchio S, Canziani A, Corain L, Generali T, Mossuto E, et al. 2014. Long-term results of sequential vein coronary artery bypass grafting compared with totally arterial myocardial revascularization: a propensity score-matched follow-up study. Eur J Cardiothorac Surg 46:1006-13.

Gatti G, Dell'Angela L, Barbati G, Benussi B, Forti G, Gabrielli M, et al. 2016. A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting. Eur J Cardiothorac Surg 49:910-917.

Gray AM, Murphy J, Altman DG, Benedetto U, Campbell H, Flather M, et al. 2017. One-year costs of bilateral or single internal mammary grafts in the Arterial Revascularization Trial. Heart.


Iribarne A, Goodney PP, Flores AM, DeSimone J, DiScipio AW, et al. 2017. National trends and geographic variation in bilateral internal mammary artery use in the United States. Ann Thorac Surg 104:1902-1907.

Iribarne A, Schmoker JD, Malenka DJ, Leavitt BJ, McCullough JN, Weldner PW, et al. 2017. Does use of bilateral internal mammary artery grafting reduce long-term risk of repeat coronary revascularization? A multicenter analysis. Circulation 136:1676-1685.

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. 2013. KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Inter Suppl 3:1-150.

LaPar DJ, Crosby IK, Rich JB, Quader MA, Speir AM, Kern JA, et al. 2015. Bilateral internal mammary artery use for coronary artery bypass grafting remains underutilized: a propensity-matched multi-institution analysis. Ann Thorac Surg 100:8-14.

Lytle BW, Blackstone EH, Sabik JF, Houghtaling P, Loop FD, Cosgrove DM. 2004. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg 78:2005-12.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. 1999. Guideline for prevention of surgical site infection. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 20:250-278.

Pasrija C, Ghoreishi M, Shah A, Rouse M, Gammie JS, Kon ZN, Taylor BS. 2018. Bilateral internal mammary artery use can be safely taught without increasing morbidity or mortality. Ann Thorac Surg 105:76-82.

Pevni D, Ben-Gal Y, Mohr R, Ganiel A, Paz Y, Kramer A, et al. 2017. One or two internal thoracic grafts? Long-term follow-up of 957 off-pump coronary bypass surgeries. Ann Thorac Surg 104:70-77.

Taggart DP, Benedetto U, Gerry S, Altman DG, Gray AM, Lees B, et al. 2019. Bilateral versus single internal-thoracic-artery grafts at 10 years. N Engl J Med 380:437-446.

Weiss AJ, Zhao S, Tian DH, Taggart DP, Yan TD. 2013. A meta-analysis comparing bilateral internal mammary artery with left internal mammary artery for coronary artery bypass grafting. Ann Cardiothorac Surg 2:390-400.



How to Cite

Perrotti, A., Reichart, D., Gatti, G., Faggian, G., Onorati, F., De Feo, M., Chocron, S., Dalén, M., Santarpino, G., Rubino, A. S., Maselli, D., Gherli, R., Salsano, A., Nicolini, F., Zanobini, M., Bounader, K., Rosato, S., Tauriainen, T., Juvonen, T., Mariscalco, G., G. Ruggieri, V., & Biancari, F. (2020). Hospital Volume and Outcome after Bilateral Internal Mammary Artery Grafting. The Heart Surgery Forum, 23(4), E475-E481.