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On-Pump and Off-Pump Coronary Bypass Surgery
- Bruce W. Lytle
Circulation Volume 116, Issue 104 September 2007

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Fractional Flow Reserve for Coronary Artery Bypass Surgery
- Bruce Lytle and
- Mario Gaudino
Circulation Volume 142, Issue 146 October 2020

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On-Pump and Off-Pump Bypass Surgery: Tools for Revascularization
- Bruce W. Lytle and
- Joseph F. Sabik
Circulation Volume 109, Issue 724 February 2004

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Superiority of Bilateral Internal Thoracic Artery Grafting: It’s Been a Long Time Comin’
- Bruce W. Lytle and
- Floyd D. Loop
Circulation Volume 104, Issue 1830 October 2001

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Right Internal Thoracic Artery for Coronary Bypass Surgery: Did We Get It Wrong?
- Mario Gaudino and
- Bruce Lytle
Circulation Volume 146, Issue 1725 October 2022

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Endovascular Repair of Thoracoabdominal Aneurysms
- Roy K. Greenberg and
- Bruce Lytle
Circulation Volume 117, Issue 1729 April 2008

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Background— Morbidity and mortality after conventional repair of thoracoabdominal aneurysms remain high. Alternative techniques have been proposed and are the subject of this report.Methods and Results— Endovascular grafts that have a means of incorporating the visceral vessels into the aortic repair were divided into devices with fenestrations and those with formal branches. Hybrid procedures whereby an extra-anatomic bypass procedure is used to provide inflow to the renal and mesenteric arteries followed by aortic relining with stent grafts were reviewed and tabulated. A description of the techniques and review of the current results are provided. Only 4 series with >10 cases of hybrid procedures have been published. The experience with such a procedure suggests feasibility, but most reports describe a persistently high risk of mortality (up to 25%). Larger series of fenestrated stent grafts to treat juxtarenal aneurysms have been published, and intermediate-term results confirm the safety and efficacy of the procedure. A larger multicenter trial is under way. Other pure endovascular methods have been used to treat thoracoabdominal aneurysms with both reinforced fenestrations and directional branches. Without counting small series (<10 cases), 2 series exist with ≈100 cases that noted perioperative mortality rates between 3% and 6%, without evidence of late ruptures.Conclusions— Endovascular repair of thoracoabdominal aneurysms is feasible and is associated with relatively low perioperative mortality. Several methods of visceral vessel incorporation have been described. Because of persistently high mortality, hybrid procedures will likely be relegated to nonsurgical and nonendovascular patients with sizable aneurysms. Endografts with branches continue to evolve and will be assessed in the context of clinical trials.
Isolated left anterior descending coronary atherosclerosis: long-term comparison of internal mammary artery and venous autografts.
- B W Lytle,
- F D Loop,
- R L Thurer,
- L K Groves,
- P C Taylor and
- D M Cosgrove
Circulation Volume 61, Issue 51 May 1980

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A consecutive series of 100 patients receiving left internal mammary artery grafts and a consecutive series of 100 patients receiving saphenous vein grafts as treatment of isolated left anterior descending coronary artery stenosis were reviewed to determine survival, graft patency, disease progression and New York Heart Association functional class. The mean follow-up was 67 months, and the mean catheterization interval was 20 months. Recommendations for revascularization can be made selectively to patients with critical isolated left anterior descending stenoses who have limiting symptoms and large areas of viable myocardium at risk.
Type IIIC Gaucher’s Disease
- Leslie Cho,
- Bruce W. Lytle and
- Douglas S. Moodie
Circulation Volume 102, Issue 105 September 2000

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Mitral valve replacement combined with myocardial revascularization: early and late results for 300 patients, 1970 to 1983.
- B W Lytle,
- D M Cosgrove,
- C C Gill,
- R W Stewart,
- L A Golding,
- M Goormastic,
- P C Taylor and
- F D Loop
Circulation Volume 71, Issue 61 June 1985

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Of 300 consecutive patients undergoing primary operation for mitral valve replacement combined with coronary bypass grafting, 22 (7.3%) died in-hospital. Multivariate testing of preoperative and operative descriptors identified radiographic cardiac enlargement, preoperative paced rhythm or atrial fibrillation, 70% or more left main coronary obstruction, and serum bilirubin of more than 2 mg% as factors associated with an increase in in-hospital mortality. Follow-up of the 278 hospital survivors (mean interval 48 months, range 2 to 165 months) documented survival of 85%, 66%, and 31% and an event-free survival of 65%, 46%, and 21% at 2, 5, and 10 postoperative years, respectively. Cox proportional-hazard regression models of late risk implicated in-hospital ventricular arrhythmias, left ventricular dysfunction, and rheumatic or ischemic causes of mitral valve disease in decreasing long-term survival. In addition, patients with bioprostheses without warfarin anticoagulation had better survival and event-free survival than those with bioprostheses taking warfarin and those with mechanical prostheses with or without warfarin.
Replacement of aortic valve combined with myocardial revascularization: determinants of early and late risk for 500 patients, 1967-1981.
- B W Lytle,
- D M Cosgrove,
- F D Loop,
- P C Taylor,
- C C Gill,
- L A Golding,
- M Goormastic and
- L K Groves
Circulation Volume 68, Issue 61 December 1983

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Five hundred consecutive patients underwent aortic valve replacement and coronary revascularization in the years from 1967 to 1981, with 29 (5.9%) in-hospital deaths. Current operative mortality (1978-1981) is 3.4%. Univariate and multivariate analyses were used to identify determinants of early and late risk. Female sex, aortic insufficiency, and advanced age increased in-hospital mortality, whereas use of cardioplegia decreased it. At follow-up of 471 patients who survived hospitalization for 1 to 135 months (mean 41) after surgery, 96 late deaths were documented. Survival rates were 87%, 80%, and 55%, and event-free survival rates were 80%, 65%, and 39% at 2, 5, and 10 years after surgery, respectively. The late survival rate was unfavorably influenced by the presence of moderately or severely impaired left ventricular function and double-vessel coronary disease; the rate was enhanced for patients in age group from 50 to 59 years old and was not influenced by the method of myocardial protection. The event-free survival rate decreased with the presence of moderately or severely impaired left ventricular function and was enhanced for patients with New York Heart Association class I or II symptoms before surgery. Patients with bioprostheses who did not receive anticoagulants had higher survival and event-free survival rates than did either patients with bioprostheses who received anticoagulants or patients with mechanical valves, whether they received anticoagulants or not.
A “Mickey Mouse” Coronary Anomaly: Aorto-Left Atrial Fistula With Aneurysm
- Matthews Chacko,
- Bruce W. Lytle,
- Richard D. White and
- Robert E. Hobbs
Circulation Volume 111, Issue 1229 March 2005

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A Benchmark for Evaluating Innovative Treatment of Left Main Coronary Disease
- Joseph F. Sabik,
- Eugene H. Blackstone,
- Michael Firstenberg and
- Bruce W. Lytle
Circulation Volume 116, Issue 11_supplement11 September 2007

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Background— Left main trunk stenosis (≥50%) has traditionally been treated with coronary artery bypass grafting. Improvements in coronary stents have led some to advocate percutaneous coronary intervention. To provide a benchmark of outcomes against which percutaneous coronary intervention may be compared, we (1) assessed survival and freedom from coronary reintervention after coronary artery bypass grafting in these patients and (2) identified their risk factors.Methods and Results— From 1971 to 1998, the first 1000 primary coronary artery bypass grafting patients (n=26 927) were followed every 5 years. Of these, 3803 had left main trunk stenosis ≥50%. A multivariable, nonproportional hazards, time-related analysis was performed to model survival and freedom from coronary reintervention (percutaneous coronary intervention or reoperation) and to identify their risk factors. Survival at 30 days, 1, 5, 10, 15, and 20 years was 97.6%, 93.6%, 83%, 64%, 44%, and 28%, respectively, and freedom from coronary reintervention was 99.7%, 98.9%, 96.6%, 89%, 76%, and 61%, respectively. Worse left ventricular function (P<0.0001), diabetes (P<0.0001), hypertension (P<0.001), peripheral arterial disease (P=0.0002), smoking (P<0.0001), and elevated triglycerides (P=0.01) decreased survival, and younger age (P<0.0001), elevated triglycerides (P=0.005), and incomplete revascularization (P=0.003) increased coronary reintervention. Internal thoracic artery grafting of the left anterior descending improved survival and decreased coronary reintervention.Conclusions— This study provides a 20-year outcome benchmark for surgical treatment of left main trunk disease. It indicates that simple comparisons of new treatments are inadequate without risk adjustment. Risk factor adjustment should be used when comparing coronary artery bypass grafting with current and future treatment innovations and when selecting the best treatment strategy for individual patients.
Asymptomatic coronary artery disease managed by myocardial revascularization: results at 5 years.
- R L Thurer,
- B W Lytle,
- D M Cosgrove and
- F D Loop
Circulation Volume 60, Issue 21 August 1979

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A consecutive series of 17 patients surgically treated for asymptomatic coronary artery disease was surveyed for survival, clinical status, and graft patency after a mean follow-up of 75 months. Documented myocardial infarction (MI), 14 transmural and 3 subendocardial, was the major indication for catheterization. All patients were asymptomatic for at least 4 months prior to surgery. Six patients had greater than 70% obstruction in one vessel, seven in two vessels, and four in three vessels. The indication for revascularization was critical stenoses in vessels supplying large areas of viable myocardium. All patients received left internal mammary artery (LIMA) grafts to the left anterior descending coronary artery; seven patients also received saphenous vein grafts (SVG) to other vessels. There was no operative or late mortality. In 12 patients, postoperative angiography (mean interval, 12 1/2 months) showed 11/12 LIMA and all SVG patent. One incompletely revascularized patient with an occluded LIMA is symptomatic. All others are fully active without symptoms or interval MI after a minimum follow-up of 5 1/2 years. The safety and long-term results of myocardial revascularization warrant its consideration for selected asymptomatic postinfarction patients.
Abstract 2124: A Benchmark for Evaluating Innovative Treatment of Left Main Coronary Disease
- Joseph F Sabik,
- Eugene H Blackstone,
- Michael S Firstenberg and
- Bruce W Lytle
Circulation Volume 114, Issue suppl_1831 October 2006

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Objectives: Left main (LM) stenosis (≥50%) has traditionally been treated with coronary artery bypass grafting (CABG), but improvements in coronary stents have led advocates of percutaneous coronary intervention (PCI) to treat it with PCI. To provide a benchmark of outcomes against which PCI and future innovations may be compared, we 1) assessed long-term survival and freedom from coronary reintervention after CABG in patients with LM stenosis, and 2) identified their risk factors.Methods: From 1971 to 1998, the first 1,000 patients undergoing primary isolated CABG (n=26,927) were followed every 5 years. Of these, 3,803 had LM stenosis ≥50%. A multivariable, nonproportional-hazards, time-related analysis was performed to model survival and freedom from coronary reintervention (PCI or reoperation) and to identify by bootstrap bagging patient and operative factors associated with these outcomes.Results: Survival at 30 days, 1, 5, 10, 15, and 20 years was 97.6%, 93.6%, 83%, 64%, 44%, and 28%, respectively, and freedom from coronary reintervention was 99.7%, 98.9%, 96.6%, 89%, 76%, and 70%. Worse left ventricular function (P<.0001), diabetes (P<.0001), hypertension (P<.001), peripheral vascular disease (P=.0002), smoking history (P<.0001), and elevated triglycerides (P=.01) decreased survival, and younger age (P<.0001), elevated triglycerides (P=.005) and incomplete revascularization (P=.003) increased coronary reintervention. Internal thoracic artery grafting of the left anterior descending improved survival and decreased coronary reintervention.Conclusions: This study provides a 20-year benchmark of outcomes for patients with LM disease treated by CABG and indicates that simple comparisons of new treatments are inadequate without risk adjustment. Using these data, we have developed benchmark software for use in risk-adjusted evaluation of current and future treatment innovations.
Influence of Racial Disparities in Procedure Use on Functional Status Outcomes Among Patients With Coronary Artery Disease
- Padma Kaul,
- Barbara L. Lytle,
- John A. Spertus,
- Elizabeth R. DeLong and
- Eric D. Peterson
Circulation Volume 111, Issue 1015 March 2005

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Background— Although black cardiac patients receive fewer revascularization procedures than whites, it is unclear whether this has a detrimental impact on outcomes. The objective of our study was to compare 6-month functional status and angina outcomes among blacks and whites with documented coronary disease and to assess whether differential use of revascularization procedures affects these outcomes.Methods and Results— We identified a prospective cohort of 1534 white and 337 black patients undergoing cardiac catheterization between August 1998 and April 2001. Health status was assessed at baseline and 6 months with the Short-Form 36 (SF-36) Health Survey and the Seattle Angina Questionnaire (SAQ) Angina Frequency Scale. Compared with whites, blacks received fewer coronary revascularization procedures (52.5% versus 66.0%; P<0.01). By 6 months, blacks had similar mortality (odds ratio, 1.03; 95% CI, 0.57 to 1.9) but worse scores in 5 SF-36 domains (physical, social, role physical, role emotional, and mental health function). Blacks also reported higher rates of angina at 6 months than whites (34.2% versus 24.6%; P<0.01). After adjustment for baseline functional status and clinical and demographic variables, blacks had significantly worse summary physical component scores, summary mental component scores, and SAQ Angina Frequency Scale scores. However, differences in physical component summary scores and SAQ scores between blacks and whites were no longer significant after adjustment for revascularization status.Conclusions— Our study is among the first to document greater symptoms and functional impairment among black cardiac patients relative to whites. Differential use of coronary revascularization may contribute to the poorer functional outcomes observed among black patients with documented coronary disease.
Abstract 1564: Does Location of the Second Internal Thoracic Artery Graft Influence Outcome?
- Aleck Stockins,
- Joseph F Sabik,
- Penny L Houghtaling,
- Eugene H Blackstone and
- Bruce W Lytle
Circulation Volume 116, Issue suppl_1616 October 2007

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Objectives: To determine whether location of the second internal thoracic artery (ITA) graft used for bilateral ITA grafting affects mortality and morbidity of patients with 3-system coronary artery disease, and to identify factors associated with location of the second ITA.Methods: From 1/1972 to 6/2006, 3,611 patients with 3-system coronary artery disease underwent bilateral ITA grafting with one ITA to the left anterior descending (LAD) system and the second to either the circumflex (LCx; n=2,926) or right coronary artery (RCA; n=685) system. Follow-up was 9.2±7.2 years. Propensity score methodology was used to obtain risk-adjusted outcome comparisons between patients with the second ITA to the LCx vs RCA.Results: In-hospital mortality (0.34% vs 0.58%; P=.4), stroke (0.96% vs 0.88%; P=.8), myocardial infarction (1.3% vs 0.73%; P=.2), renal failure (0.44% vs 0.29%; P=.6), respiratory insufficiency (3.5% vs 3.8%; P=.7), and reoperation for bleeding (3.4% vs 3.2%; P=.8) were similar in patients who received the second ITA to the LCx or RCA, and remained similar after propensity score adjustment. Late survival was also similar (Fig.). Despite this, there has been a gradual decline in ITA to RCA grafting, particularly in the presence of severe LCx disease, but more use in women and in patients without RCA occlusion or distal stenoses.Conclusions: Contrary to prevailing wisdom that the second ITA graft should be anastomosed to the next most important left-sided coronary artery in 3-system disease, the second ITA graft may be placed to either the LCx or RCA system with similar early and late outcomes.
Abstract 13757: Dilated Ascending Aorta in Hypertrophic Cardiomyopathy: Incidence and Predictors
- Fadi Asfahan,
- Nicholas G Smedira,
- Ashwat Dhillon,
- Maran THamilarasan,
- Bruce Lytle,
- Harry Lever and
- Milind Y Desai
Circulation Volume 130, Issue suppl_225 November 2014

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Background: In many hypertrophic cardiomyopathy (HCM) patients, we observed that the proximal ascending aorta (AA) is dilated. We sought to determine the frequency & potential predictors of dilated AA in HCM patients.Methods: We studied 267 consecutive HCM patients, ≥18 years (68% men) that underwent clinical, echo and contrast-enhanced cardiac magnetic resonance (CMR) assessment at a single center. Maximal (resting or provocable) left ventricular outflow tract gradient (LVOTG) was recorded on echo; LV mass recorded on CMR. True short-axis proximal AA (also aortic root) dimensions were measured using multiple CMR sequences. Expected aortic root dimensions, based on age, gender & height were calculated using the following formula: 1.519 + (age [years] х 0.010) + (height [cm] х 0.010)-(gender [1=man, 2=woman] х 0.247). If difference between actual & expected measurement was more than the product of 1.96 x 0.215 (standard error of mean for above equation), the root was considered dilated.Results: There were 49% hypertensives, 82% on betablockers & 28% on calcium blockers. Mean LV ejection fraction, LVOTG, LV thickness, LV mass, aortic root & AA dimensions were 63±5%, 105±51 mm Hg, 2±0.5 cm, 207±71 g, 3.1±0.5 cm & 3.2±0.5 cm, while 0.7% had ≥II+ aortic regurgitation. Dilated proximal AA was seen in 36 (14%) patients. After adjustment for age, gender & height, dilated AA was seen in 20 (8%) patients. Logistic regression analysis demonstrating the predictors of dilated AA (absolute as well as adjusted dimensions) are shown in Figures a-b.Conclusions: Dilation of proximal AA is frequently seen in HCM patients, & attention to AA should be paid during HCM evaluation. Hypertension is an independent predictor of dilated AA. Whether AA dilation represents a concomitant aortopathy or a secondary adaptive phenomenon remains to be elucidated.
Occurrence and Risk Factors for Reintervention After Coronary Artery Bypass Grafting
- Joseph F. Sabik,
- Eugene H. Blackstone,
- A. Marc Gillinov,
- Nicholas G. Smedira and
- Bruce W. Lytle
Circulation Volume 114, Issue 1_supplement4 July 2006

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Background— Reintervention after coronary artery bypass grafting (CABG) is common. We sought to determine its occurrence and identify patient characteristics and operative techniques that influence the need or bias for reintervention.Methods and Results— From 1971 to 1998, 48 758 patients underwent primary isolated CABG, and 1000 patients per year were actively followed-up every 5 years (n =26 927). A multivariable time-related analysis was performed to model freedom from first coronary reintervention (either reoperation or percutaneous coronary intervention) and identify patient and operative characteristics associated with first reintervention. A total of 3997 patients underwent coronary reintervention, percutaneous in 1638 and reoperation in 2359. Freedom from reintervention was 99%, 96%, 88%, 73%, 60%, and 46% at 1, 5, 10, 15, 20, and 25 years, respectively. Risk of reintervention (hazard function) demonstrated a short, rapidly declining early phase followed by a longer, slow-rising late phase. Patient variables increasing the likelihood of coronary reintervention included younger age (P<0.0001), higher triglycerides (P=0.002), lower high-density lipoprotein (P=0.006), diabetes mellitus (P<0.0001), and more extensive coronary artery disease (P=0.0005). Increasing extent of arterial grafting performed at primary operation decreased the likelihood of coronary reintervention (P<0.0001).Conclusions— Reintervention after primary CABG is common. Risk factors for arteriosclerosis and type of bypass conduit influence the need or bias for repeat coronary therapy. Aggressive post-CABG risk factor reduction and extensive arterial grafting at primary operation should decrease coronary reinterventions.
The Role of Multimodality Imaging in the Management of Pericardial Disease
- David Verhaert,
- Ruvin S. Gabriel,
- Douglas Johnston,
- Bruce W. Lytle,
- Milind Y. Desai and
- Allan L. Klein
Circulation: Cardiovascular Imaging Volume 3, Issue 31 May 2010

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Abstract 13729: Surgical Myectomy Results in Significantly Improved Long-term Event Rate in Hypertrophic Cardiomyopathy Patients With Severe Left Ventricular Outflow Tract Obstruction
- Milind Y Desai,
- Nicholas G Smedira,
- Aditya Bhonsale,
- Nitesh Ainani,
- Maran THamilarasan,
- Bruce Lytle and
- Harry Lever
Circulation Volume 130, Issue suppl_225 November 2014

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Background: In hypertrophic cardiomyopathy (HCM) with severe left ventricular outflow tract obstruction (LVOTO), surgical myectomy (SM) performed for relief of intractable symptoms is safe and associated with excellent long-term symptom-free survival. In such patients, we sought to determine if SM also results in improvement of long-term outcomes.Methods: We studied 1530 HCM patients with severe LVOTO (50±13 years, 63% men) that were evaluated at our center [excluding <18 years of age, LV ejection fraction (LVEF) <50%, LVOT gradient <30 mm Hg). Clinical, echocardiographic and surgical data were recorded. A composite endpoint of death and/or implantable defibrillator (ICD) discharge was recorded.Results: Hypertension, coronary artery disease (CAD), family history of HCM and syncope were present in 41%, 15%, 17% and 18%, while 73% patients were in Functional Class (FC) ≥ II. Mean LVEF, basal septal thickness, LVOT gradient (resting or provocable) and indexed left atrial dimensions were 62±5%, 2.2±1 cm, 101±39 mm Hg, 2.2±0.4 cm/m2. During 8±6 years of follow-up, 990 (65%) patients underwent SM (of which 65% were isolated SM), while 540 (35%) did not. 94 (6%) patients had alcohol septal ablation (66 in the non myectomy group), while 18% developed atrial fibrillation (AF), and 18% had ICD. There were 169 (11%) events (151 deaths), with 0% 30-day mortality in the SM group. On stepwise multivariable Cox Proportional Hazard analysis, increasing age (Hazard Ratio or HR 1.22 [1.06-1.40]), CAD (HR 1.57 [1.06-2.33]), worsening FC (HR 1.34 [1.05-1.71]) and AF (HR 1.73 [1.23-2.43]) predicted higher events, while SM as a time-dependent covariate (HR 0.58 [0.41-0.81]) was associated with improved event-free survival (all p<0.01). Kaplan-Meier curve showing impact of SM on outcomes is shown in Figure.Conclusion: In HCM patients with severe LVOTO, SM is associated with significant improvement in long-term outcomes when compared to watchful waiting.

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