Improved Outcomes of Total Arterial Myocardial Revascularization in Elderly Patients at Long-Term Follow-Up: A Propensity-Matched Analysis

Differences in long-term survival outcomes after coronary artery bypass grafting using single vs multiple arterial grafts: a meta-analysis with reconstructed time-to-event data and subgroup analyses

OBJECTIVE

We reviewed the available literature on patients with coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) with either single (SAG) or multiple arterial grafting (MAG).

METHODS

Original research studies that evaluated the long-term survival of MAG versus SAG were identified, from 1995 to 2022. The median overall survival (OS) and event-free OS were the primary endpoints. Comparison of median OS between the right internal mammary artery (RIMA) and radial artery (RA) as a second arterial conduit was the secondary endpoint. Subgroup analyses were performed regarding patients older than 70 years, with diabetes mellitus, and females. A sensitivity analysis was performed with the leave-one-out method.

RESULTS

Forty-four studies were included in the qualitative and thirty-nine in the quantitative synthesis. After pooling data from 180 to 459 patients, the MAG group demonstrated a higher OS (HR, 0.589; 95% CI, 0.58-0.60; p < 0.0001) and event-free OS compared with the SAG group (HR, 0.828; 95% CI, 0.80-0.86; p < 0.0001). In addition, RITA was associated with superior OS compared with RA as a second arterial conduit (HR, 0.936; 95% CI, 0.89-0.98; p = 0.009). MAG was also superior to SAG in patients over 70 years, females, and patients with diabetes mellitus. Sensitivity analysis demonstrated a small-size study effect on the female subgroup analysis.

CONCLUSION

The present meta-analysis indicates that MAG is associated with enhanced survival outcomes compared to SAG for patients undergoing isolated CABG.

Multiple versus single arterial grafting in the elderly: a meta-analysis of randomized controlled trials and propensity score studies

INTRODUCTION

The benefit of adding a second arterial conduit is still controversial, mainly in specific subgroups. We conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies comparing survival and early results in elderly patients who underwent coronary artery bypass grafting (CABG) with multiple (MAG) versus single arterial grafting (SAG).

EVIDENCE ACQUISITION

MEDLINE, Web of Science and Cochrane Library were used to find relevant literature (1960-April 2020). Survival at a ≥ 1-year follow-up and early outcomes were evaluated. Outcomes were collected from matched samples or PS adjusted analysis: hazard ratio (HR) along with their variance, frequencies or odds ratios. Random effect models were used to compute combined statistical measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events).

EVIDENCE SYNTHESIS

Eleven PS cohorts and 1 RCT comprising > 18,800 patients older than 70 (>6200 MAG and >12,500 SAG) were included in this meta-analysis. MAG was associated with lower long-term mortality (pooled HR: 0.81, 95%CI: 0.72-0.91, p<0.01, I2=64%) in the absence of higher risk of early mortality (pooled OR: 0.74, 95%CI: 0.44 to 1.25, p=0.27, I2=0%). In a meta-regression, MAG survival advantage was more pronounced in studies with a higher MAG usage rate (β = -0.0052, p=0.021).

CONCLUSIONS

Current evidence suggests that advanced age should not limit MAG's use considering its benefits in long-term survival. Of note, an individualized patient selection for this approach is warranted.

Survival effect of radial artery usage in addition to bilateral internal thoracic arterial grafting: A meta-analysis

OBJECTIVE

Little evidence shows whether the radial artery (RA) as third arterial graft provides superior outcomes compared with the use of the bilateral internal thoracic artery (BITA) and saphenous vein (SV) graft in patients undergoing coronary artery bypass grafting. A meta-analysis of propensity score-matched observational studies that compared the long-term outcomes of coronary artery bypass grafting with the use of BITA and the RA (BITA + RA) versus BITA and SV (BITA + SV) was performed.

METHODS

Electronic databases from January 2000 to November 2020 were screened. Studies that reported long-term mortality were analyzed. The primary outcome was long-term overall mortality. A secondary end point was in-hospital/30-day mortality. Pooled hazard ratio with 95% confidence interval (CI) were calculated for survival and time-to-event analysis according to a random effect model. Differences were expressed as odds ratio with 95% CI for in-hospital/30-day mortality.

RESULTS

Six propensity score-matched studies that reported on 2500 matched patients (BITA + RA: 1250; BITA + SV: 1250) were identified for comparison. The use of BITA + RA was not statistically associated with early mortality (odds ratio, 0.90; 95% CI, 0.36-2.28; P = .83). The mean follow-up time ranged from 7.5 to 12 years. The pooled analysis of long-term survival revealed a significant difference between the 2 groups favoring BITA + RA treatment (hazard ratio, 0.71; 95% CI, 0.50-0.91; P = .031). The survival rate for BITA + RA versus BITA + SV at 5, 10, and 15 years were: 96.2% versus 94.8%, 88.9% versus 87.4%, and 83% versus 77.9%, respectively (log rank test, P = .02).

CONCLUSIONS

In patients with coronary artery bypass grafting, BITA + RA usage is not associated with higher rates of operative risk and is associated with superior long-term overall survival.

Total Arterial Coronary Bypass Graft Surgery is Associated with Better Long-Term Survival in Patients with Multivessel Coronary Artery Disease: a Systematic Review with Meta-Analysis

INTRODUCTION

The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients.

METHODS

The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed.

RESULTS

Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome.

CONCLUSION

This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

Short-Term Risk of Bilateral Internal Mammary Artery Grafting in Diabetic Patients

This study compares the morbidity and mortality at 30 days following the use of bilateral internal mammary arteries (BIMA) vs a single internal mammary artery (SIMA) at the time of coronary artery bypass grafting (CABG) in patients with a preoperative HbA1c. Patients undergoing CABG from January 2008 to December 2016 reported to the Society of Thoracic Surgeons database were retrospectively reviewed. The patients were divided into 2 groups: use of BIMA or use of SIMA and propensity matched. To assess the effect of preoperative HbA1c, both groups were further divided into 5 subgroups: patients without diabetes mellitus (DM), or patients with DM and a preoperative HbA1c level in one of four groups (< 7%, 7-9%, 9-11%, or >11%). The postoperative outcomes in both the BIMA and SIMA groups were compared. There were 700,504 and 28,115 patients with measured preoperative HbA1c levels in the SIMA and BIMA groups, respectively. Propensity score matching identified 23,635 comparable patients in each group for analysis. There was no difference in postoperative mortality between the BIMA and SIMA groups (1.3% vs 1.2%). The incidences of sternal wound infection (SWI) in patients undergoing placement of BIMA vs SIMA were: 0.8% vs 0.4% with no DM (P < 0.0001), 1.9% vs 1.0% with HbA1c < 7% (P < 0.001), 2.4% vs 1.2% with HbA1c 7-9% (P < 0.001), 2.8% vs 1.4% with HbA1c 9-11% (P = 0.02), 4.1% vs 1.5% with HbA1c > 11% (P = 0.01). Based on the incidence of SWI, BIMA is a reasonable approach with an HbA1c<7%.

In situ skeletonized bilateral thoracic artery for left coronary circulation: a 20-year experience

OBJECTIVES

Our goal was to analyse the outcomes in a patient population using a standardized technique for coronary artery bypass grafting (CABG) consisting of total arterial myocardial revascularization utilizing the in situ skeletonized bilateral thoracic artery for left coronary circulation. We also explored potential predictors of long-time unfavourable outcomes.

METHODS

Patients undergoing total arterial myocardial revascularization using in situ skeletonized bilateral thoracic artery for left coronary circulation between January 1997 and May 2017 were included prospectively in this study. The median follow-up (100% complete) was 103 months (interquartile range 61-189 months) and ranged from 1 to 245 months.

RESULTS

A total of 1325 consecutive patients were recruited. During the follow-up period, there were 131 deaths (9.8%), 146 repeat revascularizations (11.0%) and 229 major adverse cardiac events (17.2%). The 18-year freedom from major adverse cardiac events was 62.6 ± 9.3%, 62.5 ± 6.3% and 53.9 ± 11.0%, respectively. Multivariable models showed that a left ventricular ejection fraction ≤35%, chronic obstructive pulmonary disease, peripheral vascular disease (P < 0.001), chronic kidney disease and age ≥80 years (P = 0.002) were independent predictors of diminished long-term survival. Moreover, peripheral vascular disease and off-pump coronary artery bypass (both, P < 0.001) predicted repeat revascularization. Finally, age ≥80 years, peripheral vascular disease, left ventricular ejection fraction ≤35%, off-pump coronary artery bypass and chronic pulmonary obstructive disease were independent predictors of major adverse cardiac events during the long-term follow-up period (all, P < 0.001).

CONCLUSIONS

Coronary artery bypass using the in situ skeletonized bilateral thoracic artery for left coronary circulation configuration for total arterial myocardial revascularization resulted in satisfactory long-term results with a low incidence of death and late events and may represent a technique of choice in selected patients having CABG. Larger and long-term prospective studies are, however, warranted.

Total arterial revascularization strategies: A meta-analysis of propensity score-matched observational studies

BACKGROUND AND AIM OF THE STUDY

We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy.

METHODS

PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding.

RESULTS

Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR with the bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77).

CONCLUSIONS

TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection.