Coronary Artery Bypass Grafting After Recent or Remote Percutaneous Coronary Intervention in the Commonwealth of Massachusetts

Coronary Artery Bypass Graft Surgery After Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction

OBJECTIVE

To determine whether primary percutaneous coronary intervention (PPCI) is associated with adverse outcomes following coronary artery bypass graft (CABG) among patients with ST-elevation myocardial infarction (STEMI).

METHODS

Patients presenting with acute STEMI who underwent CABG between September 2015 and November 2020 were included. Among 354 patients, 222 (62.7%) underwent PPCI prior to CABG (PPCI+CABG group) and were compared with the rest of the patients (CABG only group). The effects of PPCI on primary endpoints---including in-hospital mortality, length of stay (LOS), and bleeding events---were investigated using the stabilised inverse probability weighting method (S-IPW). Further, in-hospital mortality in various PPCI subgroups was analysed using univariable regression.

RESULTS

Patients with and without PPCI were comparable regarding their baseline and surgical characteristics, except that those without PPCI were more likely to have left-main disease (29.5% vs 16.2%, p-value=0.003). Among the PPCI+CABG group, 3.6% mortality and 55.9% bleeding events occurred, and the LOS was 7 [5-10] days. The respective figures for the CABG only group were 4.5%, 50.8%, and 7 [6-10.5] days. Primary percutaneous coronary intervention, as a whole, was not significantly associated with either morality (S-IPW odds ratio (S-IPW OR) 0.61; p=0.393), LOS logarithm (S-IPW β -0.050; p=0.403), or bleeding events (S-IPW OR 1.06; p=0.821). Nevertheless, the unadjusted mortality risk was significantly higher in complicated PPCIs compared with the CABG only group (OR 7.50, 95% CI 2.03-27.77); it was also higher among some other PPCI subgroups, albeit non-significantly.

CONCLUSION

This study found that PPCI did not confer additional risk regarding in-hospital mortality, LOS, or bleeding among patients with acute STEMI who underwent CABG. However, some PPCI subgroups, especially those with complicated PPCI, were at increased risk.

Late Myocardial Infarction and Repeat Revascularization after Coronary Artery Bypass Grafting in Patients with Prior Percutaneous Coronary Intervention

Objectives: The aim of the present study was to evaluate the risk of late mortality and major adverse cardiovascular and cerebral events after coronary artery bypass grafting (CABG) in patients with prior percutaneous coronary intervention (PCI). Methods: A total of 2948 patients undergoing isolated CABGs were included in a prospective multicenter registry. Outcomes were adjusted for multiple covariates in logistic regression, Cox proportional hazards analysis and competing risk analysis. Results: In all, 2619 patients fulfilled the inclusion criteria of this analysis. Of them, 2199 (79.1%) had no history of PCI and 420 (20.9%) had a prior PCI. An adjusted analysis showed that a single prior PCI and multiple prior PCIs did not increase the risk of 30-day and 5-year mortality. Patients with multiple prior PCIs had a significantly higher risk of 5-year myocardial infarction (SHR 2.566, 95%CI 1.379–4.312) and repeat revascularization (SHR 1.774, 95%CI 1.140–2.763). Similarly, 30-day and 5-year mortality were not significantly increased in patients with prior PCI treatment of single or multiple vessels. Patients with multiple vessels treated with PCI had a significantly higher risk of 5-year myocardial infarction (SHR 2.640, 95%CI 1.497–4.658), repeat revascularization (SHR 1.648, 95%CI 1.029–2.638) and stroke (SHR 2.215, 95%CI 1.056–4.646) at 5-year. The risk for repeat revascularization was also increased with a prior single vessel PCI, but not for other outcomes. Conclusions: Among patients undergoing CABGs, multiple prior PCIs seem to increase the risk of late myocardial infarction and the need for repeat revascularization, but not the risk of mortality.

Нospital outcomes of coronary artery bypass grafting in patients with coronary heart disease with previous percutaneous coronary intervention

Aim. Evaluation of the frequency hospital cardiovascular events in groups of patients with stable angina who underwent percutaneous coronary interventions (PCI) with stenting of the arteries before coronary bypass surgery, or who did not have previous myocardial revascularization. Materials and methods. The 120 patients with stable angina who underwent routine coronary artery bypass grafting were examined. Group composition: Men 80.8%, age 587.6, duration of coronary heart disease 65.7 years, history of myocardial infarction (MI) 77.5%. Arterial hypertension was present in 92.5%, diabetes mellitus in 12.5% of patients. Multivessel coronary artery disease in 72.5% of patients. 28 (23.4%) patients had previously undergone PCI with stenting of the coronary arteries. The period from PCI to coronary bypass surgery was 2032.6 months. Coronary bypass surgery on-pump was performed in 88.3%, coronary bypass surgery on off-pump in 11.7%. The number of distal anastomoses ranged from 1 to 4. Results. There were no differences in clinical and angiographic indicators, pharmacotherapy, and operation characteristics between the groups of patients who were subjected to or did not have PCI before coronary bypass surgery. There were no differences between the analyzed groups of patients in the frequency of cardiac death (0 and 1.1%, p=0.58), non-fatal MI (3.6% and 9.8%, p=0.29), stroke (0 and 1.1%, p=0.58), acute heart failure (11.7% and 34.8%, p=0.06), the number of patients with paroxysms of atrial fibrillation (28.6% and 17.4%, p=0.94), the proportion of patients with resternotomies (3.6% and 3.3%, p=0.94) and gastrointestinal bleeding (3.6% and 4.3%, p=0.86). Conclusion. PCI with coronary artery stenting, prior to coronary bypass surgery, does not affect the frequency of post-operative hospital cardiovascular and hemorrhagic complications.

Prior percutaneous coronary intervention and outcomes in patients after coronary artery bypass grafting: a meta-analysis of 308,284 patients

Background:

The association between prior percutaneous coronary intervention (PCI) and prognosis after coronary artery bypass grafting (CABG) remains uncertain. We aimed to evaluate the aforementioned association in a meta-analysis.

Methods:

PubMed, Cochrane’s Library, and Embase databases were searched for potential studies. A random-effects model was used for the meta-analysis. Meta-regression was performed to evaluate the influence of study characteristics on the outcomes.

Results:

Thirty-six follow-up studies with 308,284 patients were included, and 40,892 (13.3%) patients had prior PCI. Pooled results showed that prior PCI was associated with higher risks of early (in-hospital or within 1 month) all-cause mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 1.11–1.44, p = 0.003; I² = 64%] and major adverse cardiovascular events (MACEs; OR: 1.36, 95% CI: 1.12–1.66, p = 0.002, I² = 79%), but not with late (follow-up durations from 1 to 13 years) mortality (OR: 1.03, 95% CI: 0.95–1.13, p = 0.44, I² = 46%) or MACEs (OR: 1.03, 95% CI: 0.97–1.09, p = 0.38, I² = 0%). Meta-regression showed that the study characteristics of patient number, age, sex, diabetic status, and proportion of patients with prior PCI did not affect the outcomes. Sensitivity analyses limited to multivariate studies excluding patients with acute PCI failure showed similar results (early mortality, OR: 1.25, p = 0.003; early MACE, OR: 1.50, p = 0.001; late mortality, OR: 1.03, p = 0.70).

Conclusion:

The current evidence, mostly from retrospective observational studies, suggests that prior PCI is related to poor early clinical outcomes, but not to late clinical outcomes, after CABG.

Effect of previous coronary stenting on subsequent coronary artery bypass grafting outcomes

OBJECTIVES

The effect of previous coronary stenting on subsequent coronary artery bypass graft is inconclusive.

METHODS

We used Taiwan's National Health Insurance Database to retrospectively evaluate patients with multivessel coronary artery bypass graft between January 2000 and December 2013. Overall, 32,335 patients who received coronary artery bypass graft were included, of whom 3028 had previous coronary stenting. Propensity-score matching yielded 2977 cases each for evaluation under the previous stenting and no stenting groups. The 30-day mortality and major adverse cardiac events, including all-cause mortality, acute myocardial infarction, and revascularization, were considered primary outcomes.

RESULTS

The number of coronary artery bypass grafts decreased per year. However, the percentage of patients who had previous coronary stent implantation before coronary artery bypass graft increased steadily (P for trend <.001), and the average number of stents implanted in a patient also increased per year (P for trend <.001). The previous stent group had a significantly greater 30-day mortality rate than did the no-stent group (7.2% vs 5.0%; odds ratio, 1.47; 95% confidence interval, 1.19-1.82). The previous stent group had a greater rate of revascularization (14.4% and 10.0%; subdistribution hazard ratio, 1.50; 95% confidence interval, 1.30-1.74) in the last follow-up at year 13.

CONCLUSIONS

Previous coronary stenting before coronary artery bypass graft for multivessel coronary artery disease significantly increased 30-day mortality but did not affect late survival. However, patients who had coronary stenting before coronary artery bypass graft experienced more revascularization events during late follow-up.

Does Prior Percutaneous Coronary Intervention Influence the Outcomes of Coronary Artery Bypass Surgery?

Introduction

Percutaneous coronary intervention (PCI) has been increasingly performed to treat coronary artery disease. The performance of multiple PCI has also been increasing. Consequently, the percentage of patients presenting for coronary artery bypass graft (CABG) surgery is reported to vary from 13 to 40%. The influence of previous PCI on CABG outcomes has been studied in single center, regional studies, registries and meta-analyses. Some reports showed a negative effect on mortality and morbidity in early or long-term follow-up, but others did not find this influence.

Methods and Results

A cohort of 3007 patients consecutively operated for CABG, 261 of them with previous PCI, were included in this analysis. Comparison of the groups "previous PCI" and "primary CABG" was made in the original cohort and in a propensity score matched cohort of 261 patients. There were some differences in preoperative clinical characteristics in both types of cohort, even in the matched one. Outcomes were compared at 30 days, 1 year and 5 years of follow-up. There were no statistically significant differences in mortality in any period or cohort. There were some differences in other outcomes as readmission and composite events, including cardiovascular death at 1 and 5 years of follow-up. These differences, neverthless, were not confirmed in comparison with the matched cohort.

Conclusion

Although there are some limitations in this study, it was not found consistent negative influence of previous PCI on CABG.

Prior Percutaneous Coronary Interventions May Be Associated With Increased Mortality After Coronary Bypass Grafting: A Meta-Analysis

There is conflicting evidence for adverse outcomes after coronary artery bypass surgery (CABG) with prior percutaneous intervention (PCI). A literature search was performed from 1998 to 2017 and articles with primary or secondary outcomes of survival, major adverse cardiovascular events (MACE), and myocardial infarction in CABG patients with prior PCI were included. Forest plots were generated from odds ratios for survival, MACE, and myocardial infarction for unmatched and propensity-matched data. Heterogeneity between studies was assessed for all outcomes using I². Funnel plots were generated for early survival, survival at 5 years, survival at >5 years, and MACE. Thirty-one studies were included over 18 years with 194,544 patients without PCI prior to CABG and 23,519 patients (12.09%) with prior PCI. Prior PCI did not adversely affect survival among the included studies (inverse rate ratio: 1.12, 95% confidence interval: 0.98-1.27, P = 0.110. MACE was significantly worse for those with prior PCI (odds ratio: 1.26, confidence interval: 1.02-1.55, P = 0.03). The relative risk of mortality associated with prior PCI has decreased significantly over the last 2 decades. Studies with higher percentage of prior PCI patients had higher relative mortalities. There was significant heterogeneity between studies for the treatment effects. PCI prior to CABG in recent times does not adversely affect survival despite adverse early and late MACE rates. However, high institutional rates of prior PCI may be associated with increasing mortality after CABG.

Coronary Artery Bypass Grafting Among Patients With Prior Percutaneous Coronary Interventions

See Article by Biancari et al .

Prognostic Impact of Multiple Prior Percutaneous Coronary Interventions in Patients Undergoing Coronary Artery Bypass Grafting

Background

Multiple percutaneous coronary interventions (PCIs) are considered determinant of poor outcome in patients undergoing coronary artery bypass grafting (CABG), but scarce data exist to substantiate this.

Methods and Results

Patients who underwent CABG without history of prior PCI or with PCI performed >30 days before surgery were selected for the present analysis from the prospective, multicenter E‐CABG (European Multicenter Study on Coronary Artery Bypass Grafting) registry. Out of 6563 patients with data on preoperative SYNTAX (Synergy between PCI With Taxus and Cardiac Surgery) score, 1181 patients (18.0%) had undergone PCI >30 days before CABG. Of these, 11.6% underwent a single PCI, 4.4% 2 PCIs, and 2.1% ≥3 PCIs. PCI of a single main coronary vessel was performed in 11.3%, of 2 main vessels in 4.9%, and of 3 main vessels in 1.6% of patients. Multivariable analysis showed that differences in early mortality and other outcomes were not significantly different in the study cohorts. The adjusted hospital/30‐day mortality rate was 1.8% in patients without history of prior PCI, 1.9% in those with a history of 1 PCI, 1.4% after 2 PCIs, and 2.5% after ≥3 PCIs (adjusted P=0.8). The adjusted hospital/30‐day mortality rate was 2.0% in those who had undergone PCI of 1 main coronary vessel, 1.3% after PCI of 2 main vessels, and 3.1% after PCI of 3 main coronary vessels (adjusted P=0.6).

Conclusions

Multiple prior PCIs are not associated with increased risk of early adverse events in patients undergoing isolated CABG. The present results are conditional to survival after PCI and should not be viewed as a support for a policy of multiple PCI as opposed to earlier CABG.

Clinical Trial Registration

URL: http://www.Clinicaltrials.gov. Unique identifier: NCT02319083.

See Editorial by https://doi.org/10.1161/JAHA.118.010609

Repeated Target Vessel Revascularization After Coronary Artery Bypass for In-Stent Restenosis

BACKGROUND

The purpose of this study was to examine the impact of previous percutaneous coronary intervention with stent on long-term outcomes after off-pump coronary artery bypass grafting (OPCAB).

METHODS

Between January 2001 and December 2014, 1,668 patients with triple-vessel disease undergoing OPCAB were reviewed and divided into 2 groups. The no-stent group (n = 1,409) included patients who underwent OPCAB as a primary revascularization procedure and the stent group (n = 259) included patients with a history of percutaneous coronary intervention with stent. The mean follow-up duration was 5.32 ± 3.39 years.

RESULTS

After propensity score matching, characteristics of both groups were comparable (n = 259 in each group). In-hospital mortality (n = 3 [1.2%] in both groups; p > 0.999) was similar. The 14-year overall survival rate (75.6% ± 6.6% in the no-stent group versus 71.9% ± 8.5% in the stent group; p = 0.917) and freedom from major adverse cardiac and cerebrovascular events (MACCEs) rate (68.3% ± 6.6% versus 54.6% ± 8.5%; p = 0.239) were also similar. However, freedom from target vessel revascularization (TVR) rate at 14 years was significantly higher in the no-stent group (97.2% ± 1.7% versus 76.9% ± 6.5%; p < 0.001). The independent risk factor for late TVR was in-stent restenosis (hazard ratio, 3.355; 95% confidence interval, 1.925 to 5.848; p < 0.001) and it also was a risk factor for MACCEs (hazard ratio, 1.645; 95% CI, 1.105 to 2.448; p = 0.014).

CONCLUSIONS

Previous intracoronary stenting does not increase long-term mortality, but grafting to previously stented target vessels with in-stent restenosis increases the risk of repeat TVR and MACCEs.

Coronary Artery Bypass Grafting After Percutaneous Intervention Has Higher Early Mortality: A Meta-Analysis

BACKGROUND

We compared early adverse events and midterm survival between primary coronary artery bypass grafting (pCABG) and CABG in patients with percutaneous intervention (secondary CABG, sCABG) because data on this topic are very limited.

METHODS

A systematic review of published literature was done to obtain original studies fulfilling the search criteria. The end points studied were early mortality, stroke, renal failure, myocardial infarction, and the need for an intra-aortic balloon pump. A random-effect inverse variance weighted analysis was performed. The results are presented as risk ratios (RR) (95% confidence interval); p < 0.05 was considered statistically significant.

RESULTS

Fourteen studies (84,983 pCABG patients and 14,775 sCABG patients) were included in the systematic review. Early mortality was lower with primary CABG (RR 1.54 [1.19-2]; p = 0.007). The incidence of myocardial infarction was also less with pCABG than with sCABG. (RR 1.46 [1.04-2.06]; p = 0.06). Patients undergoing pCABG were 14% (0% to 55%; p = 0.04). Less likely to need an intra-aortic balloon pump. Although renal failure was lower with pCABG (RR 1.254 [1.047-1.502]; p = 0.014), the stroke rates were comparable in both cohorts (p = 0.95). Renal failure was favorable in the primary CABG cohort. Early stroke was comparable between the two cohorts (p = 0.95). The pooled hazard ratios demonstrated comparable survival at the end of 3 years (p = 0.36).

CONCLUSIONS

Patients undergoing CABG after prior percutaneous therapy have a higher incidence of myocardial infarction and mortality in the postoperative period. However, midterm survival is comparable in both cohorts.

Impact of prior intracoronary stenting on late outcomes of coronary artery bypass surgery in diabetics with triple-vessel disease

OBJECTIVE

Recent studies have indicated that coronary artery bypass grafting (CABG) outcomes in patients with prior stents are suboptimal. We aimed to study the impact of prior percutaneous coronary intervention (PCI) with stenting (PCI-S) on late CABG mortality in diabetic patients with triple-vessel disease.

METHODS

We reviewed the primary nonemergency CABG experience from a single U.S. institution (n = 7005; 1996-2007, Toledo, Ohio). Diabetics with triple-vessel disease (n = 1583) were identified and divided into 2 groups: (1) prior PCI-S (n = 202); and (2) no prior PCI (No-PCI [n = 1381]). Hierarchic Cox proportional hazards models were used to assess the effect of prior PCI-S on 5-year mortality after CABG. A propensity score for PCI-S and No-PCI patients was derived using a nonparsimonious logistic regression and used to generate a 1:1 (PCI-S to No-PCI) matched cohort.

RESULTS

In model 1, after adjusting for preoperative clinical characteristics, medications, off-pump surgery, and isolated CABG surgery status, prior PCI-S was associated with a 39% increased risk of mortality (hazard ratio [HR] = 1.39, with 95% confidence interval [CI; 1.02, 1.90]; P = .04). Further adjustment for date of surgery (model 2) (HR = 1.39, with 95% CI [1.02, 1.91]; P = .04) or operative parameters (model 3) (HR = 1.38, with 95% CI [1.01, 1.88]; P = .046) did not alter the association. The 1:1 matched-cohort analysis confirmed the increased risk associated with PCI-S (HR = 1.61, with 95% CI [1.03, 2.51]; P = .037).

CONCLUSIONS

Patients who have both diabetes and triple-vessel disease, and have undergone prior PCI-S, have poorer long-term outcomes after CABG compared with those who have had no prior PCI-S.