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Choi JH, Grimsley EA, Read MD, Rogers MP, Bulard B, Kuo PC. Meta-Analysis in Surgical Research: Methodology and Statistical Application. Am Surg 2024:31348241256053. [PMID: 38788217 DOI: 10.1177/00031348241256053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
In evidence-based medicine, systematic review continues to carry the highest weight in terms of quality and reliability, synthesizing robust information from previously published cohort studies to provide a comprehensive overview of a topic. Meta-analysis provides further depth by allowing for comparative analysis between the studied intervention and the control group, providing the most up-to-date evidence on their characteristics and efficacy. We discuss the principles and methodology of meta-analysis, and its applicability to the field of surgical research. The clinical question is defined using PICO framework (Problem, Intervention, Comparison, Outcome). Then a systematic article search is performed across multiple medical databases using relevant search terms, which are then filtered out based on appropriate screening tools. Pertinent data from the selected articles are collected and undergo critical appraisal by at least two independent reviewers. Additional statistical tests may be performed to identify the presence of any significant bias. The data are then synthesized to perform comparative analysis between the intervention and comparison groups. In this article, we discuss specifically the usage of R software (R Foundation for Statistical Computing, Vienna, Austria) for data analysis and visualization. Meta-analysis results of the pooled data are presented using forest plots. Concerns for potential bias may be addressed through the creation of funnel plots. Meta-analysis is a powerful tool to provide highly reliable medical evidence. It may be readily performed by independent researchers with minimal need for funding or institutional approval. The ability to conduct such studies is an asset to budding medical scholars.
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Affiliation(s)
- Jae Hwan Choi
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - Emily A Grimsley
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - Meagan D Read
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - Michael P Rogers
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - Blake Bulard
- Department of Surgery, University of South Florida, Tampa, Florida, USA
| | - Paul C Kuo
- Department of Surgery, University of South Florida, Tampa, Florida, USA
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Gaudino M, Lemma M, Sandner S, Boening A, Harik L, Albert M, Martin JA, Alcocer J, Alexander JH, Bhatt DL, Bonaros N, Borger M, Danner BC, Davierwala P, Deja MA, De Paulis R, Deutsch MA, Flather M, Kappetein P, Kurlansky P, Lamy A, Lorusso R, Mannam GC, Marzouk M, Creber RM, Milojevic M, Nasso G, Patel N, Petrovic I, Quintana E, Sajja LR, Rinaldi M, Rong L, Rudez I, Ruel M, Ruttmann-Ulmer E, Voisine P, Zhao Q, Zheng Z, Fremes SE. The ROMA trial: 7 years of trial activities and the development of the ROMA trial network. Eur J Cardiothorac Surg 2024; 65:ezae188. [PMID: 38758192 PMCID: PMC11099650 DOI: 10.1093/ejcts/ezae188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024] Open
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Massimo Lemma
- Department of Cardiac Surgery, Jilin Heart Hospital, Changchun, China
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Boening
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert-Bosch Hospital, Stuttgart, Germany
| | - Jose Albors Martin
- Department of Cardiac Surgery, Hospital Universitario del Vinalopo, Alicante, Spain
| | - Jorge Alcocer
- Department of Cardiac Surgery, Hospital Clinic de Barcelona, Barcelona, Spain
| | - John H Alexander
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC, USA
| | - Deepak L Bhatt
- Department of Medicine, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Borger
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Bernhard C Danner
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Goettingen, Goettingen, Germany
| | - Piroze Davierwala
- Department of Surgery, Division of Cardiac Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Marek A Deja
- Department of Cardiac Surgery, Medical University of Silesia-Katowice, Katowice, Poland
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Unicamillus University, Rome, Italy
| | - Marcus-Andre Deutsch
- Department of Thoracic and Cardiovascular Surgery, HDZ NRW, University Hospital Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Marcus Flather
- Department of Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Paul Kurlansky
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Andre Lamy
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Center and Cardiovascular Research Maastricht, Maastricht, Netherlands
| | - Gopi Chand Mannam
- Department of Cardiothoracic Surgery, Star Hospitals, Hyderabad, India
| | - Mohamed Marzouk
- Department of Cardiovascular Surgery, IUCPQ, Universite Laval, Quebec City, QC, Canada
| | | | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | - Giuseppe Nasso
- Department of Cardiac Surgery, Anthea Hospital, Bari, Italy
| | - Nirav Patel
- Department of Cardiovascular and Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Ivana Petrovic
- Department of Cardiosurgery, Center of Excellence, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Eduard Quintana
- Department of Cardiac Surgery, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Mauro Rinaldi
- Department of Cardiac Surgery, University of Turin, Turin, Italy
| | - Lisa Rong
- Department of Anesthesia, Weill Cornell Medicine, New York, NY, USA
| | - Igor Rudez
- Department of Cardiac and Transplant Surgery, Dubrava University Hospital, Zagreb, Croatia
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Pierre Voisine
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Qiang Zhao
- Department of Cardiac Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhe Zheng
- Department of Cardiac Surgery, Fuwai Hospital, Beijing, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Goldkuhle M, Guyatt GH, Kreuzberger N, Akl EA, Dahm P, van Dalen EC, Hemkens LG, Klugar M, Mustafa RA, Nonino F, Schünemann HJ, Trivella M, Skoetz N. GRADE concept 4: rating the certainty of evidence when study interventions or comparators differ from PICO targets. J Clin Epidemiol 2023; 159:40-48. [PMID: 37146659 DOI: 10.1016/j.jclinepi.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVES This Grading of Recommendations Assessment, Development and Evaluation (GRADE) concept article offers systematic reviewers, guideline authors, and other users of evidence assistance in addressing randomized trial situations in which interventions or comparators differ from those in the target people, interventions, comparators, and outcomes. To clarify what GRADE considers under indirectness of interventions and comparators, we focus on a particular example: when comparator arm participants receive some or all aspects of the intervention management strategy (treatment switching). STUDY DESIGN AND SETTING An interdisciplinary panel of the GRADE working group members developed this concept article through an iterative review of examples in multiple teleconferences, small group sessions, and e-mail correspondence. After presentation at a GRADE working group meeting in November 2022, attendees approved the final concept paper, which we support with examples from systematic reviews and individual trials. RESULTS In the presence of safeguards against risk of bias, trials provide unbiased estimates of the effect of an intervention on the people as enrolled, the interventions as implemented, the comparators as implemented, and the outcomes as measured. Within the GRADE framework, differences in the people, interventions, comparators, and outcomes elements between the review or guideline recommendation targets and the trials as implemented constitute issues of indirectness. The intervention or comparator group management strategy as implemented, when it differs from the target comparator, constitutes one potential source of indirectness: Indirectness of interventions and comparators-comparator group receipt of the intervention constitutes a specific subcategory of said indirectness. The proportion of comparator arm participants that received the intervention and the apparent magnitude of effect bear on whether one should rate down, and if one does, to what extent. CONCLUSION Treatment switching and other differences between review or guideline recommendation target interventions and comparators vs. interventions and comparators as implemented in otherwise relevant trials are best considered issues of indirectness.
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Affiliation(s)
- Marius Goldkuhle
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, Michael G DeGroote Cochrane Canada Centre, Cochrane Canada, McMaster GRADE Centre and Department of Medicine, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada
| | - Nina Kreuzberger
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Lebanon, P.O.Box 11-0236 and Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada
| | - Philipp Dahm
- Minneapolis VA Health Care System, Urology Section 112D, One Veterans Drive, Minneapolis, Minnesota 55417
| | - Elvira C van Dalen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584CS Utrecht, the Netherlands
| | - Lars G Hemkens
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland; Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA; Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic; Institute of Health Information and Statistics of the Czech Republic, 100 00 Prague, Czech Republic
| | - Reem A Mustafa
- Department of Medicine and Population Health, University of Kansas Health System, 3901 Rainbow Blvd, MS3002, Kansas City, KS 66160, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, Ontario L8S 4K1, Canada
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unit of Epidemiology and Statistics, Cochrane Review Group Multiple Sclerosis and Rare Diseases of the CNS, Via Altura 3, 40139 Bologna, Italy
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, Michael G DeGroote Cochrane Canada Centre, Cochrane Canada and McMaster GRADE Centre, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Milan, Italy; Cochrane Canada, Hamilton, Ontario, Canada
| | - Marialene Trivella
- Department of Cardiovascular Medicine, John Radcliffe Hospital, University of Oxford, UK; Department of Population Health, London School of Hygiene and Tropical Medicine, London
| | - Nicole Skoetz
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Terman SW, Wang C, Wang L, Braun KPJ, Otte WM, Slinger G, Kerr WT, Lossius MI, Bonnett L, Burke JF, Marson A. Reappraisal of the Medical Research Council Antiepileptic Drug Withdrawal Study: contamination‐adjusted and dose‐response re‐analysis. Epilepsia 2022; 63:1724-1735. [PMID: 35490396 PMCID: PMC9283317 DOI: 10.1111/epi.17273] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Abstract
Objective The 1991 Medical Research Council (MRC) Study compared seizure relapse for seizure‐free patients randomized to withdraw vs continue of antiseizure medications (ASMs). We re‐analyzed this trial to account for crossover between arms using contamination‐adjusted intention to treat (CA ITT) methods, to explore dose‐response curves, and to validate predictions against external data. ITT assesses the effect of being randomized to withdraw, as‐treated analysis assesses the confounded effect of withdrawing, but CA ITT assesses the unconfounded effect of actually withdrawing. Methods CA ITT involves two stages. First, we used randomized arm to predict whether patients withdrew their ASM (logistic) or total daily ASM dose (linear). Second, we used those values to predict seizure occurrence (logistic). Results The trial randomized 503 patients to withdraw and 501 patients to continue ASMs. We found that 316 of 376 patients (88%) who were randomized to withdraw decreased their dose at every pre‐seizure visit, compared with 35 of 424 (8%) who were randomized to continue (p < .01). Adjusted odds ratios of a 2‐year seizure for those who withdrew vs those who did not was 1.3 (95% confidence interval [CI] 0.9–1.9) in the as‐treated analysis, 2.5 (95% CI 1.9–3.4) comparing those randomized to withdraw vs continue for ITT, and 3.1 (95% CI 2.1–4.5) for CA ITT. Probabilities (withdrawal vs continue) were 28% vs 24% (as‐treated), 40% vs 22% (ITT), and 43% vs 21% (CA ITT). Differences between ITT and CA ITT were greater when varying the predictor (reaching zero ASMs) or outcome (1‐year seizures). As‐treated dose‐response curves demonstrated little to no effects, but larger effects in CA ITT analysis. MRC data overpredicted risk in Lossius data, with moderate discrimination (areas under the curve ~0.70). Significance CA ITT results (the effect of actually withdrawing ASMs on seizures) were slightly greater than ITT effects (the effect of recommend withdrawing ASMs on seizures). How these findings affect clinical practice must be individualized.
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Affiliation(s)
- Samuel W Terman
- University of Michigan Department of Neurology Ann Arbor MI 48109 USA
| | - Chang Wang
- University of Michigan School of Public Health Department of Biostatistics Ann Arbor MI 48109 USA
| | - Lu Wang
- University of Michigan School of Public Health Department of Biostatistics Ann Arbor MI 48109 USA
| | - Kees PJ Braun
- Utrecht University Department of Child Neurology University Medical Center Utrecht member of EpiCARE The Netherlands
| | - Willem M Otte
- Utrecht University Department of Child Neurology University Medical Center Utrecht member of EpiCARE The Netherlands
| | - Geertruida Slinger
- Utrecht University Department of Child Neurology University Medical Center Utrecht member of EpiCARE The Netherlands
| | - Wesley T Kerr
- University of Michigan Department of Neurology Ann Arbor MI 48109 USA
| | - Morten I Lossius
- Oslo University Hospital National Center for Epilepsy Oslo Norway
- University of Oslo Institute of Clinical Medicine
| | - Laura Bonnett
- University of Liverpool Department of Health Data Science Block B, Waterhouse Building, Brownlow Hill Liverpool L69 3GL United Kingdom
| | - James F Burke
- the Ohio State University Department of Neurology Columbus 43210
| | - Anthony Marson
- University of Liverpool Department of Pharmacology and Therapeutics Liverpool United Kingdom
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5
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Cancelli G, Audisio K, Perezgrovas-Olaria R, Soletti GJ, Chadow D, Rahouma M, Robinson NB, Gaudino M. Representation of racial minorities in cardiac surgery randomized clinical trials. J Card Surg 2022; 37:1311-1316. [PMID: 35238064 DOI: 10.1111/jocs.16371] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 12/26/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Racial minorities account for 39.9% of the population in the United States, but are often underrepresented in clinical research. Results from studies predominantly enrolling White patients may not apply to racial minorities. The aim of this analysis is to assess the representation of racial minorities in cardiac surgery randomized clinical trials (RCTs). METHODS A systematic search of the literature was performed. All RCTs published from 2000 to 2020 including at least 100 patients and comparing two or more adult cardiac surgery procedures were included. Meta-analytic estimates were calculated. RESULTS Among 51 cardiac surgery RCTs published between 2000 and 2020, only 9 (17.6%) reported the race of patients and were included in the final analysis. All of them were multicentric, with a mean of 33 centers included. Six RCTs enrolled patients undergoing coronary artery bypass grafting (66.7%), while the remaining three were on valve surgery (33.3%). Overall, 9193 patients were included; of them, 8034 (87.4%) were White and 1026 (11.2%) nonWhite (386 [4.2%] Black, 191 [2.1%] Hispanic, 274 [3.0%] from other races, and 175 [1.9%] nonWhite patients of unspecified race). The proportion of nonWhite patients did not change over time. CONCLUSIONS Only 9 (17.6%) of the 51 cardiac surgery RCTs published between 2000 and 2020 reported the race of the patients enrolled and only 11.2% of them were nonWhite patients. Given the association between race and clinical outcomes, future RCTs should either guarantee a balanced inclusion of racial minorities or be designed to specifically enroll them.
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Affiliation(s)
- Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - N B Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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Gaudino M, Chikwe J, Bagiella E, Bhatt DL, Doenst T, Fremes SE, Lawton J, Masterson Creber RM, Sade RM, Zwischenberger BA. Methodological Standards for the Design, Implementation, and Analysis of Randomized Trials in Cardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 145:e129-e142. [PMID: 34865513 DOI: 10.1161/cir.0000000000001037] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiac surgery presents specific methodological challenges in the design, implementation, and analysis of randomized controlled trials. The purposes of this scientific statement are to review key standards in cardiac surgery randomized trial design and implementation, and to provide recommendations for conducting and interpreting cardiac surgery trials. Recommendations include a careful evaluation of the suitability of the research question for a clinical trial, assessment of clinical equipoise, feasibility of enrolling a representative patient cohort, impact of practice variations on the safety and efficacy of the study intervention, likelihood and impact of crossover, and duration of follow-up. Trial interventions and study end points should be predefined, and appropriate strategies must be used to ensure adequate deliverability of the trial interventions. Every effort must be made to ensure a high completeness of follow-up; trial design and analytic techniques must be tailored to the specific research question and trial setting.
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Gaudino M, Benedetto U, Fremes S, Ballman K, Biondi-Zoccai G, Sedrakyan A, Nasso G, Raman J, Buxton B, Hayward PA, Moat N, Collins P, Webb C, Peric M, Petrovic I, Yoo KJ, Hameed I, Di Franco A, Moscarelli M, Speziale G, Puskas JD, Girardi LN, Hare DL, Taggart DP. Association of Radial Artery Graft vs Saphenous Vein Graft With Long-term Cardiovascular Outcomes Among Patients Undergoing Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis. JAMA 2020; 324:179-187. [PMID: 32662861 PMCID: PMC7361649 DOI: 10.1001/jama.2020.8228] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Observational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials. OBJECTIVE To compare clinical outcomes between patients receiving radial artery vs saphenous vein grafts for coronary artery bypass grafting after long-term follow-up. DESIGN, SETTING, AND PARTICIPANTS Patient-level pooled analysis comparing radial artery vs saphenous vein graft in adult patients undergoing isolated coronary artery bypass grafting from 5 countries (Australia, Italy, Serbia, South Korea, and the United Kingdom), with enrollment from 1997 to 2009 and follow-up completed in 2019. INTERVENTIONS Patients were randomized to undergo either radial artery (n = 534) or saphenous vein (n = 502) grafts for coronary artery bypass grafting. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death, myocardial infarction, or repeat revascularization and the secondary outcome was a composite of death or myocardial infarction. RESULTS A total of 1036 patients were randomized (mean age, 66.6 years in the radial artery group vs 67.1 years in the saphenous vein group; 376 [70.4%] men in the radial artery group vs 351 [69.9%] in the saphenous vein group); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 in the radial artery group). At a median (interquartile range) follow-up of 10 (10-11) years, the use of the radial artery, compared with the saphenous vein, in coronary artery bypass grafting was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction, or repeat revascularization (220 vs 237 total events; 41 vs 47 events per 1000 patient-years; hazard ratio, 0.73 [95% CI, 0.61-0.88]; P < .001) and of the composite of death or myocardial infarction (188 vs 193 total events; 35 vs 38 events per 1000 patient-years; hazard ratio, 0.77 [95% CI, 0.63-0.94]; P = .01). CONCLUSIONS AND RELEVANCE In this individual participant data meta-analysis with a median follow-up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with the saphenous vein was associated with a lower risk of a composite of cardiovascular outcomes.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Umberto Benedetto
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, United Kingdom
| | - Stephen Fremes
- Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Karla Ballman
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Art Sedrakyan
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Giuseppe Nasso
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - Jai Raman
- Austin Hospital, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Brian Buxton
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Philip A. Hayward
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Neil Moat
- NHLI, Imperial College London, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Peter Collins
- NHLI, Imperial College London, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Carolyn Webb
- NHLI, Imperial College London, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Miodrag Peric
- Dedinje Cardiovascular Institute and Belgrade University School of Medicine, Belgrade, Serbia
| | - Ivana Petrovic
- Dedinje Cardiovascular Institute and Belgrade University School of Medicine, Belgrade, Serbia
| | - Kyung J. Yoo
- Yonsei University College of Medicine, Seoul, South Korea
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - Giuseppe Speziale
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
| | - John D. Puskas
- Department of Cardiovascular Surgery, Mount Sinai St. Luke's, New York, New York
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - David L. Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
| | - David P. Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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Gaudino M, Chikwe J, Falk V, Lawton JS, Puskas JD, Taggart DP. Transatlantic editorial: the use of multiple arterial grafts for coronary revascularization in Europe and North America. Eur J Cardiothorac Surg 2020; 57:1032-1037. [PMID: 32191293 DOI: 10.1093/ejcts/ezaa077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Joanna Chikwe
- Department of Cardiothoracic Surgery, Stony Brook School of Medicine, Stony Brook, NY, USA
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charite Berlin, Berlin, Germany.,German Center of Cardiovascular Research, Partner Site Berlin, Berlin, Germany.,Department of Health Science and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Jennifer S Lawton
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, NY, USA
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, Oxford, UK
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9
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Gaudino M, Fremes SE, Ruel M, Di Franco A, Di Mauro M, Chikwe J, Frati G, Girardi LN, Taggart DP, Biondi-Zoccai G. Prevalence and Impact of Treatment Crossover in Cardiac Surgery Randomized Trials: A Meta-Epidemiologic Study. J Am Heart Assoc 2019; 8:e013711. [PMID: 31663420 PMCID: PMC6898839 DOI: 10.1161/jaha.119.013711] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Crossover dilutes treatment effect and reduces statistical power of intention-to-treat analysis. We examined incidence and impact on cardiac surgery randomized controlled trial (RCT) outcomes of crossover from experimental to control interventions, or vice versa. Methods and Results MEDLINE, EMBASE, and Cochrane Library were searched, and RCTs (≥100 patients) comparing ≥2 adult cardiac surgical interventions were included. Crossover from the initial treatment assignment and relative risks (RRs) for each trial's primary end point and mortality at longest available follow-up were extracted. All RRs were calculated as >1 favored control group and <1 favored experimental arm. Primary outcome was the effect estimate for primary end point of each RCT, and secondary outcome was all-cause mortality; both were appraised as RR at the longest follow-up available. Sixty articles reporting on 47 RCTs (25 440 patients) were identified. Median crossover rate from experimental to control group was 7.0% (first quartile, 2.0%; third quartile, 9.7%), whereas from control to experimental group, the rate was 1.3% (first quartile, 0%; third quartile, 3.6%). RRs for primary end point and mortality were higher in RCTs with higher crossover rate from experimental to control group (RR, 1.01 [95% CI, 0.94-1.07] versus RR, 0.80 [95% CI, 0.66-0.97] and RR, 1.02 [95% CI, 0.95-1.11] versus RR, 0.94 [95% CI, 0.82-1.07], respectively). Crossover from control to experimental group did not alter effect estimates for primary end point or mortality (RR, 0.82 [95% CI, 0.63-1.05] versus RR, 0.95 [95% CI, 0.86-1.04] and RR, 0.88 [95% CI, 0.73-1.07] versus RR, 1.02 [95% CI, 0.95-1.09], respectively). Conclusions Crossover from experimental to control group is associated with outcomes of cardiac surgery RCTs. Crossover should be minimized at designing stage and carefully appraised after study completion.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Stephen E Fremes
- Schulich Heart Centre Division of Cardiac Surgery Department of Surgery Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Marc Ruel
- University of Ottawa Heart Institute University of Ottawa Ontario Canada
| | | | | | - Joanna Chikwe
- Department of Cardiothoracic Surgery Stony Brook School of Medicine New York NY.,Department of Cardiothoracic Surgery Mount Sinai Hospital New York NY
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome Latina Italy.,Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.) Neuromed Pozzilli Italy
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - David P Taggart
- Nuffield Department of Surgical Sciences University of Oxford United Kingdom
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome Latina Italy.,Mediterranea Cardiocentro Napoli Italy
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