Author + information
- Received June 4, 2019
- Revision received June 20, 2019
- Accepted June 21, 2019
- Published online September 2, 2019.
- Zaza Samadashvili, MDa,
- Thoralf M. Sundt III, MDb,
- Andrew Wechsler, MDc,
- Joanna Chikwe, MDd,
- David H. Adams, MDe,
- Craig R. Smith, MDf,
- Desmond Jordan, MDf,
- Leonard Girardi, MDg,
- Stephen J. Lahey, MDh,
- Jeffrey P. Gold, MDi,
- Mohammed H. Ashraf, MDj and
- Edward L. Hannan, PhDa,∗ (, )@UAlbanySPH
- aSchool of Public Health, University at Albany, State University of New York, Rensselaer, New York
- bCardiac Surgical Division, Massachusetts General Hospital, Boston, Massachusetts
- cDepartment of Cardiothoracic Surgery, Drexel University, Philadelphia, Pennsylvania
- dDepartment of Cardiothoracic Surgery, Stony Brook School of Medicine, Stony Brook, New York
- eDepartment of Surgery, Mount Sinai Hospital, New York, New York
- fDepartment of Surgery, Columbia-Presbyterian Medical Center, New York, New York
- gDepartment of Cardiothoracic Surgery, Weill Cornell Medical Center, New York, New York
- hDivision of Cardiothoracic Surgery, University of Connecticut, Storrs, Connecticut
- iChancellor, University of Nebraska Medical Center, Omaha, Nebraska
- jDepartment of Cardiothoracic Surgery, Kaleida Health, Buffalo, New York
- ↵∗Address for correspondence:
Dr. Edward L. Hannan, School of Public Health, State University of New York, University at Albany, One University Place, Rensselaer, New York 12144-3456.
Background Despite recent guideline statements, there is still wide practice variation in the use of multiple arterial grafts (MAGs) versus single arterial grafts (SAGs) for patients with multivessel disease undergoing coronary artery bypass graft surgery. This may be related to differences in findings between observational and randomized controlled studies.
Objectives This study sought to compare intermediate-term MAG and SAG outcomes with enhanced matching to reduce selection bias.
Methods New York’s cardiac registry identified 63,402 multivessel disease patients undergoing coronary artery bypass graft surgery between January 1, 2005, and December 31, 2014, to compare outcomes (median follow-up 6.5 years) for patients receiving SAGs and MAGs. SAG and MAG patients were propensity matched using 38 baseline characteristics to reduce selection bias. The primary endpoint was mortality, and secondary endpoints included repeat revascularization and a composite endpoint of mortality, acute myocardial infarction, and stroke.
Results Before matching, 20% of procedures employed MAG. At 1 year, there was no mortality difference between matched MAG and SAG patients (2.4% vs. 2.2%, adjusted hazard ratio [AHR]: 1.11; 95% confidence interval [CI]: 0.93 to 1.32). At 7 years, MAG patients had lower mortality (12.7% vs. 14.3%, AHR: 0.86; 95% CI: 0.79 to 0.93), a lower composite outcome (20.2% vs. 22.8%, AHR: 0.88; 95% CI: 0.83 to 0.93), and a lower repeat revascularization rate (11.7% vs. 14.6%, AHR: 0.80; 95% CI: 0.74 to 0.87). At 7 years, the subgroups for which MAG did not have a lower mortality rate included patients with off-pump surgery, 2-vessel disease with right coronary artery disease, recent acute myocardial infarction, renal dysfunction, and patient ≥70 years of age.
Conclusions Mortality and the composite outcome were similar between MAG and SAG patients at 1 year, but lower for MAG after 7 years. Patients of higher volume MAG surgeons experienced lower MAG mortality.
- CABG surgery
- mortality differences
- multiple arterial revascularization
- multiple vessel disease
- observational study
Dr. Sundt has served on a clinical events committee for Medpace. Dr. Wechsler has received consulting fees from Bioventrix. Dr. Chikwe has received speakers honoraria from Edwards Lifesciences. Dr. Adams has served as co-principal investigator on trials for Medtronic and Abbott; and his institution receives royalties for intellectual property related to the development of valve repair products from Edwards Lifesciences and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received June 4, 2019.
- Revision received June 20, 2019.
- Accepted June 21, 2019.
- 2019 American College of Cardiology Foundation
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