Completeness of coronary revascularization and survival: Impact of age and off-pump surgery
ABSTRACT We conducted a multicenter observational cohort study of the effect of completeness of revascularization on long-term survival after coronary artery bypass grafting. We also investigated the impact of age and off-pump surgery.
The Veterans Affairs Continuous Improvement in Cardiac Surgery Program was used to identify all patients (N = 41,139) with left main and 3-vessel coronary artery disease who underwent nonemergency coronary artery bypass grafting from October 1997 to April 2011. The primary outcome measure, all-cause mortality, was compared between patients with complete revascularization and patients with incomplete revascularization. Survival functions were estimated with the Kaplan-Meier method and compared by using the log-rank test. Propensity scores calculated for each patient were used to match 5509 patients undergoing complete revascularization to 5509 patients undergoing incomplete revascularization. A subgroup analysis was performed in patients aged at least 70 years and patients who underwent off-pump coronary artery bypass grafting.
In the unmatched groups, several risk factors were more common in the incomplete revascularization group, as was off-pump coronary artery bypass grafting. In the matched groups, risk-adjusted mortality was higher in the incomplete revascularization group than in the complete revascularization group at 1 year (6.96% vs 5.97%; risk ratio [RR], 1.17; 95% confidence interval [CI], 1.01-1.34), 5 years (18.50% vs 15.96%; RR, 1.16; 95% CI, 1.07-1.26), and 10 years (32.12% vs 27.40%; RR, 1.17; 95% CI, 1.11-1.24), with an overall hazard ratio of 1.18 (95% CI, 1.09-1.28; P < .0001). The hazard ratio for patients aged 70 years or more was 1.125 (95% CI, 1.001-1.263; P = .048). The hazard ratio was 1.47 (95% CI, 1.303-1.655) for the unmatched off-pump coronary artery bypass grafting group and 1.156 (95% CI, 1.000-1.335) for the matched off-pump coronary artery bypass grafting group.
Incomplete revascularization is associated with decreased long-term survival, even in elderly patients. Surgeons should consider these findings when choosing a revascularization strategy, particularly if off-pump coronary artery bypass grafting is contemplated.
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ABSTRACT: The aim of this study was to compare clinical outcome at 5 years in patients with complete and incomplete revascularization treated with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents. Baseline and procedural angiograms and surgical case-record forms were centrally assessed for completeness of revascularization. Patients treated with PCI for incomplete revascularization were stratified according to Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score tertiles. Complete revascularization was achieved in 360 of 588 patients (61.2%) in the PCI with sirolimus-eluting stent group and 477 of 567 patients (84.1%) in the CABG group (p <0.05). There was no significant difference in 5-year survival without major adverse cardiac and cerebrovascular events (MACCEs; death, cerebrovascular accident, myocardial infarction, and any revascularization) between patients with complete and incomplete revascularization treated with PCI or CABG. Survival free from MACCEs in patients with incomplete revascularization treated with PCI was significantly lower than those with complete revascularization treated with CABG (hazard ratio 1.66, 0.96 to 1.80, log-rank p = 0.001). The 5-year MACCE-free survival in patients with incomplete revascularization treated with PCI stratified according to SYNTAX score tertiles showed a significantly lower MACCE survival in the higher SYNTAX tertile compared to the low (hazard ratio 0.56, 0.32 to 0.96, log-rank p = 0.04) and intermediate (hazard ratio 0.50, 0.28 to 0.91, log-rank p = 0.02) tertiles, whereas survival between the low and intermediate SYNTAX tertiles was not significantly different (hazard ratio 1.13, 0.60 to 2.13, log-rank p = 0.71). In conclusion, this study suggests that patients with complex coronary disease, in whom complete revascularization cannot be achieved with PCI, should be offered surgical revascularization. However, in those patients with less complex disease, PCI is a valid alternative even if complete revascularization cannot be achieved.The American journal of cardiology 11/2010; 106(10):1369-75. DOI:10.1016/j.amjcard.2010.06.069 · 3.43 Impact Factor
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ABSTRACT: To determine the independent influence of the extent and site of residual disease on late survival, we analyzed the fate of 1448 consecutive patients who had coronary artery bypass surgery during 1968-1974. There were 1274 males, mean age 53.4 ± 8 years (range 24-75 years). Females were excluded from further analysis. 226 patients (17.7%) had one-vessel disease, 492 (38.6%) had two-vessel disease, 408 (32.0%) had three-vessel disease and 148 (11.6%) had left main stenosis. Survival was determined at a follow-up of at least 5 years. Survival data were analyzed by Kaplan-Meier survival curves for the patients with two- and three-vessel disease according to the extent of residual disease. For patients with two-vessel disease and good ventricular function, survival was similar at 5 years, 89.1% and 87.7% for no and one residual lesion; for those with two-vessel disease and poor ventricular function, 5-year survival was 84.5% and 52.6% for no and one residual lesion; for those with three-vessel disease and good ventricular function, it was 92.0%, 83.4%, and 75.0% for no, one and two residual lesions, respectively. With poor ventricular function, the corresponding results were 83.1%, 72.5% and 23.1%. The Cox multivariate analysis technique was used to analyze the influence of age at operation, number of vessels diseased preoperatively, preoperative left ventricular function, period of surgery, and the number and site of residual lesions after operation. Residual disease, age at operation and left ventricular function were the most important variables affecting survival of patients with two- and three-vessel disease. Residual lesions of the left anterior descending or circumflex coronary arteries were the most important predictors of survival; residual lesions of the right coronary artery exerted a lesser influence. The results of this study suggest that the greatest benefit in terms of improved survival may come from the first two to three grafts placed.Circulation 11/1982; 66(4):717-23. DOI:10.1161/01.CIR.66.4.717 · 14.95 Impact Factor