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Published on: March 27, 2018
Completeness of coronary revascularization and survival: Impact of age and off-pump surgery
Shuab Omer1, Lorraine D Cornwell1, Todd K Rosengart2
1Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
Insights
Incomplete revascularization after coronary artery bypass grafting significantly reduces long-term survival, especially in elderly patients. Surgeons should prioritize complete revascularization to improve patient outcomes.
Area of Science:
- Cardiovascular Surgery
- Outcomes Research
Background:
- Completeness of revascularization is crucial for long-term survival post-coronary artery bypass grafting (CABG).
- The impact of incomplete revascularization, particularly in elderly patients and those undergoing off-pump surgery, requires further investigation.
Purpose of the Study:
- To evaluate the effect of complete versus incomplete revascularization on long-term survival after CABG.
- To assess the influence of patient age and surgical technique (off-pump vs. on-pump) on these outcomes.
Main Methods:
- A multicenter observational cohort study of 41,139 patients with left main and 3-vessel coronary artery disease undergoing nonemergency CABG.
- Survival analysis using Kaplan-Meier and log-rank tests, with propensity score matching to compare complete and incomplete revascularization groups.
- Subgroup analyses were conducted for patients aged ≥70 years and those who underwent off-pump CABG.
Main Results:
- Incomplete revascularization was associated with higher risk-adjusted mortality at 1, 5, and 10 years post-CABG (overall hazard ratio: 1.18).
- The negative impact of incomplete revascularization was observed in elderly patients (aged ≥70 years; hazard ratio: 1.125).
- Off-pump CABG showed a higher hazard ratio for mortality in unmatched (1.47) and matched (1.156) groups, suggesting increased risk with incomplete revascularization.
Conclusions:
- Incomplete revascularization is linked to diminished long-term survival following coronary artery bypass grafting.
- These findings underscore the importance of achieving complete revascularization, even in elderly individuals and when considering off-pump procedures.
Objectives:
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.
Methods:
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.
Results:
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.
Conclusions:
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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