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Three Arterial Grafts Improve Late Survival: A Meta-Analysis of Propensity-Matched Studies
Mario Gaudino1, John D Puskas2, Antonino Di Franco2
1From Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., A.D.F., L.B.O., L.N.G.); Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.D.P.); Città della Scienza e della Salute, Department of Cardiology, University of Turin, Italy (M.I., U.B., F.D., F.G.); Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (D.G., J.B.G.); Bristol Heart Institute, University of Bristol, UK (U.B.); and Department of Cardiac Surgery, John Radcliffe Hospital, University of Oxford, UK (D.P.T.). mfg9004@med.cornell.edu.
Background:
Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed.
Methods:
A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals.
Results:
Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71-1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75-0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33-0.98; P=0.04).
Conclusions:
The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status.
