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Single Versus Multiple Arterial Revascularization in Patients With Reduced Renal Function: Long-term Outcome
Yukihiro Hayatsu1, Marc Ruel1, Anan Bader Eddeen2
1Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON, Canada.
Insights
Minimally invasive aortic valve replacement (MAR) did not show a significant benefit in major adverse cardiac events (MACE) for patients with moderate to severe renal insufficiency undergoing coronary artery bypass grafting (CABG). Survival benefits observed may be due to indication bias, suggesting risks offset potential advantages.
Area of Science:
- Cardiovascular Surgery
- Nephrology
- Outcomes Research
Background:
- Coronary Artery Bypass Grafting (CABG) is a common procedure.
- Renal insufficiency is a significant comorbidity in CABG patients.
- The long-term comparative effectiveness of Minimally Invasive Aortic valve Replacement (MAR) versus Standard Aortic valve Replacement (SAR) in this population remains unclear.
Purpose of the Study:
- To compare the long-term outcomes of MAR versus SAR in patients with varying degrees of renal insufficiency undergoing isolated CABG.
- To determine if MAR offers a significant advantage over SAR in reducing major adverse cardiac events (MACE) and mortality in patients with renal dysfunction.
Main Methods:
- Retrospective cohort study of 23,406 patients undergoing isolated CABG in Ontario, Canada.
- Patients were stratified by preoperative Glomerular Filtration Rate (GFR): ≥60, 30-60, and <30 mL/min/1.73 m².
- Propensity score matching was used to compare outcomes between MAR and SAR groups within each GFR stratum.
Main Results:
- In patients with GFR ≥60, MAR was associated with lower MACE (HR 0.87) and mortality (HR 0.87).
- In patients with GFR 30-60, MAR showed no difference in MACE (HR 1.04) but was associated with lower mortality (HR 0.75).
- In patients with GFR <30, MAR was not associated with a significant difference in MACE or mortality.
Conclusions:
- MAR does not appear to confer a significant MACE benefit over SAR in patients with moderate to severe renal insufficiency undergoing CABG.
- Observed survival benefits in some groups may be influenced by indication bias.
- The potential long-term benefits of MAR in renal insufficiency may be outweighed by competing health risks.
Objective:
To compare the long-term outcomes of MAR versus SAR in patients with renal insufficiency.
Summary Of Background Data:
Previous studies have been insufficiently powered to address whether MAR confers long-term benefit over SAR in patients with renal dysfunction who require CABG.
Methods:
We conducted retrospective cohort study in Ontario, Canada of patients who underwent isolated CABG (n = 23,406). The primary outcome was MACE, defined as the composite of stroke, myocardial infarction, and repeat revascularization. We compared patients by matching them on the propensity to have received SAR versus MAR, within groups with preoperative glomerular filtration rate (GFR) ≥60 mL/min/1.73 m2; GFR between 30 and 60; and GFR <30.
Results:
In patients with GFR ≥60, the use of MAR versus SAR was associated with a lower rate of MACE [hazard ratio (HR) 0.87 (0.80-0.94)], and a lower rate of long-term mortality [HR 0.87 (0.79-0.97)]. In those with GFR between 30 and 60, MAR was not associated with a difference in MACE [HR 1.04 (0.87-1.26)], and a lower rate of long-term mortality [HR 0.75 (0.65-0.87)] was observed. In those with GFR <30, MAR was not associated with a difference in outcomes.
Conclusions:
MAR versus SAR does not correlate with a difference in MACE amongst patients with GFR between 30 and 60 and better survival raises the possibility of indication bias. Furthermore, MAR did not confer a benefit in those with severely reduced renal function. These data suggest that the potential long-term benefits of using MAR in CABG patients with renal insufficiency may be offset by competing health risks.
