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Multiple versus single arterial grafting in the elderly: a meta-analysis of randomized controlled trials and
Francisca A Saraiva1, Raquel Moreira1, Rui J Cerqueira1,2
1Department of Surgery and Physiology, Cardiovascular Research and Development Center, Faculty of Medicine, University of Porto, Porto, Portugal.
Insights
Multiple arterial grafting (MAG) in elderly patients undergoing coronary artery bypass grafting (CABG) is linked to better long-term survival without increasing early mortality. Advanced age should not restrict MAG use, but patient selection is key.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Surgical Outcomes Research
Background:
- The use of multiple arterial grafts (MAG) versus single arterial grafting (SAG) in coronary artery bypass grafting (CABG) remains controversial, particularly in elderly patient subgroups.
- This meta-analysis addresses the debate by comparing survival and early outcomes in patients over 70 undergoing CABG with MAG versus SAG.
Purpose of the Study:
- To evaluate the long-term survival and early outcomes of elderly patients undergoing coronary artery bypass grafting (CABG) using multiple arterial grafts (MAG) compared to single arterial grafting (SAG).
- To determine if advanced age is a contraindication for MAG in CABG procedures.
Main Methods:
- A meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies published between 1960 and April 2020.
- Inclusion criteria focused on elderly patients (>70 years) undergoing CABG, comparing MAG to SAG.
- Outcomes including long-term survival (≥1 year) and early mortality were analyzed using random-effect models, hazard ratios (HR), and odds ratios (OR).
Main Results:
- The meta-analysis included 1 RCT and 11 PS cohorts, totaling over 18,800 patients.
- MAG was associated with significantly lower long-term mortality (HR: 0.81, 95% CI: 0.72-0.91) compared to SAG.
- No significant increase in early mortality risk was observed with MAG (OR: 0.74, 95% CI: 0.44-1.25).
- Meta-regression indicated that the survival benefit of MAG was more pronounced in studies with higher MAG utilization rates.
Conclusions:
- Advanced age should not be a limiting factor for employing multiple arterial grafting (MAG) in coronary artery bypass grafting (CABG) due to its demonstrated long-term survival benefits.
- Individualized patient selection is recommended to optimize outcomes when considering MAG for elderly patients.
Introduction:
The benefit of adding a second arterial conduit is still controversial, mainly in specific subgroups. We conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies comparing survival and early results in elderly patients who underwent coronary artery bypass grafting (CABG) with multiple (MAG) versus single arterial grafting (SAG).
Evidence Acquisition:
MEDLINE, Web of Science and Cochrane Library were used to find relevant literature (1960-April 2020). Survival at a ≥1-year follow-up and early outcomes were evaluated. Outcomes were collected from matched samples or PS adjusted analysis: hazard ratio (HR) along with their variance, frequencies or odds ratios. Random effect models were used to compute combined statistical measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events).
Evidence Synthesis:
Eleven PS cohorts and 1 RCT comprising >18,800 patients older than 70 (>6200 MAG and >12,500 SAG) were included in this meta-analysis. MAG was associated with lower long-term mortality (pooled HR: 0.81, 95% CI: 0.72-0.91, P<0.01, I2=64%) in the absence of higher risk of early mortality (pooled OR: 0.74, 95% CI: 0.44 to 1.25, P=0.27, I2=0%). In a meta-regression, MAG survival advantage was more pronounced in studies with a higher MAG usage rate (β=-0.0052, P=0.021).
Conclusions:
Current evidence suggests that advanced age should not limit MAG's use considering its benefits in long-term survival. Of note, an individualized patient selection for this approach is warranted.
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