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Published on: November 19, 2019
Graft Failure After Coronary Artery Bypass Grafting and Its Association With Patient Characteristics and Clinical
Mario Gaudino1, Sigrid Sandner2, Kevin R An1,3
1Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.).
Insights
Graft failure after coronary artery bypass grafting (CABG) is common, affecting over a third of patients. This failure significantly increases the risk of major adverse cardiac events, including heart attack and repeat procedures.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Clinical Trial Meta-Analysis
Background:
- Coronary artery bypass grafting (CABG) benefits are linked to graft patency.
- Systematic graft imaging post-CABG is infrequent, limiting data on graft failure.
- Contemporary data on factors influencing graft failure and its clinical impact are scarce.
Purpose of the Study:
- To assess the incidence of graft failure following CABG using pooled data from randomized trials.
- To identify clinical risk factors associated with CABG graft failure.
- To evaluate the association between graft failure and subsequent adverse clinical events.
Main Methods:
- Pooled individual patient data from randomized clinical trials featuring systematic CABG graft imaging.
- Assessed primary outcome: composite of myocardial infarction or repeat revascularization before imaging.
- Employed a 2-stage meta-analytic approach to link graft failure with clinical outcomes, including post-imaging events and all-cause death.
Main Results:
- Graft failure observed in 33.7% of patients (16.6% of grafts) across 4413 patients from 7 trials.
- Independent predictors of graft failure included older age, female sex, and smoking; statin use showed a protective effect.
- Graft failure significantly increased the risk of myocardial infarction, repeat revascularization, and all-cause death both before and after imaging.
Conclusions:
- Graft failure remains a prevalent issue in contemporary CABG practice.
- Graft failure is a strong predictor of adverse cardiac events and mortality post-CABG.
Background:
Graft patency is the postulated mechanism for the benefits of coronary artery bypass grafting (CABG). However, systematic graft imaging assessment after CABG is rare, and there is a lack of contemporary data on the factors associated with graft failure and on the association between graft failure and clinical events after CABG.
Methods:
We pooled individual patient data from randomized clinical trials with systematic CABG graft imaging to assess the incidence of graft failure and its association with clinical risk factors. The primary outcome was the composite of myocardial infarction or repeat revascularization occurring after CABG and before imaging. A 2-stage meta-analytic approach was used to evaluate the association between graft failure and the primary outcome. We also assessed the association between graft failure and myocardial infarction, repeat revascularization, or all-cause death occurring after imaging.
Results:
Seven trials were included comprising 4413 patients (mean age, 64.4±9.1 years; 777 [17.6%] women; 3636 [82.4%] men) and 13 163 grafts (8740 saphenous vein grafts and 4423 arterial grafts). The median time to imaging was 1.02 years (interquartile range [IQR], 1.00-1.03). Graft failure occurred in 1487 (33.7%) patients and in 2190 (16.6%) grafts. Age (adjusted odds ratio [aOR], 1.08 [per 10-year increment] [95% CI, 1.01-1.15]; P=0.03), female sex (aOR, 1.27 [95% CI, 1.08-1.50]; P=0.004), and smoking (aOR, 1.20 [95% CI, 1.04-1.38]; P=0.01) were independently associated with graft failure, whereas statins were associated with a protective effect (aOR, 0.74 [95% CI, 0.63-0.88]; P<0.001). Graft failure was associated with an increased risk of myocardial infarction or repeat revascularization occurring between CABG and imaging assessment (8.0% in patients with graft failure versus 1.7% in patients without graft failure; aOR, 3.98 [95% CI, 3.54-4.47]; P<0.001). Graft failure was also associated with an increased risk of myocardial infarction or repeat revascularization occurring after imaging (7.8% versus 2.0%; aOR, 2.59 [95% CI, 1.86-3.62]; P<0.001). All-cause death after imaging occurred more frequently in patients with graft failure compared with patients without graft failure (11.0% versus 2.1%; aOR, 2.79 [95% CI, 2.01-3.89]; P<0.001).
Conclusions:
In contemporary practice, graft failure remains common among patients undergoing CABG and is strongly associated with adverse cardiac events.
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