Survival Outcomes After Multiple vs Single Arterial Grafting Among Patients With Reduced Ejection Fraction
Justin Ren1,2, Jason E Bloom3,4,5, William Chan3,5,6,7
1Department of Surgery, The University of Melbourne, Melbourne, Australia.
Insights
Multiarterial coronary bypass grafting significantly reduces long-term mortality compared to single arterial grafting, regardless of left ventricular ejection fraction. Total arterial revascularization offers superior survival benefits, especially in patients with preserved ejection fraction.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery Outcomes
Background:
- Multiarterial coronary bypass grafting (CABG) demonstrates superior clinical outcomes compared to single arterial grafting with saphenous vein grafts.
- The survival advantage of multiarterial grafting in patients with varying degrees of left ventricular impairment remains unclear.
Purpose of the Study:
- To compare long-term survival outcomes between multiarterial and single arterial grafting strategies.
- To stratify survival benefits based on preoperative left ventricular ejection fraction (LVEF).
Main Methods:
- Retrospective cohort study utilizing a multicenter cardiac registry (Australian & New Zealand Society of Cardiac & Thoracic Surgeons) linked to the National Death Index.
- Included 59,641 patients undergoing primary isolated coronary bypass surgery between 2001 and 2020.
- Analyzed long-term all-cause mortality, stratified by LVEF.
Main Results:
- Multiarterial grafting was associated with a 19.0% relative reduction in all-cause mortality compared to single arterial grafting in patients with normal LVEF.
- Similar survival benefits were observed across all LVEF strata (mild, moderate, severe impairment).
- Total arterial revascularization showed enhanced survival, particularly in patients with preserved LVEF, except when LVEF was below 30%.
Conclusions:
- Multiarterial bypass procedures are associated with reduced long-term mortality risk across the spectrum of LVEF.
- The findings suggest a potential benefit in shifting current grafting strategies towards multiarterial procedures.
- Total arterial revascularization offers incrementally improved survival, warranting consideration in surgical practice.
Importance:
Multiarterial coronary bypass procedures offer improved clinical outcomes compared with single arterial grafting with supplementary saphenous vein grafts. However, the survival advantage of multiarterial grafting across varying levels of left ventricular impairment remains uncertain.
Objective:
To compare long-term survival outcomes of patients undergoing multiple vs single arterial grafting, stratified by preoperative ejection fraction.
Design, Setting, And Participants:
A complete-case retrospective cohort study was conducted using data from a multicenter population-based cardiac registry established by the Australian & New Zealand Society of Cardiac & Thoracic Surgeons with linkage to the National Death Index. Participants were individuals who underwent primary isolated coronary bypass surgery between June 1, 2001, and January 31, 2020. Exclusion criteria were nonadults, reoperations, concomitant or previous cardiac surgical procedures, single-graft procedure, and cases without any arterial grafts. Statistical analyses were conducted in September 2024.
Exposures:
Patients underwent either multiple or single arterial grafting, stratified by their preoperative left ventricular ejection fraction.
Main Outcomes And Measures:
Long-term all-cause mortality.
Results:
The study included 59 641 patients (mean [SD] age at the time of surgery, 65.8 [10.2] years; 48 321 men [81.0%]). The median follow-up duration was 5.0 years (IQR, 2.3-8.6 years). Multiarterial grafting was associated with a 19.0% relative reduction in all-cause mortality compared with single arterial grafting among patients with a normal left ventricular ejection fraction (hazard ratio [HR], 0.81; 95% CI, 0.75-0.87; P < .001). Similar survival benefits were observed among patients with mild (HR, 0.83; 95% CI, 0.77-0.90; P < .001), moderate (HR, 0.82; 95% CI, 0.74-0.90; P < .001), and severe left ventricular impairment (HR, 0.82; 95% CI, 0.71-0.96; P = .01). A multivariable Cox proportional hazards regression interaction-term analysis indicated no significant differences in the multiarterial survival benefit by ejection fraction stratification (P = .75). Multiarterial grafting with exclusively arterial conduits was associated with enhanced survival benefits compared with other multiarterial procedures with saphenous vein grafts, except when the left ventricular ejection fraction was below 30% (HR, 0.87; 95% CI, 0.67-1.13; P = .30).
Conclusions And Relevance:
In this retrospective cohort study using data from a binational database, multiarterial procedures were associated with reduced long-term mortality risk compared with single arterial grafting across the spectrum of preoperative left ventricular ejection fractions. Total arterial revascularization was associated with incrementally improved survival, particularly among patients with preserved ejection fraction. Because most coronary surgery practice continues to use single arterial grafting, consideration to alter grafting strategy to multiarterial procedures may be indicated.
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