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Coronary artery bypass grafting with or without preoperative physiological stenosis assessment: a SWEDEHEART study
Emma C Hansson1,2, Elmir Omerovic2,3, Dimitrios Venetsanos4
1Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Blå Stråket 5, plan 5, Gothenburg S-413 45, Sweden.
Insights
Preoperative physiological flow assessment in coronary artery bypass grafting (CABG) did not improve outcomes but increased later revascularization risk. Current flow assessment cut-offs may not suit CABG patients, requiring further research.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Medical Diagnostics
Background:
- Physiological flow assessment, like fractional flow reserve, is standard for percutaneous coronary intervention but less established for coronary artery bypass grafting (CABG).
- This study investigates the mid-term impact of preoperative flow assessment on outcomes in isolated first-time CABG patients.
Purpose of the Study:
- To compare mid-term clinical outcomes in CABG patients who underwent preoperative flow assessment versus those who did not.
- To evaluate the association between preoperative flow assessment and risks of mortality, stroke, myocardial infarction, and revascularization after CABG.
Main Methods:
- A nationwide cohort of 18,211 first-time isolated CABG patients in Sweden (2013-2020) from the SWEDEHEART registry was analyzed.
- Data linkage with national registries provided information on flow assessment and clinical outcomes, with a median follow-up of 3.6 years.
- Adjusted Cox regression models compared outcomes, with follow-up stratified into 0-2 and >2 years due to violated proportional hazard assumptions for revascularization events.
Main Results:
- 15.8% of patients had preoperative flow assessment, with usage increasing from 2013 to 2020.
- No significant association was found between flow assessment and mortality, post-discharge myocardial infarction, or stroke.
- While not increasing early risks (0-2 years), preoperative flow assessment was linked to higher rates of new angiography and revascularization beyond 2 years post-CABG.
Conclusions:
- Preoperative flow assessment in CABG patients did not demonstrate improved clinical outcomes at mid-term follow-up.
- A higher risk of late ( >2 years) repeat angiography and revascularization was observed in patients with preoperative flow assessment.
- Current criteria for flow assessment may not be optimal for guiding CABG, necessitating further investigation and refinement.
Background And Aims:
Physiological flow assessment of coronary stenoses, such as fractional flow reserve, are routinely used to guide percutaneous coronary intervention, but it has not been equally recognized to guide coronary artery bypass grafting (CABG). Mid-term outcomes in CABG patients with and without preoperative flow assessment were compared.
Methods:
All patients with first-time isolated CABG in Sweden 2013-2020 were identified in the SWEDEHEART registry (n = 18 211), which also provided information on flow assessment. Data were linked with three mandatory national registries. Median follow-up was 3.6 years (range 0-7.5). Incidence of all-cause mortality, stroke, new myocardial infarction, new coronary angiography, and new revascularization was compared using adjusted Cox regression models. The proportional hazard assumption was violated for new angiography and revascularization. Hence, follow-up was divided into 0-2 and >2 years.
Results:
Overall, 2869 patients (15.8%) had flow assessment before surgery, increasing from 7.1% in 2013% to 21.5% in 2020. Patients with flow assessment were younger, had a lower EuroSCORE II, and received fewer distal anastomoses (3.0 ± 0.9 vs 3.2 ± 1, P < .001). There were no associations between flow assessment and mortality, post-discharge myocardial infarction, or stroke. New angiography and new revascularization were not significantly different 0-2 years, but preoperative flow assessment was associated with a higher risk for new angiography [adjusted hazard ratio (aHR) 1.32, 95% confidence interval (CI) 1.08-1.62, P = .008] and new revascularization (aHR 1.55, 95% CI 1.18-2.04, P = .002) >2 years after CABG.
Conclusions:
Preoperative flow assessment was not associated with improved clinical outcomes but with a higher risk for new angiography and new revascularization >2 years after CABG. The results suggest that the use of flow assessment with current cut-off levels may not be applicable in CABG, and further studies are needed.
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