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Spectrum of surgical risk for left main coronary stenoses: benchmark for potentially competing percutaneous therapies
Insights
Coronary artery bypass grafting offers survival benefits for left main trunk stenoses. Surgical outcomes are predictable, with most patients having low mortality risk, establishing a benchmark for new therapies.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Coronary artery bypass grafting (CABG) is the standard treatment for left main trunk coronary stenoses due to survival advantages.
- Percutaneous interventions, including stenting and atherectomy, are being explored as alternatives.
- A need exists to establish benchmarks for surgical outcomes in this patient population.
Purpose of the Study:
- To analyze surgical outcomes for patients with left main trunk coronary stenoses.
- To identify predictors of in-hospital and 3-year mortality.
- To develop predictive models for patient outcomes.
Main Methods:
- Retrospective analysis of 1585 patients undergoing CABG for left main trunk stenoses (January 1990 - December 1995).
- Evaluation of 14 potential covariates for in-hospital and 3-year mortality.
- Construction and validation of predictive models for patient risk stratification.
Main Results:
- In-hospital mortality was 2.3%, independently predicted by renal dysfunction, age, and severe heart failure (NYHA Class III-IV).
- A predictive model identified that only 9% of patients were at highest risk (>5% mortality).
- Three-year mortality in a subgroup (n=285) was 15.6%, predicted by age, renal dysfunction, and chronic pulmonary disease, with distinct risk groups identified.
Conclusions:
- Coronary artery bypass grafting provides a benchmark for clinical outcomes in left main trunk coronary stenoses.
- Predictive models can stratify patients into risk groups, aiding in treatment decisions.
- These findings are crucial for comparing surgical outcomes with emerging percutaneous interventions.
Abstract:
Coronary artery bypass grafting is the preferred therapy for left main trunk coronary stenoses because of a demonstrated survival advantage compared with medical therapy. Recently, however, advocates of percutaneous intervention have suggested that stenting or atherectomy may provide acceptable results for these patients. To determine the spectrum of surgical outcome among patients with left main trunk coronary stenoses, we analyzed 14 potential covariates of in-hospital and 3-year mortality for a consecutive series of patients without prior coronary artery bypass grafting treated at our institution from January 1990 to December 1995. In-hospital mortality (2.3%) for 1585 consecutively treated patients correlated independently with renal dysfunction, age, and class III to IV heart failure. A model was constructed that allowed prediction of outcome (c-statistic = 0.77, p < 0.0001), and only the 9% of patients at highest risk were found to be at risk for death >5%. Mortality at 3 years (15.6%+/-2.2%) in a previously specified subgroup (n = 285) correlated independently with baseline age, renal dysfunction, and chronic pulmonary disease. A model was constructed that allowed prediction of outcome for the validation sample (four risk groups with 3-year mortality rates of 4.5%+/-2.5%, 6.5%+/-2.8%, 20.0%+/-4.2%, and 39.8%+/-8.5%; p < 0.0001. These data provide a contemporary benchmark of clinical outcome against which possible competing therapies may be compared.