Contemporary Coronary Artery Bypass Grafting Research Articles

Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multi-vessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multi-centred, retrospective observational study from a large, hospital system in the United States. We abstracted data on patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG or medically managed (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality (ACM) and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and sex. There were 295 CABG patients [median age 66 (IQR 59.7, 73.1); 73% male], 1,559 PCI patients [median age 68.3 (IQR 60, 76.6); 69.1% male], and 307 MM patients [median age 70 (60.9, 77.1) 74% male]. Patients revascularized with PCI had higher ACM at 1 year [14.1% vs. 5.1%; HR 2.4, CI (1.5, 3.8), p<0.001] and similar mortality to MM (13.4%). CABG also demonstrated reduced 1 year MI rate compared to PCI (1.7% vs 3.9%; HR 0.36, CI 0.21, 0.61, p=<0.001), with similar 1 year rate of MI to MM (3.9%). In conclusion, CABG, compared to PCI and MM, is associated with lower mortality, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

Contemporary Coronary Artery Bypass Grafting vs Multivessel Percutaneous Coronary Intervention

BackgroundInterpretation of recent alterations to the guideline priority of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel disease contests historical data and practice. To reevaluate contemporary outcomes, a large contemporary analysis was conducted comparing CABG with multivessel PCI among Medicare beneficiaries. MethodsThe United States Centers for Medicare and Medicaid Services database was evaluated all beneficiaries with acute coronary syndrome undergoing isolated CABG or multivessel PCI (2018-2020). Risk adjustment was performed using multilevel regression analysis, Cox proportional hazards time to event models, and inverse probability of treatment weighting propensity scores. ResultsA total of 104,127 beneficiaries were identified undergoing CABG (n = 51,389) or multivessel PCI (n = 52,738). Before risk adjustment, compared with PCI, CABG patients were associated with younger age (72.9 vs 75.2 years, P < .001), higher Elixhauser Comorbidity Index (5.0 vs 4.2, P < .001), more diabetes (48.5% vs 42.2%, P < .001), higher cost ($54,154 vs $33,484, P < .001), and longer length of stay (11.9 vs 5.8 days, P < .001). After inverse probability of treatment weighting propensity score adjustment, compared with PCI, CABG was associated with lower hospital mortality (odds ratio, 0.74; P < .001), fewer hospital readmissions at 3 years (odds ratio, 0.85; P < .001), fewer coronary reinterventions (hazard ratio, 0.37; P < .001), and improved 3-year survival (hazard ratio, 0.51; P < .001). ConclusionsContemporary real-world data from Medicare patients with multivessel disease reveal that CABG outcomes were superior to PCI, providing important longitudinal data to guide patient care and policy development.

Individual Versus Sequential Saphenous Vein Grafts for on-Pump Coronary Artery Bypass Grafting - Does Smaller Coronaries in Indians Affect Graft Choice? - A Mid-Term Patency Comparison Study.

PurposeAlthough multiarterial grafting or bilateral mammary artery use is being increasingly emphasized for contemporary coronary artery bypass grafting (CABG) practice, saphenous vein graft (SVG) still accounts for 80% of all CABG conduits (Park et al., 2020) [1]. In India, both the individual and sequential saphenous grafting techniques are used arbitrarily, and there has not been a study that compares the mid-term patency of these two. This is specially relevant in view of smaller coronaries in Indians than the Caucasian counterparts. This study aims to compare the patency for on pump CABG’s.MethodsIn the present study, 323 patients underwent either sequential (group A, N = 151 grafts, each graft having two anastomoses each) or individual (group B, N = 344 grafts) saphenous vein CABG, between February 2014 and June 2017. The SVG anastomoses were created on obtuse marginal (OM1/OM2) and posterior descending artery (PDA). The graft patency of the vein grafts as well as the left internal mammary artery were assessed by serial coronary angiograms.ResultsResults were evaluated at 6 months, 1, 2 and 3 years post operatively. Group A showed a higher graft patency at 3 years at 80.8%, and group B, 67.1% (P = 0.002). Also, anastomoses on sequential conduits had overall better patency rates at three years (77.2% vs 67.2%, P = 0.005). The groups showed similar results at one year post operatively.ConclusionsSequential bypass grafts were associated with superior mid-term patency compared with individual grafts. These findings suggest the more favourable results of sequential bypass grafting to be attributed to the enhanced flow haemodynamics.

Generalizability of Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial in patients with a history of coronary artery bypass graft surgery.

Following coronary artery bypass grafting (CABG), there remains persistent risk of ischemic events despite secondary prevention strategies, including low-density lipoprotein cholesterol lowering. Although REDUCE-IT recently demonstrated the benefits of icosapent ethyl (IPE) on reducing ischemic events in a broad population of primary and secondary prevention patients, its generalizability to a contemporary CABG population is not known. This article aims to ascertain the proportion of patients with a history of CABG that would be eligible for IPE treatment. A review of recent literature highlights the presence of residual ischemic following CABG. Using the Québec Heart Database, a repository of contemporary Canadian cardiac patient information, was searched between 1 January 2006 and 31 December 2016, to ascertain generalizability of IPE. In a large (N = 12 641), contemporary, Canadian cohort of patients with a history of CABG and currently on statin therapy, 21.9, 33.6 and 26.4% would be eligible for IPE, according to REDUCE-IT, Health Canada, and Food and Drug Administration criteria, respectively. These analyses would support IPE as an adjunct to secondary prevention therapies post-CABG.

Sequential Versus Individual Saphenous Vein Grafting During Coronary Arterial Bypass Surgery

Although multiarterial grafting or bilateral mammary artery use is being increasingly emphasized for contemporary coronary artery bypass grafting (CABG) practice, saphenous vein graft (SVG) is still the most frequently used CABG conduit, and it accounts for 80% of all CABG conduits. Research focusing on modifiable surgical factors such as anastomosis technique, however, is scarce. This study aimed to compare clinical outcomes and graft patency according to anastomosis methods of vein grafting. From January 2005 through December 2016, patients who underwent CABG using SVG either by a sequential or an individual grafting technique were enrolled in this study. Graft patency was evaluated with coronary computed tomographic angiography. Propensity-score matching was used to compare the clinical outcomes and graft patency of these 2 grafting techniques to reduce treatment selection bias. Overall 2515 eligible patients, 1,037 in the sequential SVG graft group (41.3%) and 1478 (58.8%) in the individual SVG graft group were enrolled. After propensity-score matching, 901 matched pairs of patients and 891 matched pairs of grafts were included in the final outcome analysis. There were no significant differences in unadjusted (P= .83) and adjusted overall mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.79 to 1.17; P= .67). The composite outcome of death, nonfatal myocardial infarction, and repeat revascularization also did not significantly differ between the sequential SVG and the individual SVG groups for both before (P= .20) and after matching (HR, 0.91; 95% CI, 0.75 to 1.09; P= .30). The sequential grafts showed superior patency as compared with the individual grafts for both before (P= .015) and after adjustment (HR, 0.61; 95% CI, 0.45 to 0.82; P < .001). The sequential grafting technique of SVG showed fairly acceptable safety and efficacy with superior long-term graft patency than individual grafts.Sequential SVG grafts perhaps can be a reasonable option as a second graft in CABG in some clinical situations.

Contemporary coronary artery bypass grafting.

Current evidence clearly demonstrates that coronary artery bypass grafting (CABG) remains the "gold standard" treatment for most patients with multivessel and left main stem disease. This article summarizes the relevant evidence basis demonstrating that CABG, in comparison to stenting, reduces mortality and subsequent myocardial infarction and the need for repeat revascularization. The article also describes the evidence basis to support the use of more arterial grafts during CABG and the current role of off-pump CABG.

Bilateral internal thoracic artery use: will another retrospective study ever strengthen the prospect?

Since the introduction of coronary artery bypass grafting (CABG) 50 years ago [1], the conduit choice to bypass coronary artery stenosis continues to be a debate [2]. Already in the early years, CABG was performed using internal thoracic arteries (ITAs). However, it took several decades before evidence supported the use of ITAs, when Loop et al. showed that the left ITA (LITA) to the left anterior descending (LAD) artery prolonged long-term survival when compared with a saphenous vein graft [3]. Several research groups went even further by claiming that bilateral ITA (BITA) grafting was superior to the use of a single ITA (SITA). Although these initial studies were merely retrospective, the use of the LITA to the LAD became widely accepted with >90% of patients receiving this construction in contemporary CABG practice [4]. The fate of BITA grafting has been less fortunate. Over the past 25 years, a staggering number of retrospective and prospective observational studies have published long-term results of BITA versus SITA use. The majority of studies concluded that BITA grafting either reduced mortality or showed to have comparable results with SITA grafting. In a recent meta-analysis that exclusively included studies with long-term follow-up of at least a mean of 9 years (n = 9 studies comprising 15 583 patients with nearly 200 000 patient-years of follow-up), BITA versus SITA grafting significantly reduced mortality with a hazard ratio of 0.79, 95% confidence interval (CI) 0.75–0.84 [5]. Despite these encouraging results, BITA use remains remarkably low. Among patients who underwent CABG in the SYNTAX trial and registry, BITA grafting was performed in 10% in the USA and 25% in Europe [6]. Another ‘real-world’ analysis of 541 368 patients receiving CABG in the USA showed that the rate of BITA use increased over consecutive years but remained low during the entire study period: 3.6% in 2002 to 4.5% in 2005 [7]. The reason for the disappointing adoption of BITA use is multifactorial. The choice to use both ITA conduits depends strongly on the motivation of the surgeon. Surgeons in favour of BITA grafting cite evidence of observational studies that reported improved long-term survival, while those surgeons not particularly in favour of BITA grafting refer to the fact that there is currently no randomized clinical trial with long enough follow-up to confirm that BITA is indeed better than SITA. Moreover, surgeons may be reticent to using both ITA grafts because of the higher complexity of the procedure and the increased risk of sternal wound complications found particularly in diabetic, obese women. Besides patient characteristics like diabetes, body mass index and gender, age is a decisive factor [7], as the benefit of BITA over SITA only occurs after prolonged follow-up. A life expectancy of at least 10 years appears to be needed to show significant benefit of BITA use. In this regard, the current issue of the European Journal of CardioThoracic Surgery includes a retrospective study from Pettinari et al. in which they performed a propensity-matched analysis comparing BITA with SITA in elderly patients >70 years of age, to assess whether the benefit of BITA grafting can be extended to elderly patients [8]. The authors showed that patients who underwent BITA grafting, when compared with patients who received only a SITA, were younger, and less often had peripheral vascular disease, diabetes, chronic obstructive pulmonary disease or a recent myocardial infarction, all factors known to be associated with impaired survival during follow-up. The authors therefore were correct in performing a propensity-matched analysis after which no differences in the BITA and SITA groups existed. In terms of outcomes, BITA grafting showed to have superior survival after 3 months, 1 year and 10 years in the unmatched groups. After matching and as anticipated due to the differences in baseline characteristics, the difference between BITA and SITA was smaller, with BITA grafting only being superior after 10 years of follow-up (multivariate hazard ratio of 0.78, 95% CI 0.64–0.96; P = 0.04) [8]. The authors have to be congratulated for achieving such good results with BITA grafting. However, several significant limitations of the current study should be acknowledged, putting these results in the correct perspective. Of the 1328 and 2168 patients who underwent BITA and SITA grafting, respectively, only 892 propensity-matched pairs could be achieved. The fact that two-thirds of patients could not be matched indicates that these groups were significantly different. Although there were no longer any significant differences between the groups after matching, the authors were unable to match patients on the refinement of the surgical technique; the inclusion was during 1972–2006, with BITA being performed in the later decades, during which the CABG procedure changed considerably with improved outcomes. Furthermore, clinical variables as well as clinical judgement, which

Predictors of contemporary coronary artery bypass grafting outcomes

The study objective was to identify the predictors of outcomes in a contemporary cohort of patients from the Reduction in cardiovascular Events by acaDesine in patients undergoing CABG (RED-CABG) trial. Despite the increasing risk profile of patients who undergo coronary artery bypass grafting, morbidity and mortality have remained low, and identification of the current predictors of adverse outcomes may permit new treatments to further improve outcomes. The RED-CABG trial was a multicenter, randomized, double-blind, placebo-controlled study that determined that acadesine did not reduce adverse events in moderately high-risk patients undergoing nonemergency coronary artery bypass grafting. The primary efficacy end point was a composite of all-cause death, nonfatal stroke, or the need for mechanical support for severe left ventricular dysfunction through postoperative day 28. Logistic regression modeling with stepwise variable selection identified which prespecified baseline characteristics were associated with the primary outcome. A second logistic model included intraoperative variables as potential covariates. The 4 independent preoperative risk factors predictive of the composite end point were (1) a history of heart failure (odds ratio, 2.9); (2) increasing age (odds ratio, 1.033 per decade); (3) a history of peripheral vascular disease (odds ratio, 1.6); and (4) receiving aspirin before coronary artery bypass grafting (odds ratio, 0.5), which was protective. The duration of the cardiopulmonary bypass (odds ratio, 1.8) was the only intraoperative variable that contributed to adverse outcomes. Patients who had heart failure and preserved systolic function had a similar high risk of adverse outcomes as those with low ejection fractions, and new approaches may mitigate this risk. Recognition of patients with excessive atherosclerotic burden may permit perioperative interventions to improve their outcomes. The contemporary risks of coronary artery bypass grafting have changed, and their identification may permit new methods to improve outcomes.

Differences in baseline characteristics, practice patterns and clinical outcomes in contemporary coronary artery bypass grafting in the United States and Europe: insights from the SYNTAX randomized trial and registry.

To investigate the until now undefined extent of differences in baseline characteristics, practice patterns and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG) for complex coronary artery disease in the USA versus Europe. The impact of geographic enrollment on clinical outcomes was explored using the as-treated population of 1510 patients with de novo left main and/or three-vessel disease who underwent CABG in either the SYNTAX randomized trial or registries, and who were followed up for 5 years. There were 259 (17%) patients enrolled in the USA. Patients in the USA had more comorbidities. Off-pump procedures were more frequent in the USA (32 vs 13% in Europe; P < 0.001), and crystalloid cardioplegia was used less often (17 vs 38% in Europe; P < 0.001). In the USA, more grafts per patient were used (3.1 ± 0.8 vs 2.7 ± 0.7 in Europe; P < 0.001), with less complete arterial grafting (5 vs 18% in Europe; P < 0.001) but more complete revascularization (80 vs 66% in Europe; P < 0.001). At 5-year follow-up, patients treated in the USA versus Europe had comparable rates of major adverse cardiac and cerebrovascular events (MACCEs: 28.7 vs 24.3%, respectively; P = 0.11) and the composite safety endpoint of death, stroke and myocardial infarction (MI; 15.3 vs 17.5%, respectively; P = 0.43), but a significantly higher rate of repeat revascularization (15.0 vs 9.8%, respectively; P = 0.011) driven by repeat percutaneous coronary intervention (14.6 vs 9.2%; P = 0.005) and not repeat CABG (0.4 vs 0.8%; P = 0.48). Rates of graft occlusion were significantly higher in the USA versus Europe (8.7 vs 3.2%; P < 0.001). In multivariate analysis, enrollment in the USA was a non-significant predictor of MACCE [hazard ratio (HR) = 1.31, 95% confidence interval (95% CI) 1.00-1.73; P = 0.053], but independently predicted repeat revascularization (HR = 1.66, 95% CI 1.12-2.46; P = 0.011) and graft occlusion (HR = 2.65, 95% CI 1.52-4.62; P = 0.001). It was also a non-significant predictor of reduced rates of MI (HR = 0.38, 95% CI 0.14-1.06; P = 0.064). Differences between the USA and Europe were most pronounced among patients who underwent off-pump CABG. Repeat revascularization rates following CABG in the USA versus Europe were increased at 5 years, particularly in off-pump patients. There was no significant difference in the rate of death, stroke and MI.

Cardioplegia in contemporary coronary artery bypass grafting: Effects on high-sensitivity troponins and outcomes

Cardioplegia in contemporary coronary artery bypass grafting: Effects on high-sensitivity troponins and outcomes

O047 Comparing Contemporary Coronary Artery Bypass Grafting Across Six Main Ethnic Groups of New Zealand: Another Example of Inequalities In Cardiovascular Disease

O047 Comparing Contemporary Coronary Artery Bypass Grafting Across Six Main Ethnic Groups of New Zealand: Another Example of Inequalities In Cardiovascular Disease

The Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease (FREEDOM) trial: Clinical and angiographic profile at study entry

The optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD) remains uncertain for lack of an adequately powered, randomized trial. The FREEDOM trial was designed to compare contemporary coronary artery bypass grafting (CABG) to percutaneous coronary intervention (PCI) with drug-eluting stents in diabetic patients with MVD against a background of optimal medical therapy. A total of 1,900 diabetic participants with MVD were randomized to PCI or CABG worldwide from April 2005 to March 2010. FREEDOM is a superiority trial with a mean follow-up of 4.37 years (minimum 2 years) and 80% power to detect a 27.0% relative reduction. We present the baseline characteristics of patients screened and randomized, and provide a comparison with other MVD trials involving diabetic patients. The randomized cohort was 63.1 ± 9.1 years old and 29% female, with a median diabetes duration of 10.2 ± 8.9 years. Most (83%) had 3-vessel disease and on average took 5.5 ± 1.7 vascular medications, with 32% on insulin therapy. Nearly all had hypertension and/or dyslipidemia, and 26% had a prior myocardial infarction. Mean hemoglobin A1c was 7.8 ± 1.7 mg/dL, 29% had low-density lipoprotein <70 mg/dL, and mean systolic blood pressure was 134 ± 20 mm Hg. The mean SYNTAX score was 26.2 with a symmetric distribution. FREEDOM trial participants have baseline characteristics similar to those of contemporary multivessel and diabetes trial cohorts. The FREEDOM trial has successfully recruited a high-risk diabetic MVD cohort. Follow-up efforts include aggressive monitoring to optimize background risk factor control. FREEDOM will contribute significantly to the PCI versus CABG debate in diabetic patients with MVD.

Seizures After Adult Cardiac Surgery

Seizures After Adult Cardiac Surgery

Excellent Results of Contemporary Coronary Artery Bypass Grafting with Systematic Application of Modern Perioperative Strategies

The patient population referred for coronary artery bypass grafting (CABG) has become more challenging. The surgical population is aging and patients present with significant preoperative comorbidities. This worsening risk profile has led to the development of operative techniques (off-pump CABG) and perioperative measures (epi-aortic scanning, intensive insulin therapy) to preserve the quality of care following CABG. The aim of this study was to determine the outcome of contemporary CABG following the implementation of the above measures in our practice. We retrospectively analyzed prospectively collected data of 2725 patients undergoing CABG between 01/1998 and 12/2005 (mean age, 65 +/- 11 years; 843 [31%] female; mean ejection fraction, 45% +/- 14%). Outcome measures included hospital mortality, postoperative complications, and long-term survival and independent predictors of outcome. Subgroup analyses were performed for 2 study periods (1998-2002 versus 2003-2005) where the above measures were implemented and for patients undergoing conventional versus off-pump CABG. When comparing the 2 study periods, we observed a substantial worsening of the risk profile with an increased EuroSCORE predicted mortality from 6.4% +/- 6.8% to 7.0% +/- 7.8% (P = .028). During the same period, operative mortality decreased from 2.4% to 0.7% (P < .001). This reduction in mortality was also observed in diabetic patients (3.1% versus 1.0%, P = .021) and those with low ejection fraction (4% versus 2.6%, P = not significant). Off-pump procedures were performed with an increasing frequency in high-risk patients in whom we obtained excellent results. Finally, we observed a reduction of postoperative complications including respiratory failure (P = .013), gastrointestinal complications (P = .017), and stroke (P = .094). Independent predictors of mortality included renal failure (OR = 5.7), peripheral vascular disease (OR = 2.9), intra-aortic balloon pump (OR = 4.8), reoperation (OR = 3.3), and hypertension (OR = 2.3). Despite a worsening case mix, contemporary CABG can be performed with excellent results (operative mortality < 1%). Off-pump CABG performed in very high-risk patients obtains results similar to those of the general CABG population. Diabetes and ejection fraction were not independent predictors of early outcome. In our experience, these excellent outcomes were achieved by adopting an operative approach using modern perioperative management (epi-aortic scanning, intensive insulin therapy) and surgical techniques (off-pump CABG) based on individual patients.

Diabetes is not a risk factor for hospital mortality following contemporary coronary artery bypass grafting

The outcome of coronary artery bypass grafting (CABG) in diabetic patients has traditionally been worse than in non-diabetic patients. Recent studies have suggested an improvement in outcome in diabetic patients undergoing contemporary CABG. However, the direct impact of diabetes on mortality and morbidities following CABG remains unclear. We retrospectively analyzed prospectively collected data of 2725 CABG patients from January 1998 to December 2005: one thousand and eighty-five (40%) diabetics and 1640 (60%) non-diabetics [mean age 65+/-11 years, 1882 (69%) male]. Subgroup analysis was performed for two study periods (1998-2002 vs. 2003-2005). The overall hospital mortality was 1.8% [n=50; diabetics: 2.4%, non-diabetics: 1.5% (P=0.07)]. The mortality rate among diabetics decreased from 3.1% in 1998-2002 to 1.0% in 2003-2005 (P=0.021). Diabetes was not an independent predictor of hospital mortality but predicted the occurrence of deep sternal wound infection (OR=3.77). Diabetes significantly decreased long-term survival [1-year and 5-year survival 94.7+/-0.7% and 81.9+/-1.4% for diabetic vs. 95.4+/-0.5% and 85.9+/-1.0% for non-diabetic patients (P=0.01)]. Excellent results following contemporary CABG can be expected in diabetics with a similar mortality compared to non-diabetics. Therefore, our data suggest that diabetes may, in fact, not be a risk factor for adverse outcome following CABG. However, long-term survival in diabetics remains significantly inferior compared to non-diabetics.

Projected long-term costs of coronary stenting in multivessel coronary disease based on the experience of the Bypass Angioplasty Revascularization Investigation (BARI)

Background Stents are now used in the majority of percutaneous coronary revascularization procedures. It is not clear whether the higher initial cost of stenting is later repaid by reducing costly complications and repeat revascularization procedures, especially for patients with multivessel disease. Methods To project the long-term costs of using coronary stents, angioplasty, or bypass surgery to treat patients with multivessel coronary artery disease, we developed a decision model based on the outcomes documented in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial of coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). We studied 2 clinical strategies: provisional stenting of suboptimal PTCA results and primary stenting of all angiographically eligible lesions. The cost of CABG was also updated to reflect contemporary practice. Results Provisional stenting had lower projected costs over a 4-year period than either traditional PTCA (–$1742, or –3.4%) or contemporary CABG (–$832, or –1.7%), mostly because of reductions in emergency CABG after PTCA. In contrast, primary stenting had higher projected costs over a 4-year period than either PTCA (+$333, or +0.7%) or contemporary CABG (+$1243, or +2.5%), mainly because of the higher initial procedure costs. These results were not substantially altered when we systematically varied the key parameters of the models in 1-way and 2-way sensitivity analyses. Conclusions A primary stenting strategy in patients with multivessel disease has higher projected long-term costs than CABG. In contrast, a provisional stenting strategy in multivessel disease has lower projected costs than either PTCA or CABG. (Am Heart J 2000;140:556-64.)