Multivessel Revascularization Research Articles

TCT-221 Treatment Recommendations Based on SYNTAX Score II and Observed 3-year Mortality in the EXCEL Trial

The SYNTAX Score II (SSII) risk score was developed from the SYNTAX trial to predict 4-year mortality after left main (LM) or multivessel disease revascularization. SSII combines anatomic lesion data and selected clinical characteristics (age, sex, COPD, peripheral artery disease, LVEF, creatinine

Bilateral Internal Thoracic Artery Grafts in Hemodialysis: A Single-Center Propensity Score Analysis

Clinical evidence comparing the surgical risk and long-term effectiveness of the bilateral internal thoracic artery (BITA) and single internal thoracic artery (SITA) for coronary artery bypass grafting (CABG) in hemodialysis patients is limited. We sought to clarify the short-term and midterm outcomes of CABG using BITA or SITA grafts in hemodialysis patients. Between October 2000 and December 2015, 161 hemodialysis patients underwent isolated CABG by internal thoracic artery grafting; 67 received BITA grafts and 94 SITA grafts. Propensity score matching was used to compare 59 BITA and SITA patient pairs. BITA and SITA grafts resulted in comparable 30-day mortality (1.7% vs 0%, p= 1.00), incidence of deep sternal wound infection (5.1% vs 1.7%, p= 0.62), stroke (3.4% vs 3.4%, p= 1.00), and respiratory failure (8.5% vs 11.9%, p= 0.75). The Kaplan-Meier model showed the survival rate in the BITA and SITA groups was 83.4% ± 5.1% vs 87.0% ± 4.6% at 1 year, 69.1% ± 7.3% vs 68.5% ± 6.9% at 3 years, and 47.4% ± 10.45% vs 58.2% ±8.1% at 5 years of follow-up, respectively. There were no statistical differences in survival (p= 0.81), freedom from cardiac death (p= 0.51), or freedom from cardiac events (p= 0.85). CABG using BITA grafts showed no advantages in midterm outcome among hemodialysis patients; however, there were no adverse effects on perioperative morbidity or death. For hemodialysis patients with limited available conduits, BITA may be an important option for multivessel revascularization.

IMPACT OF TOTAL ARTERIAL REVASCULARIZATION ON LONG-TERM SURVIVAL: A SYSTEMATIC REVIEW AND META-ANALYSIS OF 130,305 PATIENTS

This meta-analysis compares total arterial revascularization (TAR) versus conventional coronary artery bypass and additionally to two arterial grafts. We searched MEDLINE and EMBASE Databases from 1996-to-2016 for studies comparing TAR versus non-TAR for multi-vessel surgical revascularization. Data were extracted by 2 independent investigators. Meta-analysis used random effects, which incorporates heterogeneity. There were 4 smaller shorter follow-up randomized controlled trials (RCTs), plus 15 matched/adjusted and 6 unmatched/unadjusted larger longer follow-up observational studies that met inclusion criteria (N = 130,305 patients; mean follow-up range: 1–15 years). There were no differences in perioperative stroke, myocardial infarction or mortality. However, TAR was associated with lower long term all-cause mortality in observational studies matched/adjusted for confounders (incident rate ratio 0.85, 95% CI: 0.81–0.89, p b 0.0001; I2 = 0%) and unmatched/unadjusted (incident rate ratio 0.67, 95% CI: 0.59–0.76, p b 0.0001; I2 = 67%) for TAR. Decreases in major cardiovascular outcomes and revascularization did not achieve statistical significance. There were greater sternal complications with TAR in the matched/adjusted studies (pooled risk ratio 1.21, 95% CI: 1.03–1.42, p = 0.02; I2 = 0%). When compared to patients with two arterial grafts, TAR was still associated with reduced long-term all-cause mortality (incident rate ratio 0.85, 95% CI: 0.73–0.99, p = 0.04) with minimal heterogeneity (I2 = 5%). Data from primarily observational studies suggest that TAR may improve long-term survival compared with conventional coronary bypass by 15–20% even when compared with two arterial grafts. Prospective randomized trials of TAR with long-term follow-up are needed.

PCI Versus CABG in Patients With Type 1 Diabetes and Multivessel Disease

BackgroundIt is unknown if coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) may offer a survival benefit in patients with type 1 diabetes (T1D) in need of multivessel revascularization. ObjectivesThis study sought to determine if patients with T1D and multivessel disease may benefit from CABG compared with PCI. MethodsIn an observational cohort study, the authors included all patients with T1D who underwent a first multivessel revascularization in Sweden from 1995 to 2013. The authors used the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register, the Swedish National Diabetes Register, and the Swedish National Patient Register to retrieve information about patient characteristics and outcomes. They estimated hazard ratios (HRs) adjusted for confounders with 95% confidence intervals (CIs) for all-cause and coronary heart disease mortality, myocardial infarction, repeat revascularization, stroke, and heart failure using inverse probability of treatment weighting based on propensity scores. ResultsIn total, 683 patients who underwent CABG and 1,863 patients who underwent PCI were included. During a mean follow-up of 10.6 years, 53% of patients in the CABG group and 45% in the PCI group died. PCI, compared with CABG, was associated with a similar risk of all-cause mortality (HR: 1.14; 95% CI: 0.99 to 1.32), but higher risks of death from coronary heart disease (HR: 1.45; 95% CI: 1.21 to 1.74), myocardial infarction (HR: 1.47; 95% CI: 1.23 to 1.78), and repeat revascularization (HR: 5.64; 95% CI: 4.67 to 6.82). No differences in risks of stroke or heart failure were found. ConclusionsNotwithstanding the inclusion of patients with T1D who might not have been able to undergo CABG in the PCI group we found that PCI, compared with CABG, was associated with higher rates and risks of coronary heart disease mortality, myocardial infarction, and repeat revascularizations. Our findings indicate that CABG may be the preferred strategy in patients with T1D in need of multivessel revascularization.

Revascularization Strategies in STEMI with Multivessel Disease: Deciding on Culprit Versus Complete-Ad Hoc or Staged.

This review will address the clinical conundrum of those who may derive clinical benefit from complete revascularization of coronary stenosis that are discovered at the time of ST segment elevation myocardial infarction (STEMI). The decision to revascularize additional vessels with angiographic stenosis beyond the culprit lesion remains controversial, as does the timing of revascularization. STEMI patients represent a high-risk patient population that have up to a 50% prevalence of multivessel disease. Multivessel disease represents an important risk factor for short- and long-term morbidity and mortality. Potential benefits of multivessel PCI for STEMI might include reduced short- and long-term mortality, revascularization, reduced resource utilization, and costs. Which population will benefit and what the optimal timing of revascularization in the peri-MI period remains controversial. Consideration of multivessel revascularization in the setting of STEMI may occur in up to one half of STEMI patients. Evaluation of the comorbidities including diabetes, extent of myocardium at risk, lesion complexity, ventricular function, and risk factors for complications such as contrast induced nephropathy which is important in determining the appropriate care pathway.

A case of chronic mesenteric ischemia managed by ascending aorta to superior mesenteric and hepatic artery bypass

Chronic mesenteric ischemia is a rare and life-threatening condition which occurs due to occlusion of two or more mesenteric arteries following atherosclerosis. Multi-vessel revascularization forms the mainstay of treatment. This is a case of a middle-aged smoker who presented with abdominal angina and was diagnosed to have chronic mesenteric ischemia due to atherosclerotic occlusive aortic disease with coeliac artery and superior mesenteric artery occlusion. He was successfully managed with extra anatomic bypass from the ascending aorta to superior mesenteric and hepatic artery.

Left main or multivessel coronary revascularization: applying both anatomy and physiology to individualize care.

Left main or multivessel coronary revascularization: applying both anatomy and physiology to individualize care.

Coronary revascularization strategies in patients with multivessel disease: is it all about diabetes?

Coronary artery disease (CAD) is the worldwide leading cause of mortality, with increasingly prevalent manifestations due to population aging and growth (1). From an anatomic standpoint, CAD varies from atherosclerosis of a single major epicardial vessel to more advanced presentations with multiple vessels simultaneously involved. Numerous clinical trials have appraised the comparative efficacy and safety of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel CAD revascularization (2). In particular, SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) randomized patients with left main and/or three-vessel CAD (3), whereas BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) randomized patients with two- or three-vessel CAD (and was prematurely interrupted due to slow enrollment) (4). Both studies reported increased rates of combined ischemic events in multivessel CAD patients treated by PCI, driven by higher rates of repeat revascularization (3,4).

23 The influence of collateral regression post coronary chronic total occlusion (cto) percutaneous coronary intervention (pci) on donor vessel coronary pressure-derived measurements

Background There is strong evidence of FFR guided treatment in multi-vessel disease. The presence of a concomitant CTO may influence the FFR measurement in donor vessel as suggested in previous studies and reports. This has an important implication on clinical decision making for complete revascularisation in patients with chronic total occlusion. We sought to investigate the influence of collateral regression after successful CTO recanalisation on donor vessel pressure-derived indices. Methods The study participants were patients with angina who had RCA CTO. 28 out of 34 consecutive patients underwent successful PCI to RCA CTOs during the study period and completed the follow study (at 3 months post CTO PCI) were included in this analysis. Coronary pressure-derived indices (resting PD/PA, iFR and FFR) were measured pre and post successful RCA CTO PCI in donor vessels and at follow up procedures. Results The mean age was 62.38 years. The mean estimated CTO duration was 238.72 weeks and CTO length was 32.44 mm. 25 patients had ischaemia and or viability in the RCA territory assessed with cardiac MRI. LAD was the major donor vessel in 24 patients and LCX was the minor donor vessel in 4 patients. Percent stenosis on QCA in the major and minor donor vessel were 40.6% and 35.1% respectively. The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI and at follow-up procedures in major donor vessel were (0.893, 0.862, 0.764), (0.907, 0.886, 0.753) and (0.918, 0.901, 0.787) respectively. The mean resting Pd/Pa, iFR and FFR pre and post RCA CTO PCI and at follow-up procedures in minor donor vessel were (0.979, 0.966, 0.890), (0.983, 0.979, 0.880) and (0.981, 0.974, 0.898) respectively. The changes in coronary pressure-derived indices pre and post RCA CTO PCI and at follow up procedures are summarised in table 1. In major donor vessel, there was significant changes in the difference between follow up and pre-CTO PCI values for Pd/Pa, iFR and FFR values (p values 0.006, 0.003 and 0.047 respectively). There was also significant change in the difference between follow up and post-CTO PCI FFR value (P value 0.002). FFR collateral reduced significantly at follow-up (p value 0.000). Conclusion Successful recanalisation of a RCA CTO results in increase in major donor vessel coronary pressure-derived indices at follow up procedure associated with the regression of collateral function. In patients with multi-vessel disease, the expected change and the optimal timing to perform PCI in donor vessel should be considered when planning multi-vessel revascularisation in this setting.

Meta-Analysis of the Optimal Percutaneous Revascularization Strategy in Patients With Acute Myocardial Infarction, Cardiogenic Shock, and Multivessel Coronary Artery Disease

The optimal percutaneous coronary intervention (PCI) revascularization strategy in patients with multivessel (MV) coronary artery disease (CAD) who present with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has not been systematically addressed. Accordingly, we performed a study-level meta-analysis comparing 2 PCI strategies in these patients-infarct-related artery (IRA) only versus MV revascularization. Studies including patients with AMI and MV CAD complicated with CS who received primary PCI were searched from 2000 to 2016. The primary end points were in-hospital/30-day and mid- to long-term (≥6 month) mortality. Fixed and random effects models were used for analysis. Ten studies (9 prospective and 1 retrospective) involving 6,068 patients met our inclusion criteria. IRA-only PCI was the most frequently used revascularization strategy (4,872 patients, 80%), while MV PCI was performed in 1,196 patients (20%). The MV PCI strategy was associated with higher short-term mortality compared with the IRA-only PCI strategy (odds ratio 1.41, 95% confidence interval 1.15 to 1.71, p= 0.008). There was no difference in mid- to long-term mortality between MV PCI and IRA-only strategies (odds ratio 1.02, 95% confidence interval 0.65 to 1.58, p= 0.94). In conclusion, in patients with AMI and MV CAD complicated by CS, the IRA-only PCI strategy seems to be associated with lower short-term, but not mid- to long-term mortality compared with MVPCI. This finding is different from the revascularization strategy recommended by current professional guidelines and suggests the need for dedicated randomized clinical trials.

Impact of total arterial revascularization on long term survival: A systematic review and meta-analysis of 130,305 patients

ObjectivesThis meta-analysis compares total arterial revascularization (TAR) versus conventional coronary artery bypass and additionally to two arterial grafts. MethodsWe searched MEDLINE and EMBASE Databases from 1996-to-2016 for studies comparing TAR versus non-TAR for multi-vessel surgical revascularization. Data were extracted by 2 independent investigators. Meta-analysis used random effects, which incorporates heterogeneity. ResultsThere were 4 smaller shorter follow-up randomized controlled trials (RCTs), plus 15 matched/adjusted and 6 unmatched/unadjusted larger longer follow-up observational studies that met inclusion criteria (N=130.305 patients; mean follow-up range: 1–15years). There were no differences in perioperative stroke, myocardial infarction or mortality. However, TAR was associated with lower long term all-cause mortality in observational studies matched/adjusted for confounders (incident rate ratio 0.85, 95% CI: 0.81–0.89, p<0.0001; I2=0%) and unmatched/unadjusted (incident rate ratio 0.67, 95% CI: 0.59–0.76, p<0.0001; I2=67%) for TAR. Decreases in major cardiovascular outcomes and revascularization did not achieve statistical significance. There were greater sternal complications with TAR in the matched/adjusted studies (pooled risk ratio 1.21, 95% CI: 1.03–1.42, p=0.02; I2=0%). When compared to patients with two arterial grafts, TAR was still associated with reduced long-term all-cause mortality (incident rate ratio 0.85, 95% CI: 0.73–0.99, p=0.04) with minimal heterogeneity (I2=5%). ConclusionsData from primarily observational studies suggest that TAR may improve long-term survival compared with conventional coronary bypass by 15–20% even when compared with two arterial grafts. Prospective randomized trials of TAR with long term follow-up are needed.

Pathfinding to an optimal strategy of revascularization in primary coronary intervention in patients with multivessel disease: a network meta-analysis of randomized trials

Objectives: In ST-segment elevation myocardial infarction (STEMI), current guidelines discourage treatment of the non-culprit lesions at the time of the primary intervention. Latest trials have challenged this strategy suggesting benefit of early complete revascularization. We performed a Bayesian multiple treatment network meta-analysis of randomized clinical trials (RCTs) in STEMI on culprit-only intervention (CO) versus different timing multivessel revascularization, including immediate (IM), same hospitalization (SH) or later staged (ST).Methods: Outcome parameters were pooled with a random-effects model. For multiple-treatment meta-analysis, a Bayesian Markov chain Monte Carlo method was used.Results: Eight RCTs involving 2077 patients were identified. ST and IM revascularization was associated with a decrease in major adverse cardiac events (MACEs) compared to culprit-only approach (risk ratio [RR]: 0.43 credible interval [CrI]: 0.22–0.77 and RR: 0.36 CrI: 0.24–0.54, respectively). IM was superior to SH (RR: 0.49 CrI: 0.29–0.80). With regards to myocardial infarction IM was superior to SH (RR: 0.18 CrI: 0.02–0.99). The posterior probability of being the best choice of treatment regarding the frequency of MACEs was 71.2% for IM, 28.5% for ST, 0.3% for SH and 0.05% for culprit-only approach.Conclusions: Results from RCTs indicate that immediate or staged revascularization of non-culprit lesions reduces major adverse events in patients after primary percutaneous coronary intervention. Differences in MACEs suggest superiority of the immediate or staged intervention; however, further randomized trials are needed to determine the optimal timing of revascularization of the non-culprit lesions.

TCT-154 Multivessel Revascularization versus Culprit Vessel Only Revascularization in Patients with ST-Elevation Myocardial Infarction and multivessel disease: An Updated Meta-analaysis

Several observational studies and randomized clinical trials (RCTs) have demonstrated conflicting results on the benefit of multivessel percutaneous coronary intervention (MV-PCI) vs. culprit only vessel percutaneous coronary intervention (CV-PCI) in ST-elevation myocardial infarction (STEMI) and

GW27-e1109 The Prognosis of Multi-vessel Coronary Revascularization in Patients with or Without Diabetes Mellitus

GW27-e1109 The Prognosis of Multi-vessel Coronary Revascularization in Patients with or Without Diabetes Mellitus

Survival After Varying Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease

The authors conducted a systematic pairwise and network meta-analysis to assess optimal treatment strategies in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MV-CAD) undergoing primary percutaneous coronary intervention (PCI). Patients with STEMI and MV-CAD have a worse prognosis than those with single-vessel CAD. The optimal revascularization strategy for these patients is uncertain. Studies of revascularization strategies for MV-CAD in STEMI patients undergoing primary PCI published between 2001 and 2015 were identified using an electronic search. Pairwise and network meta-analyses were performed for 3 PCI strategies in prospective and retrospective studies: 1) infarct-related artery (IRA)-only PCI; 2) single procedure MV-PCI; and 3) staged MV-PCI. Information on study design, inclusion and exclusion criteria, and clinical outcomes was extracted. The outcomes of interest were short-term and long-term mortality. Thirty-two studies (13 prospective and 19 retrospective) with 54,148 patients (IRA-only PCI [n= 42,112], single procedure MV-PCI [n= 8,138], and staged MV-PCI [n= 3,898]) were included in the analysis. Pairwise meta-analyses showed that staged MV-PCI was associated with lower short-term and long-term mortality compared with both IRA-only PCI and single stage MV-PCI, whereas IRA-only PCI was associated with lower mortality compared with single stage MV-PCI. Staged MV-PCI was also associated consistently with improved survival in network analyses. The present systematic review and meta-analysis supports the hypothesis that in patients with MV-CAD presenting with STEMI undergoing primary PCI, a staged multivessel revascularization strategy may improve early and late survival.

Multivessel Revascularization Does Not Increase Contrast-Induced Acute Kidney Injury Incidence in Acute Myocardial Infarction: A Meta-Analysis.

Recent studies and meta-analysis have shown that complete revascularization (CR) compared with infarct-related artery revascularization (IRA) during percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) is associated with decreased mortality. However, it is unclear if CR versus IRA in STEMI during indexed hospitalization is associated with risk of contrast-induced acute kidney injury (CI-AKI). A database search was conducted for all randomized controlled trials that enrolled STEMI patients and compared CR versus IRA and reported CI-AKI. Comprehensive Meta-Analysis Version 2.0 (Wiley, Chichester) was used to determine summary effect size with a fixed-effect model and expressed as a risk ratio with 95% confidence intervals. A total of four trials were identified and had a mean follow-up of 24.5±9.9months, a total sample size of 1537, a mean age of 63.8±1.2 versus 64.2±2.1years, 31.2±5.3 versus 30.1±4.7% three-vessel disease, and 33.7±4.1 versus 37.2±4.5% anterior STEMI in the CR versus IRA groups, respectively. A total of 276.7±25.2 versus 186.7±15.3mL contrast was used in the CR versus IRA respectively (p=0.006). There were no statistical significant differences between the two groups in the reported incidence of CI-AKI (1.3% CR vs. 1.9% IRA; p=0.4), major bleeding (1.7% CR vs. 2.5% IRA; p=0.4) and stroke (1.1% CR vs. 0.4% IRA; p=0.24). However, there was a significantly increased incidence of cardiovascular death (2.0% CR vs. 4.7% IRA; p=0.01) and ischemia-driven revascularization (6.2% CR vs. 18.3% IRA; p<0.01). In the index hospitalization, CR in STEMI patients is associated with significant risk reduction in cardiac death and revascularization and a non-significant reduced trend of CI-AKI, despite increased use of contrast when compared with IRA.

Staged re-evaluation of non-culprit lesions in ST segment elevation myocardial infarction: a retrospective study

ObjectiveIt remains unknown whether complete revascularisation is optimally performed in patients with ST segment elevation myocardial infarction (STEMI) during the index or at staged procedures. The aims of this study...

Safety and Efficacy of Sequential Left Internal Thoracic Artery Grafting to Left Circumflex Area

This study investigated short-term and long-term results of coronary artery bypass grafting (CABG) with in situ sequential left internal thoracic artery (LITA) grafting to the left circumflex area. The study divided 452 patients who underwent CABG with bilateral ITA grafting to the left coronary artery into two groups: 191 in the sequential group and 261 in the individual group. The 147 pairs were matched by the propensity score. In the matched pairs, the rates of off-pump, complete revascularization, and hospital death were comparable between the two groups. Early graft evaluation was performed in 78.6%. There was no occlusion of the sequential LITA graft itself, but 5 complications occurred involving the distal segment of the LITA graft (occlusion, 2; string, 2; and competition, 1), and 3 complications (occlusion, 2; and string, 1) developed in the individual group. Event-free anastomosis rates were 97.8% in the sequential group and 97.4% in the individual group (p= 0.847). Diamond anastomosis of proximal sequential grafting showed a better patency of the distal part of sequential anastomosis compared with a parallel anastomosis of proximal sequential grafting (98.4% vs 90.7%, respectively). The freedom from target lesion revascularization and overall survival at 8 years was 94.6% and 96.3% in the sequential and individual groups, respectively (log-rank p= 0.645) and 80.7% and 77.4% (p= 0.300), respectively. In situ sequential LITA grafting provides acceptable early graft patency and freedom from repeat revascularization, resulting in excellent survival. This technique is a useful strategy for multivessel revascularization including the left circumflex area.

Cardiovascular disease in chronic kidney disease in 2015.

Chronic kidney disease (CKD) is strongly linked to premature cardiovascular disease, which is the leading cause of death before end-stage renal disease in these patients. Herein, we review recent literature from 2014 to 2015 that has advanced our understanding of cardiovascular outcomes in patients with advanced and/or progressive CKD. We focus on new data describing the mechanisms of cardiac death in patients with CKD as well as the novel associations between cardiac events and the competing risks of end-stage renal disease and pre-end-stage renal disease death. We review new controversies in multivessel revascularization of complex coronary artery disease in CKD and, finally, the treatment of systolic heart failure in advanced CKD, including the use of implantable defibrillator therapy. Marked advances in the understanding of cardiovascular disease in CKD have occurred in the past year, namely from retrospective and registry data. Although exciting, these recent studies highlight the urgent need for randomized control trials to guide therapeutic decisions.

Trends in Patient Characteristics and Outcomes of Coronary Artery Bypass Grafting in the 2000 to 2012 Medicare Population

The purpose of this analysis was to examine the trends in patient characteristics and outcomes in patients who underwent coronary artery bypass grafting (CABG) over a 12-year period in the Medicare database. The study included 1,264,265 isolated CABG procedures in the Medicare population from January 2000 through November 2012. Comorbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes. Trends in patient characteristics and hospital outcomes were assessed with Cochran-Armitage trend tests. Long-term survival was examined with Kaplan-Meier survival curves. The median age was 74 years. Comorbidity profiles increased significantly over time. The number of patients undergoing CABG decreased from 131,385 in 2000 to 71,086 in 2012. The majority of patients underwent multivessel revascularization (13.5% single-vessel CABG, 35.2% 2-vessel CABG, 32.1% 3-vessel CABG, and 15.7% ≥4-vessel CABG). The percentage of patients undergoing 1- and 2-vessel revascularization increased over time, whereas that of ≥3-vessel CABG decreased. Single internal mammary artery (IMA) use increased from 75.6% to 88.6%. Median length of stay (LOS) was 8 days. Thirty-day mortality decreased from 4.2% to 3.0%. Hospital mortality fell from 4.0% in 2000 to 2.7% in 2012 (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.69-0.77). Survival was 93% at 6 months, 91% at 1 year, 84% at 3 years, and 76% at 5 years. Five-year survival changed little over time (range, 75%-77%). Despite rising comorbidities in Medicare patients undergoing CABG, hospital mortality fell significantly from 2000 to 2012. When adjusted for comorbidities, this signified a 27% reduction in hospital mortality. IMA use increased during the study period, and there was a trend of decreased use of 3 or more grafts.