Differences in Long-Term Outcomes After CABG Using Single vs Multiple Arterial Grafts and Association With Gender
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Sex-related differences in the outcome of using multiple arterial grafts during coronary artery bypass grafting (CABG) remain uncertain.
Objective
To compare the outcomes of the use of multiple arterial grafts vs a single arterial graft during CABG for women and men.
Design, Setting, and Participants
This statewide cohort study used data from New York's Cardiac Surgery Reporting System and New York's Vital Statistics file on 63 402 patients undergoing CABG from January 1, 2005, to December 31, 2014. Statistical analysis was performed from January 10 to August 20, 2020.
Exposures
Multiple arterial grafting or single arterial grafting.
Main Outcomes and Measures
Mortality, acute myocardial infarction (AMI), stroke, repeated revascularization, major adverse cardiac and cerebrovascular event (composite of mortality, AMI, and stroke), and major adverse cardiac event (composite of mortality, AMI, or repeated revascularization) were compared among propensity-matched patients and stratified by the risk of long-term mortality.
Results
Of the 63 402 patients (48 155 men [76.0%]; mean [SD] age, 69.9 [10.5] years) in the study, women had worse baseline characteristics than men for most of the explored variables. Propensity matching yielded a total of 9512 male pairs and 1860 female pairs. At 7 years of follow-up, mortality was lower among men who underwent multiple arterial grafting (adjusted hazard ratio, 0.80; 95% CI, 0.73-0.87) but not women who underwent multiple arterial grafting (adjusted hazard ratio, 0.99; 95% CI, 0.84-1.15). When stratified by the estimated risk of death, the use of multiple arterial grafts was associated with better survival and a lower rate of a major adverse cardiac event among low-risk, but not high-risk, patients of both sexes, and the risk cutoff was different for men and women.
Conclusions and Relevance
This study suggests that women have a worse preoperative risk profile than men. Multiple arterial grafting is associated with better outcomes among low-risk, but not high-risk, patients, and the risk cutoffs differ between sexes. These data highlight the need for new studies on the outcome of multiple arterial grafts in women.
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Additional Info
Differences in Long-Term Outcomes After Coronary Artery Bypass Grafting Using Single vs Multiple Arterial Grafts and the Association With Sex
JAMA 2020 Dec 23;[EPub Ahead of Print], M Gaudino, Z Samadashvili, I Hameed, J Chikwe, LN Girardi, EL HannanFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
The study by Gaudino and colleagues joins a host of others seeking to identify a subset of patients who demonstrably benefit from multiple arterial grafting (MAG). Although this approach to coronary revascularization is commonplace in Europe, it has been stubbornly resistant to adoption on this side of the pond. The logic for MAG is inescapable given demonstrably superior graft patency for arterial versus venous conduits, and is supported perhaps by anecdotal observation, yet it has been remarkably challenging to demonstrate such a benefit even in the recently published ARTS study randomizing patients between arterial and venous grafts. That study has been challenged because of the remarkably high degree of crossover; however, the data to support the converse have been remarkably difficult to demonstrate. In this study, MAG did show benefit in men overall, consistent with the European approach, although this was not the case for women. Interestingly, when stratified by risk category, it was the low-risk patients who most benefited. Perhaps this is because the survival of those high-risk patients is dominated by these other comorbidities, a hypothesis that would be supported by the shape of the survival curve for high-risk females, which demonstrates significant mortality in the first year and almost parallel survival thereafter. Of course, the impact of arterial grafting would be expected to be seen in the long run. Regardless, although the paper focuses on outcomes in women, the results in men should not be overlooked as scarce as support for MAG remains. As for coronary bypass in women, once again it is clear there is work to be done to improve their outcomes.