Coronary Artery Bypass Grafting in Octogenarians-Risks, Outcomes, and Trends in 1283 Consecutive Patients.

OBJECTIVE: To describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG). METHODS: We retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients' survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality. RESULTS: Operative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality. CONCLUSION: Although CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.

Association of Aspirin Treatment With Cardiac Allograft Vasculopathy Progression and Adverse Outcomes After Heart Transplantation.

BACKGROUND: Enhanced platelet reactivity may play a role in cardiac allograft vasculopathy (CAV) progression. The use of antiplatelet agents after heart transplantation (HT) has been inconsistent and although aspirin (ASA) is often a part of the medication regimen after HT, limited evidence is available on its benefit. METHODS AND RESULTS: CAV progression was assessed by measuring the difference in plaque volume and plaque index between the last follow-up and the baseline coronary intravascular ultrasound examination. Overall, 529 HT recipients were retrospectively analyzed (337 had ≥2 intravascular ultrasound studies). The progression in plaque volume (P = .007) and plaque index (P = .002) was significantly attenuated among patients treated with early ASA (within the first year after HT). Over a 6.7-year follow-up, all-cause mortality was lower with early ASA compared with late or no ASA use (P < .001). No cardiac deaths were observed in the early ASA group, and the risk of CAV-related graft dysfunction was significantly lower in this group (P = .03). However, the composite of all CAV-related events (cardiac death, CAV-related graft dysfunction, or coronary angioplasty) was not significantly different between the groups (P = .16). CONCLUSIONS: Early ASA use after HT may delay CAV progression and decrease mortality and CAV-related graft dysfunction, but does not seem to affect overall CAV-associated events.

Repeat Coronary Bypass Surgery or Percutaneous Coronary Intervention After Previous Surgical Revascularization.

OBJECTIVE: To assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG. METHODS: From January 1, 2000, through December 31, 2013, 1612 Mayo Clinic patients underwent RCABG (n=215) or PCI (n=1397) after previous CABG. The RCABG cohort was grouped by use of saphenous vein grafts only (n=75), or with additional arterial grafts (n=140); the PCI cohort by, bare metal stents (BMS; n=628), or drug-eluting stents (DES; n=769), and by the treated target into native coronary artery (n=943), bypass grafts only (n=338), or both (n=116). Multivariable regression and propensity score analysis (n=280 matched patients) were used. RESULTS: In multivariable analysis, the 30-day mortality was increased in RCABG versus PCI patients (hazard ratio [HR], 5.32; 95%CI, 2.34-12.08; P<.001), but overall survival after 30 days improved with RCABG (HR, 0.72; 95% CI, 0.55-0.94; P=.01). Internal mammary arteries were used in 61% (129 of 215) of previous CABG patients and improved survival (HR, 0.82; 95% CI, 0.69-0.98; P=.03). Patients treated with drug-eluting stent had better 10-year survival (HR, 0.74; 95% CI, 0.59-0.91; P=.001) than those with bare metal stent alone. In matched patients, RCABG had improved late survival over PCI: 48% vs 33% (HR, 0.57; 95% CI, 0.35-0.91; P=.02). Compared with RCABG, patients with PCI involving bypass grafts (n=60) had increased late mortality (HR, 1.62; 95% CI, 1.10-2.37; P=.01), whereas those having PCI of native coronary arteries (n=80) did not (HR, 1.09; 95% CI, 0.75-1.59; P=.65). CONCLUSION: RCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.

Current trends in bilateral internal thoracic artery use for coronary revascularization: Extending benefit to high-risk patients.

BACKGROUND: We sought to identify the trends in bilateral internal thoracic artery use and determine the degree to which the survival advantage of bilateral internal thoracic artery revascularization persists among perceived "high-risk" patients, compared with the use of left internal thoracic artery alone. METHODS: A retrospective review was conducted of patients who underwent isolated coronary artery bypass grafting for multivessel coronary artery disease at the Mayo Clinic between January 2000 and December 2015. Propensity score matching was performed between patients with bilateral internal thoracic artery and left internal thoracic artery alone grafts (1011 matched pairs). Effect of bilateral internal thoracic artery use on survival in "high-risk" patients (ejection fraction <40%, body mass index ≥30, age ≥70 years, diabetes, chronic lung disease, cerebrovascular accident) was evaluated. RESULTS: A total of 6468 isolated coronary artery bypass grafts were performed (5431 using left internal thoracic artery alone, 1037 using bilateral internal thoracic artery). There was an increasing trend in bilateral internal thoracic artery use (P value for linear trend = .005), with the percentage of coronary artery bypass grafting cases with bilateral internal thoracic artery doubling over the last 4 years (13% in 2012 to 27% in 2015). Propensity-matched comparisons showed a survival advantage for bilateral internal thoracic artery (hazard ratio, 0.81; 95% confidence interval, 0.66-0.99; P = .043). Risk of deep sternal wound infection, although higher in the bilateral internal thoracic artery group, was not significant (1.2% vs 0.5%; P = .088). None of the "high-risk" subsets of patients showed an adverse effect of bilateral internal thoracic artery on survival. CONCLUSIONS: Bilateral internal thoracic artery use in coronary artery bypass grafting is increasing over time. There is a consistent survival benefit with bilateral internal thoracic artery use, extending to patients with higher-risk comorbidities, suggesting the need for further expansion in use of this technique.

Multiarterial grafts improve the rate of early major adverse cardiac and cerebrovascular events in patients undergoing coronary revascularization: analysis of 12 615 patients with multivessel disease.

OBJECTIVES: Our goal was to compare the rates of in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) including death, stroke, myocardial infarction and repeat revascularization in patients with multivessel disease undergoing multiarterial (MultArt) coronary artery bypass grafting (CABG) with the left internal mammary artery/saphenous vein (LIMA/SV) CABG or percutaneous coronary intervention (PCI). METHODS: From 1 January 1993 to 31 December 2009, 12 615 consecutive patients underwent isolated primary CABG (n = 6667) with LIMA/SV (n = 5712) or MultArt (n = 955) or were treated by PCI (n = 5948) with balloon angioplasty (n = 1020), bare metal stent (n = 3242), and drug-eluting stent (n = 1686). We excluded patients with acute myocardial infarction. We matched the CABG group with the 3 PCI subgroups, and the PCI group with the 2 CABG subgroups. Multivariable analyses were used to evaluate the impact of CABG versus PCI and their subgroups on early MACCE. RESULTS: Unadjusted early MACCE were lower for MultArt (1.5%) than for LIMA/SV (4.5%, P < 0.001) and PCI (8.5%, P < 0.001). In matched analysis, CABG had lower early MACCE versus balloon angioplasty (4.7% vs 13.2%, P < 0.001), bare metal stent (4.3% vs 8.3%, P < 0.001), and drug-eluting stent (2.9% vs 5.5%, P = 0.008), as well as LIMA/SV versus PCI (4.6% vs 9.2%, P < 0.001) and MultArt versus PCI (1.8% vs 7.8%, P < 0.001). Stroke rate was similar in MultArt versus PCI (0.8% vs 0.3%, P = 0.18) but higher with LIMA/SV versus PCI (2.3% vs 0.4%, P < 0.001). In multivariable analysis, PCI (odds ratio 4.53, 95% confidence interval: 2.62-7.83; P < 0.001) and LIMA/SV (odds ratio 2.04, 95% confidence interval: 1.18-3.53; P < 0.011) were strong predictors of early MACCE compared with MultArt. CONCLUSIONS: MultArt confers the lowest rate of early MACCE.

Left Internal Mammary Artery Versus Coronary Stents: Impact on Downstream Coronary Stenoses and Conduit Patency.

BACKGROUND: The study compared downstream coronary and conduit disease progression in the left anterior descending coronary artery treated with coronary artery bypass grafting using the left internal mammary artery (LIMA) versus percutaneous coronary intervention with bare metal stent (BMS) or drug eluting stent (DES). METHODS AND RESULTS: A total of 12 301 consecutive patients underwent isolated primary coronary revascularization, of which 2386 met our inclusion criteria (Percutaneous coronary intervention, n=1450; coronary artery bypass grafting, n=936). Propensity score analysis matched 628 patients, of which 468 were treated to the left anterior descending with coronary artery bypass grafting with LIMA (n=314), percutaneous coronary intervention with BMS (n=94), and DES (n=60). Coronary angiograms were analyzed by quantitative coronary angiography (QCA; n=433). Cumulative downstream coronary and conduit disease progression were estimated by Kaplan-Meier method and effect of treatment type by Cox proportional hazard models. Patients treated with LIMA had significantly lower risk of downstream coronary disease progression at follow-up angiogram compared with BMS and DES (hazard ratio [HR] [95% CI], 0.34; [0.20-0.59]; P=0.0002; and HR [95% CI], 0.39; [0.20-0.79]; P=0.01, respectively). LIMA was associated with a lower risk of conduit disease progression compared to BMS and DES (HR [95% CI], 0.18; [0.12-0.28]; P<0.001; and HR [95% CI], 0.27; [0.16-0.46]; P<0.001, respectively). BMS was associated with higher HR for downstream coronary and conduit disease progression compared with DES, but the difference did not reach statistical significance (HR [95% CI], 1.13; [0.57-2.36]; P=0.73; and HR [95% CI], 1.46; [0.88-2.50]; P=0.14, respectively). CONCLUSIONS: LIMA grafting to left anterior descending is associated with significantly lower risk of downstream coronary and conduit disease progression compared to percutaneous coronary intervention with BMS and DES.