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.

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). 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. 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. MultArt confers the lowest rate of early MACCE.

Locker C ，Schaff HV ，Daly RC ，Bell MR ，Frye RL ，Stulak JM ，Said SM ，Dearani JA ，Joyce LD ，Greason KL ，Pochettino A ，Li Z ，Lennon RJ ，Lerman A ... -  《-》

Multiple arterial grafts improve survival with coronary artery bypass graft surgery versus conventional coronary artery bypass grafting compared with percutaneous coronary interventions.

To compare long-term survival with multiple arterial coronary artery bypass grafting (CABG) (MultArt) versus percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD). We reviewed 12,615 patients with MVD with isolated primary CABG or PCI from 1993 to 2009. Patients with CABG (n = 6667) were grouped according to the number of arterial grafts into left internal thoracic artery (LITA)/saphenous vein (SV) (n = 5712) or MultArt (n = 955); patients with PCI (n = 5948) were grouped into balloon angioplasty (BA) (n = 1020), drug-eluting stent (DES) (n = 1686), and bare metal stent (BMS) (n = 3242). Unadjusted long-term survival was lower for CABG than PCI (15-year survival, 34% vs 46%; P < .001); however, in patients with MultArt, survival was greater than LITA/SV, BA, BMS (15-year survival, 65% vs 31%, 47%, 45%, respectively; P < .001), and DES (8-year survival, 87% vs 70%; P < .001). In matched analyses, 15-year survival of MultArt was higher than BA (66% vs 57%; P = .002), LITA/SV (64% vs 56%; P = .02), and BMS (5-year survival 94% vs 90%; P = .01), and similar to DES at 8 years. In multivariate analysis, compared with MultArt, LITA/SV had worse survival (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.09-1.52; P = .003). BMS (HR, 0.87; 95% CI, 0.80-0.94; P < .001) and DES (HR, 0.76; 95% CI, 0.66-0.88; P < .001) had improved survival versus LITA/SV but not versus MultArt (HR, 1.12; 95% CI, 0.94-1.34; P = .21, and HR, 0.98; 95% CI, 0.79-1.21; P = .83, respectively). Secondary analyses for treatment crossover indicated lower survival for LITA/SV versus MultArt and PCI. In patients with MVD undergoing primary revascularization, MultArt increased survival benefit versus LITA/SV compared with PCI. Use of MultArt must increase.

Locker C ，Schaff HV ，Daly RC ，Dearani JA ，Bell MR ，Frye RL ，Greason KL ，Stulak JM ，Joyce LD ，Pochettino A ，Li Z ，Lennon RJ ，Lerman A ... -  《-》

[Comparison on the long-term outcomes post percutaneous coronary intervention or coronary artery bypass grafting for bifurcation lesions in unprotected left main coronary artery].

Yang BG ，Yu XP ，Chen F ，Lyu SZ ，Li Q ，He JQ ，Yuan F ... -  《-》

Multiple arterial grafting confers survival advantage compared to percutaneous intervention with drug-eluting stents in multivessel coronary artery disease: A propensity score adjusted analysis.

The best revascularisation strategy for multivessel coronary artery disease (MVD) is still controversial. Percutaneous coronary intervention (PCI) utilising drug eluting stents (DES) has emerged as an acceptable alternative to conventional coronary artery bypass grafting (CABG) in the last decade. However, multiple arterial grafting (MAG) is superior revascularisation strategy compared with conventional CABG utilising single internal mammary artery and currently there is a paucity of comparison of DES and MAG. We aimed to investigate whether MAG offers advantage over DES-PCI in MVD. A total of 6126 patients with MVD (≥ 2 vessel) underwent CABG (n = 4652) or PCI (n = 1474) at a single institution. MAG was performed in 1372 CABG cases and DES were implanted in 1222 PCI cases. Propensity score adjusted analysis was performed to investigate the potential survival advantage of MAG over PCI. Mean follow-up was 4.9 years. Risk for late death was comparable after DES-PCI and conventional CABG (HR 1.11; 95%CI 0.9 to 1.33; P = 0.25). However, DES-PCI was associated with an increased risk for late death compared to MAG (HR 1.53; 95%CI 1.08 to 2.91; P = 0.02). DES-PCI was also associated with a 3.51 fold increased risk for repeat revascularisation over MAG (95%CI 2.60 to 4.75; P < 0.0001) and 2.66 fold increased risk for repeat revascularisation over conventional CABG (95%CI 2.11 to 3.36; P < 0.0001). MAG improved late survival and offered superior freedom from repeat revascularisation compared to DES-PCI. When feasible, MAG should be strongly recommended in patients with MVD.

Raja SG ，Benedetto U ，Ilsley CD ，Amrani M ，Harefield Cardiac Outcomes Research Group ... -  《-》

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

To assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG. 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. 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). RCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.

Locker C ，Greiten LE ，Bell MR ，Frye RL ，Lerman A ，Daly RC ，Greason KL ，Said SM ，Lahr BD ，Stulak JM ，Dearani JA ，Schaff HV ... -  《-》