Cardiac Services BC, Vancouver, British Columbia, Canada.
Vancouver General Hospital, Vancouver, British Columbia, Canada.
JAMA Cardiol. 2017 Nov 1;2(11):1187-1196. doi: 10.1001/jamacardio.2017.3705.
Although the long-term survival advantage of multiple arterial grafting (MAG) vs the standard use of left internal thoracic artery (LITA) supplemented by saphenous vein grafts (LITA+SVG) has been demonstrated in several observational studies, to our knowledge its safety and other long-term clinical benefits in a large, population-based cohort are unknown.
To compare the safety and long-term outcomes of MAG vs LITA+SVG among overall and selected subgroups of patients.
DESIGN, SETTING, AND PARTICIPANTS: In this population-based observational study, we included 20 076 adult patients with triple-vessel or left-main disease who underwent primary isolated coronary artery bypass grafting (MAG, n = 5580; LITA+SVG, n = 14 496) in the province of British Columbia, Canada, from January 2000 to December 2014, with follow-up to December 2015. We performed propensity-score analyses by weighting and matching and multivariable Cox regression to minimize treatment selection bias.
Multiple arterial grafting or LITA+SVG.
Mortality, repeated revascularization, myocardial infarction, heart failure, and stroke.
Of 5580 participants who underwent MAG, 586 (11%) were women and the mean (SD) age was 60 (8.7) years. Of 14 496 participants who underwent LITA+SVG, 2803 (19%) were women and the mean (SD) age was 68 (8.9) years. The median (interquartile range) follow-up time was 9.1 (5.1-12.6) years and 8.1 (4.5-11.7) years for the groups receiving MAG and LITA+SVG, respectively. Compared with LITA+SVG, MAG was associated with reduced mortality rates (hazard ratio [HR], 0.79; 95% CI, 0.72-0.87) and repeated revascularization rates (HR, 0.74; 95% CI, 0.66-0.84) in 15-year follow-up and reduced incidences of myocardial infarction (HR, 0.63; 95% CI, 0.47-0.85) and heart failure (HR, 0.79; 95% CI, 0.64-0.98) in 7-year follow-up. The long-term benefits were coherent by all 3 statistical methods and persisted among patient subgroups with diabetes, obesity, moderately impaired ejection fraction, chronic obstructive pulmonary disease, peripheral vascular disease, or renal disease. Multiple arterial grafting was not associated with increased morbidity or mortality rates at 30 days overall or within patient subgroups.
Compared with LITA+SVG, MAG is associated with reduced mortality, repeated revascularization, myocardial infarction, and heart failure among patients with multivessel disease who are undergoing coronary artery bypass grafting without increased mortality or other adverse events at 30 days. The long-term benefits consistently observed across multiple outcomes and subgroups support the consideration of MAG for a broader spectrum of patients who are undergoing coronary artery bypass grafting in routine practice.
虽然多项动脉旁路移植术（MAG）与标准使用左内乳动脉（LITA）联合大隐静脉移植（LITA+SVG）相比具有长期生存优势，这在几项观察性研究中已经得到证实，但就我们所知，在一个大型基于人群的队列中，其安全性和其他长期临床获益尚不清楚。
比较 MAG 与 LITA+SVG 在整体和选定亚组患者中的安全性和长期结局。
设计、设置和参与者：在这项基于人群的观察性研究中，我们纳入了 2076 名在加拿大不列颠哥伦比亚省接受单纯冠状动脉旁路移植术的三血管或左主干疾病成年患者（MAG，n=5580；LITA+SVG，n=14496），随访至 2015 年 12 月。我们通过加权和匹配以及多变量 Cox 回归进行倾向评分分析，以尽量减少治疗选择偏倚。
MAG 或 LITA+SVG。
死亡率、再次血运重建、心肌梗死、心力衰竭和卒中。
5580 名接受 MAG 的患者中，586 名（11%）为女性，平均（SD）年龄为 60（8.7）岁。在 14496 名接受 LITA+SVG 的患者中，2803 名（19%）为女性，平均（SD）年龄为 68（8.9）岁。MAG 组和 LITA+SVG 组的中位（四分位距）随访时间分别为 9.1（5.1-12.6）年和 8.1（4.5-11.7）年。与 LITA+SVG 相比，MAG 与 15 年随访时的死亡率降低（风险比[HR]，0.79；95%置信区间[CI]，0.72-0.87）和再次血运重建率（HR，0.74；95% CI，0.66-0.84）相关，与 7 年随访时的心肌梗死发生率（HR，0.63；95% CI，0.47-0.85）和心力衰竭发生率（HR，0.79；95% CI，0.64-0.98）降低相关。这三种统计学方法的长期获益均一致，并且在糖尿病、肥胖、射血分数中度受损、慢性阻塞性肺疾病、外周血管疾病或肾脏疾病的患者亚组中持续存在。MAG 与 30 天内的总体死亡率或任何患者亚组内的死亡率或其他不良事件发生率增加无关。
与 LITA+SVG 相比，MAG 与多血管疾病患者的死亡率、再次血运重建、心肌梗死和心力衰竭降低相关，而在 30 天内没有增加死亡率或其他不良事件。在多个结局和亚组中一致观察到的长期获益支持在常规实践中为更广泛的接受冠状动脉旁路移植术的患者考虑使用 MAG。
