Division of Cardiac Surgery (R.V.R., D.Y.T., R.K., R.N., S.E.F.), University of Toronto, Ontario, Canada.
Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management, and Evaluation (D.Y.T., R.K., S.E.F.), University of Toronto, Ontario, Canada.
Circulation. 2018 Nov 6;138(19):2081-2090. doi: 10.1161/CIRCULATIONAHA.118.034464.
Observational studies have shown better survival in patients undergoing coronary artery bypass grafting (CABG) with 2 arterial grafts compared with 1. However, whether a third arterial graft is associated with incremental benefit remains uncertain. We sought to analyze the outcomes of 3 versus 2 arterial grafts during CABG. As a secondary objective, we compared CABG with 2 or 3 arterial grafts (multiple arterial grafts [MAG]) with CABG using a single arterial graft (SAG).
Retrospective cohort analyses of all patients undergoing primary isolated CABG in Ontario, Canada, from October 2008 to March 2016. Propensity score matching was performed between patients with 3 arterial grafts (3Art group) versus 2 (2Art group). The primary outcome was time to first event of a composite of death, myocardial infarction, stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events). Additional analyses were performed to evaluate the association between MAG versus SAG and long-term outcomes using propensity score matching.
Fifty thousand, two hundred thirty patients underwent isolated CABG during our study period; 3044 (6.1%) and 8253 (16.4%) patients had 3 and 2 arterial grafts, respectively, resulting in 2789 propensity score matching pairs for the primary analyses. Mean and maximum follow-up was 4.2 and 8.5 years, respectively. Radial artery grafting was more common in the 3Art versus 2Art group (79.3% versus 65.6%, P<0.01). In-hospital outcomes were not significantly different, including death (3Art 0.8% versus 2Art 0.5%, P=0.26). Up to 8 years, there were no differences in major adverse cardiac and cerebrovascular events (3Art 27%, 95% confidence interval [CI], 24% to 30% versus 2Art 25%, 95% CI, 22% to 28%; hazard ratio [HR], 1.08, 95% CI, 0.94-1.25), death (HR, 1.08; 95% CI, 0.90-1.29), myocardial infarction (HR, 1.15; 95% CI, 0.87-1.51), stroke (HR, 1.39; 95% CI, 0.95-2.06), or repeat revascularization (HR, 1.04; 95% CI, 0.82-1.32). When evaluating MAG versus SAG, 8629 patient pairs were formed using propensity score matching. At 8 years, cumulative incidences of major adverse cardiac and cerebrovascular events (HR, 0.82, 95% CI, 0.77-0.88), survival (HR, 0.80; 95% CI, 0.73-0.88), repeat revascularization (HR, 0.79; 95% CI, 0.69-0.90), and myocardial infarction (HR, 0.83; 95% CI, 0.72-0.97) were superior in the MAG group.
CABG with 3 arterial grafts was not associated with increased in-hospital death nor with better clinical outcomes at 8-year follow-up, compared with CABG with 2 arterial grafts. MAG was associated with superior outcomes compared with SAG.
观察性研究表明，与使用 1 根动脉移植物进行冠状动脉旁路移植术（CABG）相比，使用 2 根动脉移植物进行 CABG 可提高患者的生存率。然而，使用第 3 根动脉移植物是否能带来额外的益处仍不确定。我们试图分析在 CABG 中使用 3 根与 2 根动脉移植物的结果。作为次要目标，我们比较了使用 2 或 3 根动脉移植物（多动脉移植物 [MAG]）与使用单根动脉移植物（SAG）进行 CABG 的结果。
回顾性分析 2008 年 10 月至 2016 年 3 月期间在加拿大安大略省接受初次孤立性 CABG 的所有患者。在 3 根动脉移植物（3Art 组）与 2 根动脉移植物（2Art 组）患者之间进行倾向评分匹配。主要结局是首次发生死亡、心肌梗死、卒中和再次血运重建（主要心脏和脑血管不良事件）的复合事件的时间。还进行了额外的分析，以评估 MAG 与 SAG 与长期结果之间的关联，使用倾向评分匹配。
在我们的研究期间，共有 52300 名患者接受了孤立性 CABG；分别有 3044（6.1%）和 8253（16.4%）名患者进行了 3 根和 2 根动脉移植物，分别有 2789 对倾向评分匹配用于主要分析。平均和最大随访时间分别为 4.2 年和 8.5 年。桡动脉移植在 3Art 组比 2Art 组更为常见（79.3%比 65.6%，P<0.01）。住院期间的结果没有显著差异，包括死亡（3Art 0.8%比 2Art 0.5%，P=0.26）。在 8 年内，主要心脏和脑血管不良事件没有差异（3Art 27%，95%置信区间 [CI]，24%至 30%比 2Art 25%，95%CI，22%至 28%；危险比 [HR]，1.08，95%CI，0.94-1.25）、死亡（HR，1.08；95%CI，0.90-1.29）、心肌梗死（HR，1.15；95%CI，0.87-1.51）、卒中和（HR，1.39；95%CI，0.95-2.06）或再次血运重建（HR，1.04；95%CI，0.82-1.32）。当评估 MAG 与 SAG 时，使用倾向评分匹配形成了 8629 对患者。在 8 年时，主要心脏和脑血管不良事件的累积发生率（HR，0.82，95%CI，0.77-0.88）、生存率（HR，0.80；95%CI，0.73-0.88）、再次血运重建（HR，0.79；95%CI，0.69-0.90）和心肌梗死（HR，0.83；95%CI，0.72-0.97）在 MAG 组中更优。
与使用 2 根动脉移植物进行 CABG 相比，使用 3 根动脉移植物进行 CABG 并未增加住院期间的死亡风险，也未在 8 年随访时改善临床结局。MAG 与 SAG 相比，结果更优。
