Division of Cardiothoracic Surgery, Department of Surgery, Clinical Research Unit, Emory University School of Medicine, Atlanta, Ga.
Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Ga.
J Thorac Cardiovasc Surg. 2021 Jun;161(6):2070-2078.e6. doi: 10.1016/j.jtcvs.2019.11.125. Epub 2019 Dec 20.
Both completeness of revascularization and multiple arterial grafts (multiple arterial coronary artery bypass grafting) have been associated with increased midterm survival after coronary artery bypass grafting. The purpose of this study was to evaluate the relative impact of completeness of revascularization and multiple arterial coronary artery bypass grafting on midterm survival after coronary artery bypass grafting.
A retrospective review of 17,411 isolated, primary coronary artery bypass grafting operations from January 2002 to June 2016 at a US academic institution was performed. Patients were divided into groups based on complete or incomplete revascularization and number of arterial grafts. Inverse probability of treatment weighting based on the generalized propensity score was performed to minimize imbalance in preoperative characteristics. Between-group differences in outcomes were assessed using multivariable logistic and Cox regression analyses, incorporating the propensity score weights.
Patients undergoing multiple arterial coronary artery bypass grafting in this study were younger, had fewer comorbid conditions, and had lower incidence of left main stenosis compared with patients undergoing single-arterial coronary artery bypass grafting. Short-term perioperative outcomes were similar between groups once propensity score weighting was used to minimize between-group differences in preoperative variables. Median follow-up in the entire population was 630 days, but was 1366 days in the cohort with data available from the Social Security Death Index. Multiple arterial coronary artery bypass grafting was protective for midterm survival compared with single arterial coronary artery bypass grafting, regardless of complete or incomplete revascularization or strategy (multiple arterial complete revascularization vs single-arterial complete revascularization: hazard ratio, 0.82; 95% confidence interval, 0.69-0.97; P = .02; multiple arterial incomplete revascularization vs single-arterial incomplete revascularization: hazard ratio, 0.70; 95% confidence interval, 0.53-0.90; P = .007).
After controlling for preoperative comorbidities, multiple arterial coronary artery bypass grafting provides a modest midterm survival benefit over single-arterial coronary artery bypass grafting irrespective of completeness of revascularization, suggesting that when forced to choose, surgeons may elect to pursue multiple arterial conduits.
在冠状动脉旁路移植术后，完全血运重建和多支动脉桥（多支动脉冠状动脉旁路移植术）与中期生存率的提高有关。本研究的目的是评估完全血运重建和多支动脉冠状动脉旁路移植术对冠状动脉旁路移植术后中期生存率的相对影响。
对 2002 年 1 月至 2016 年 6 月在美国一家学术机构进行的 17411 例单纯性、原发性冠状动脉旁路移植术进行回顾性分析。患者根据完全或不完全血运重建和动脉桥数量分为两组。基于广义倾向评分的逆概率治疗加权最小化术前特征的不平衡。使用多变量逻辑和 Cox 回归分析评估组间差异，并纳入倾向评分权重。
与接受单支动脉冠状动脉旁路移植术的患者相比，接受多支动脉冠状动脉旁路移植术的患者年龄较小，合并症较少，左主干狭窄的发生率较低。一旦使用倾向评分加权最小化术前变量组间差异，两组间短期围手术期结果相似。在整个队列中，中位数随访时间为 630 天，但在有社会安全死亡索引数据的队列中为 1366 天。与单支动脉冠状动脉旁路移植术相比，多支动脉冠状动脉旁路移植术无论完全或不完全血运重建或策略如何，均能保护中期生存（多支动脉完全血运重建与单支动脉完全血运重建相比：风险比为 0.82；95%置信区间为 0.69-0.97；P=0.02；多支动脉不完全血运重建与单支动脉不完全血运重建相比：风险比为 0.70；95%置信区间为 0.53-0.90；P=0.007）。
在控制术前合并症后，多支动脉冠状动脉旁路移植术与单支动脉冠状动脉旁路移植术相比，提供了适度的中期生存获益，无论血运重建的完整性如何，这表明当被迫选择时，外科医生可能会选择多支动脉导管。
