Schulich Heart Centre, Sunnybrook Health Sciences Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
JAMA Cardiol. 2020 May 1;5(5):507-514. doi: 10.1001/jamacardio.2019.6104.
The optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease.
To compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019.
Total arterial revascularization.
Primary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome.
Of 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization.
Total arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.
在多支冠状动脉疾病中，冠状动脉旁路移植术（CABG）的最佳导管仍然存在争议。
在一项多中心基于人群的研究中，比较全动脉血运重建（TAR）与非-TAR（至少有 1 个动脉和 1 个大隐静脉移植物的 CABG）的长期临床结果。
设计、设置和参与者：这项多中心基于人群的队列研究使用倾向评分匹配，于 2008 年 10 月至 2017 年 3 月在加拿大安大略省进行，平均和最长随访时间分别为 4.6 年和 9.0 年。确定了有原发性孤立 CABG 的个体，至少有 1 个动脉移植物。排除标准为来自外省的个体和年龄小于 18 岁的个体。还排除了接受心脏再手术或心源性休克的患者，因为这些情况可能会使外科医生偏向于不进行 TAR。分析于 2019 年 4 月开始。
全动脉血运重建。
主要结局是首次发生死亡、心肌梗死、卒中和/或再次血运重建（主要心脏和脑血管不良事件）的复合时间。次要结局包括主要结局的各个组成部分。
在 49404 例原发性孤立 CABG 患者中，2433 例（4.9%）接受了 TAR，总旁路数分别为 2、3 和 4 个或更多血管，分别为 1521 例（62.5%）、865 例（35.6%）和 47 例（1.9%）。平均（SD）年龄为 61.2（10.4）岁，1983 例（81.5%）为男性。在进行倾向评分匹配后，形成了 2132 对患者，总旁路数相等（平均[SD]，2.4[0.5]），但 TAR 组的动脉移植物更多（平均[SD]，2.4[0.5]比 1.2[0.4]；P<.01）。TAR 与非-TAR 组在院内死亡率（15[0.7%]与 21[1.0%]；P=.32）方面无差异。在 8 年的时间里，TAR 与主要心脏和脑血管不良事件（风险比，0.78；95%置信区间，0.68-0.89）、死亡（风险比，0.80；95%置信区间，0.66-0.97）和心肌梗死（风险比，0.69；95%置信区间，0.51-0.92）的改善无关。中风和再次血运重建没有差异。
全动脉血运重建与长期主要心脏和脑血管不良事件、死亡和心肌梗死的改善相关，对于有合理预期寿命需要 CABG 的患者，可能是首选的手术方法。
