冠状动脉旁路移植术后移植物失败及其与患者特征和临床事件的关联：一项有影像学随访的临床试验的汇总个体患者数据分析
Graft Failure After Coronary Artery Bypass Grafting and Its Association With Patient Characteristics and Clinical Events: A Pooled Individual Patient Data Analysis of Clinical Trials With Imaging Follow-Up.
作者信息
Gaudino Mario, Sandner Sigrid, An Kevin R, Dimagli Arnaldo, Di Franco Antonino, Audisio Katia, Harik Lamia, Perezgrovas-Olaria Roberto, Soletti Giovanni, Fremes Stephen E, Hare David L, Kulik Alexander, Lamy Andre, Peper Joyce, Ruel Marc, Ten Berg Jurrien M, Willemsen Laura M, Zhao Qiang, Wojdyla Daniel M, Bhatt Deepak L, Alexander John H, Redfors Bjorn
机构信息
Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY (M.G., K.R.A., A.D., A.D.F., K.A., L.H., R. P.-O., G.S.).
Department of Cardiac Surgery, Medical University of Vienna, Austria (S.S.).
出版信息
Circulation. 2023 Oct 24;148(17):1305-1315. doi: 10.1161/CIRCULATIONAHA.123.064090. Epub 2023 Jul 7.
BACKGROUND
Graft patency is the postulated mechanism for the benefits of coronary artery bypass grafting (CABG). However, systematic graft imaging assessment after CABG is rare, and there is a lack of contemporary data on the factors associated with graft failure and on the association between graft failure and clinical events after CABG.
METHODS
We pooled individual patient data from randomized clinical trials with systematic CABG graft imaging to assess the incidence of graft failure and its association with clinical risk factors. The primary outcome was the composite of myocardial infarction or repeat revascularization occurring after CABG and before imaging. A 2-stage meta-analytic approach was used to evaluate the association between graft failure and the primary outcome. We also assessed the association between graft failure and myocardial infarction, repeat revascularization, or all-cause death occurring after imaging.
RESULTS
Seven trials were included comprising 4413 patients (mean age, 64.4±9.1 years; 777 [17.6%] women; 3636 [82.4%] men) and 13 163 grafts (8740 saphenous vein grafts and 4423 arterial grafts). The median time to imaging was 1.02 years (interquartile range [IQR], 1.00-1.03). Graft failure occurred in 1487 (33.7%) patients and in 2190 (16.6%) grafts. Age (adjusted odds ratio [aOR], 1.08 [per 10-year increment] [95% CI, 1.01-1.15]; =0.03), female sex (aOR, 1.27 [95% CI, 1.08-1.50]; =0.004), and smoking (aOR, 1.20 [95% CI, 1.04-1.38]; =0.01) were independently associated with graft failure, whereas statins were associated with a protective effect (aOR, 0.74 [95% CI, 0.63-0.88]; <0.001). Graft failure was associated with an increased risk of myocardial infarction or repeat revascularization occurring between CABG and imaging assessment (8.0% in patients with graft failure versus 1.7% in patients without graft failure; aOR, 3.98 [95% CI, 3.54-4.47]; <0.001). Graft failure was also associated with an increased risk of myocardial infarction or repeat revascularization occurring after imaging (7.8% versus 2.0%; aOR, 2.59 [95% CI, 1.86-3.62]; <0.001). All-cause death after imaging occurred more frequently in patients with graft failure compared with patients without graft failure (11.0% versus 2.1%; aOR, 2.79 [95% CI, 2.01-3.89]; <0.001).
CONCLUSIONS
In contemporary practice, graft failure remains common among patients undergoing CABG and is strongly associated with adverse cardiac events.
背景
移植血管通畅被认为是冠状动脉旁路移植术（CABG）获益的机制。然而，CABG术后进行系统的移植血管成像评估很少见，并且缺乏关于移植血管失败相关因素以及移植血管失败与CABG术后临床事件之间关联的当代数据。
方法
我们汇总了来自进行系统CABG移植血管成像的随机临床试验的个体患者数据，以评估移植血管失败的发生率及其与临床危险因素的关联。主要结局是CABG术后至成像检查前发生心肌梗死或再次血运重建的复合情况。采用两阶段荟萃分析方法评估移植血管失败与主要结局之间的关联。我们还评估了移植血管失败与成像检查后发生心肌梗死、再次血运重建或全因死亡之间的关联。
结果
纳入了7项试验，共4413例患者（平均年龄64.4±9.1岁；女性777例[17.6%]；男性3636例[82.4%]）以及13163条移植血管（8740条大隐静脉移植血管和4423条动脉移植血管）。成像检查的中位时间为1.02年（四分位间距[IQR]，1.00 - 1.03）。1487例（33.7%）患者和2190条（16.6%）移植血管发生了移植血管失败。年龄（校正比值比[aOR]，1.08[每增加10岁][95%CI，1.01 - 1.15]；P = 0.03）、女性（aOR，1.27[95%CI，1.08 - 1.50]；P = 0.004）和吸烟（aOR，1.20[95%CI，1.04 - 1.38]；P = 0.01）与移植血管失败独立相关，而他汀类药物具有保护作用（aOR，0.74[95%CI，0.63 - 0.88]；P < 0.001）。移植血管失败与CABG至成像评估之间发生心肌梗死或再次血运重建的风险增加相关（移植血管失败患者为8.0%，无移植血管失败患者为1.7%；aOR，3.98[95%CI，3.54 - 4.47]；P < 0.001）。移植血管失败还与成像检查后发生心肌梗死或再次血运重建的风险增加相关（7.8%对2.0%；aOR，2.59[95%CI，1.86 - 3.62]；P < 0.001）。与无移植血管失败的患者相比，移植血管失败的患者成像检查后的全因死亡更常见（11.0%对2.1%；aOR，2.79[95%CI，2.01 - 3.89]；P < 0.001）。
结论
在当代实践中，移植血管失败在接受CABG的患者中仍然很常见，并且与不良心脏事件密切相关。
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