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Outcomes After CABG for Left Main Disease
Study Questions:
How have outcomes of patients undergoing coronary artery bypass grafting (CABG) for left main disease changed over time?
Methods:
This is a propensity-matched analysis of patients from the SYNTAX (conducted from 2005-2007) and EXCEL (conducted from 2010-2014) trials, who were randomized to CABG for left main disease. The propensity score model included age, sex, body mass index, smoking status, diabetes, heart failure, hyperlipidemia, hypertension, previous myocardial infarction (MI), prior cerebrovascular accident, chronic obstructive pulmonary disease, peripheral vascular disease, pulmonary hypertension, creatinine >1.7 mg/dl, and SYNTAX score. Analyses were performed as intention-to-treat. The primary endpoint was a composite of major adverse cardiac and cerebrovascular events (MACCE) (all-cause death, MI, stroke, or ischemia-driven revascularization) at 3 years, with a secondary endpoint of a composite of all-cause death, stroke, or MI at 30 days and 3 years.
Results:
There was a total of 909 patients (SYNTAX n = 329, EXCEL n = 580) in the study. Baseline characteristics were comparable. CABG procedures in the EXCEL trial were more often off-pump (29.6 vs. 15.4%, p < 0.001). Although use of in situ left internal mammary artery (LIMA) and radial artery was more common in the SYNTAX trial (98.7% vs. 94.4%, p = 0.002 and 10.3% vs. 5.7%, p = 0.01, respectively), overall there was no significant difference between groups in the total number of arterial or venous grafts or use of bilateral IMA. Guideline-directed medical therapy (GDMT) was more frequently used in the EXCEL trial, both at discharge and at 3 years. The composite endpoint of MACCE at 3 years was higher in the earlier trial (20.9% vs. 14.0%, p = 0.008), as was a composite endpoint of death, stroke, or MI (14.0% vs. 9.6%, p = 0.05).
Conclusions:
Outcomes of CABG for left main disease, as measured by 3-year rates of MACCE, have improved over time. This may be related to the more frequent use of off-pump CABG and/or the greater use of GDMT.
Perspective:
Despite the limitations of a post hoc propensity analysis, Modolo and colleagues have demonstrated that 3-year outcomes after CABG for left main disease have improved over time. All-cause 30-day mortality in both trials was very low at <1% (even better than the 2.3% for all-comers who underwent CABG in 2017, as reported in the most recent update of the Society of Thoracic Surgeons Adult Cardiac Surgery Database), but by 3 years, mortality was significantly lower in the more recent EXCEL trial. The authors suggest that advances in both PCI and CABG outcomes may underlie the consistency in relative outcomes between the two procedures over time. This study also showed that optimized GDMT still plays a very important role in the management of patients with coronary artery disease, regardless of how coronary artery disease is treated procedurally. While frequency of off-pump CABG is not likely to increase notably in the near future, more recent trends towards multi- and total-arterial grafting may begin to influence longer-term outcomes of CABG.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Acute Heart Failure, Pulmonary Hypertension, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Hypertension, Smoking
Keywords: Body Mass Index, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Bypass, Off-Pump, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hyperlipidemias, Hypertension, Hypertension, Pulmonary, Myocardial Infarction, Myocardial Revascularization, Peripheral Vascular Diseases, Pulmonary Disease, Chronic Obstructive, Smoking, Stroke, Vascular Diseases
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