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Single or Multiple Arterial CABG vs. PCI in 3VD or Left Main Disease
Quick Takes
- CABG with multi-arterial grafting (MAG) but not single-arterial grafting (SAG) was associated with significantly lower all-cause mortality compared to PCI in a post hoc analysis of the SYNTAXES trial.
- Subgroup analysis showed that both MAG and SAG were associated with lower all-cause mortality compared to PCI in patients with three-vessel disease; the difference between MAG or SAG and PCI was not observed in patients with left main disease.
Study Questions:
What is the difference in long-term all-cause mortality between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) using multiple or single arterial grafts?
Methods:
This is a post hoc analysis of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) trial, a multicenter, international, randomized controlled trial comparing PCI versus CABG in patients with three-vessel disease (3VD) or left main coronary artery disease (LMCAD), with follow-up out to ≥10 years. The cohort of patients who received PCI, CABG with single-arterial grafting (SAG; defined as 1 arterial graft and ≥1 venous graft), or CABG with multi-arterial grafting (MAG; defined as ≥2 arterial grafts with or without additional venous grafts) was analyzed, with analyses done in the as-treated population. The primary endpoint was all-cause mortality at maximum follow-up, examined by Kaplan-Meier analysis. Subgroup analyses in patients with LMCAD versus 3VD and in diabetes mellitus (DM) versus non-DM were also performed.
Results:
Of 1,743 patients, 901 (51.7%) received PCI, 532 (30.5%) received SAG, and 310 (17.8%) received MAG. Median maximum follow-up was 11.9 years (interquartile range, 11.2-12.4 years). MAG patients were younger and had higher left ventricular ejection fraction (LVEF) and lower median EuroSCOREs compared to PCI patients, while SAG patients had lower LVEF than PCI patients. At maximum follow-up, all-cause death occurred in 305 (33.9%) patients in the PCI group, 175 (32.9%) in the SAG group, and 70 (22.6%) in the MAG group. MAG was associated with significantly lower all-cause mortality compared to PCI (adjusted hazard ratio ([HR], 0.66; 95% confidence interval [CI], 0.49-0.89; p = 0.007) but not when SAG was compared to PCI (adjusted HR, 0.83; 95% CI, 0.67-1.03; p = 0.088). Results after 1:1 propensity score matching (balancing for age) were similar. In subgroup analysis, all-cause mortality was significantly lower for patients with 3VD who underwent SAG versus PCI (adjusted HR, 0.68; 95% CI, 0.50-0.91; p = 0.009) or MAG versus PCI (adjusted HR, 0.55; 95% CI, 0.37-0.81; p = 0.002), while in LMCAD patients, there was no difference in all-cause mortality between CABG (either MAG or SAG) and PCI. No treatment-by-subgroup interaction existed for patients stratified by DM status.
Conclusions:
Patients who receive CABG with MAG have significantly lower all-cause mortality compared to those who receive PCI, notably in patients with 3VD.
Perspective:
While current guidelines support the use of MAG in CABG, it is performed in anywhere from 4-34% of CABG procedures across North America and Europe. There are wide variations in practice, which may be explained by lack of “compelling evidence,” technical/procedural factors with harvest and use of radial artery or right internal mammary artery conduit, and lack of incentives to perform a procedure that takes longer, is technically more difficult, may be associated with higher risk of complications, reimburses about the same as SAG, and certainly penalizes the surgeon and hospital if the patient develops sternal wound infection. This study adds to the collection of conflicting data in support of MAG. We await the results of the ROMA (Randomized comparison of the Outcome of single versus Multiple Arterial grafts) trial.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease
Keywords: Acute Coronary Syndrome, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Myocardial Ischemia, Percutaneous Coronary Intervention, Stroke Volume, Ventricular Function, Left
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