Efficacy of multiple arterial coronary bypass grafting in patients with diabetes mellitus

Type 2 diabetes mellitus and In-hospital Major Adverse Cardiac and Cerebrovascular Events (MACCEs) and postoperative complications among patients undergoing on-pump isolated coronary artery bypass surgery in Northeastern Iran

BACKGROUND

Diabetes Mellitus (DM) is a rapidly growing disorder worldwide, especially in the Middle East. A higher incidence of coronary artery diseases requiring coronary artery bypass graft (CABG) surgery has been reported in patients with diabetes. We assessed the association between type 2 diabetes mellitus (T2DM) and in-hospital major adverse cardiac and cerebrovascular events (MACCEs) and postoperative complications among patients who underwent on-pump isolated CABG.

METHODS

In this retrospective cohort study, we used the data registered for CABG patients from two heart centers in the Golestan province (North of Iran) between 2007 and 2016. The study population included 1956 patients divided into two groups: 1062 non-diabetic patients and 894 patients with diabetes (fasting plasma glucose ≥126 mg/dl or using antidiabetic medications). The study outcome was in-hospital MACCEs, a composite outcome of myocardial infarction (MI), stroke and cardiovascular death, and postoperative complications, including postoperative arrhythmia, acute atrial fibrillation (AF), major bleeding (defined as reoperation due to bleeding), and acute kidney injury (AKI).

RESULTS

During the 10-year study period, 1956 adult patients with a mean (SD) age of 59.0 (9.60) years were included. After adjustment for age, gender, ethnicity, obesity, opium consumption, and smoking, diabetes was a predictor of postoperative arrhythmia (AOR 1.30, 95% CI 1.08-1.57; P = 0.006). While it was not a predictor of in-hospital MACCEs (AOR 1.35, 95% CI 0.86, 2.11; P = 0.188), AF (AOR 0.85, 95% CI 0.60-1.19; P = 0.340), major bleeding (AOR 0.80, 95% CI 0.50, 1.30; P = 0.636) or AKI (AOR 1.29, 95% CI 0.42, 3.96; P 0.656) after CABG surgery.

CONCLUSION

Findings indicated that diabetes increased the risk of postoperative arrhythmia by 30%. However, we found similar in-hospital MACCEs, acute AF, major bleeding, and AKI following CABG surgery in both diabetic and non-diabetic patients.

Differences in long-term survival outcomes after coronary artery bypass grafting using single vs multiple arterial grafts: a meta-analysis with reconstructed time-to-event data and subgroup analyses

OBJECTIVE

We reviewed the available literature on patients with coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) with either single (SAG) or multiple arterial grafting (MAG).

METHODS

Original research studies that evaluated the long-term survival of MAG versus SAG were identified, from 1995 to 2022. The median overall survival (OS) and event-free OS were the primary endpoints. Comparison of median OS between the right internal mammary artery (RIMA) and radial artery (RA) as a second arterial conduit was the secondary endpoint. Subgroup analyses were performed regarding patients older than 70 years, with diabetes mellitus, and females. A sensitivity analysis was performed with the leave-one-out method.

RESULTS

Forty-four studies were included in the qualitative and thirty-nine in the quantitative synthesis. After pooling data from 180 to 459 patients, the MAG group demonstrated a higher OS (HR, 0.589; 95% CI, 0.58-0.60; p < 0.0001) and event-free OS compared with the SAG group (HR, 0.828; 95% CI, 0.80-0.86; p < 0.0001). In addition, RITA was associated with superior OS compared with RA as a second arterial conduit (HR, 0.936; 95% CI, 0.89-0.98; p = 0.009). MAG was also superior to SAG in patients over 70 years, females, and patients with diabetes mellitus. Sensitivity analysis demonstrated a small-size study effect on the female subgroup analysis.

CONCLUSION

The present meta-analysis indicates that MAG is associated with enhanced survival outcomes compared to SAG for patients undergoing isolated CABG.

Five-year follow-up on two revascularization methods used on patients with left main artery disease and/or multivessel coronary artery disease

BACKGROUND

Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are the main treatment methods for left main artery disease (LMAD) and triple-vessel coronary artery disease (TVCAD).

OBJECTIVE

This study aimed to evaluate the five-year post-treatment effects of CABG and PCI in patients with severe coronary vasculopathy.

METHODS

A total of 430 patients with LMAD and/or triple-vessel coronary artery disease from November 2014 to July 2015 were enrolled retrospectively in the affiliated cardiovascular hospital of Shanxi Medical University and divided into the CABG group and PCI group. The living conditions of the patients were obtained through medical records and telephonic follow-ups five years after the surgery date. The independent risk factors for major adverse cardiovascular and cerebrovascular events (MACCE) were analyzed using logistic regression analysis. The effects of the two treatment methods were followed up and evaluated to measure the predictive ability of the Global Risk Classification (GRC) scoring system for MACCE after five years.

RESULTS

There were 212 cases in the CABG group and 218 cases in the PCI group. Smoking (P= 0.047), diabetes (P= 0.031), LVEF (P= 0.020), LMAD (P= 0.008), and anterior descending branch lesions (P= 0.038) were significantly correlated with MACCE. The prevalence of MACCE in the CABG group and PCI group had no significant difference (P= 0.549). The GRC scoring system received an AUC of 0.701 for predicting MACCE.

CONCLUSION

For patients with severe coronary artery disease, there was no significant difference in the prevalence of MACCE between the CABG and the PCI groups. Several independent risk factors for MACCE were found. The GRC scoring system showed a strong predictive ability for MACCE after five years of revascularization.

Single versus multiple arterial grafting in diabetic patients at 10 years: the Arterial Revascularization Trial

AIMS

To evaluate the impact of multiple arterial grafting (MAG) vs. single arterial grafting (SAG) in a post hoc analysis of 10-year outcomes in patients with diabetes mellitus (DM) from the Arterial Revascularization Trial (ART).

METHODS AND RESULTS

The primary endpoint was all-cause mortality and the secondary endpoint was a composite of major adverse cardiac events (MACE) at 10-year follow-up. Patients were stratified by diabetes status (non-DM and DM) and grafting strategy (MAG vs. SAG). A total of 3020 patients were included in the analysis; 716 (23.7%) had DM. Overall, 55.8% non-DM patients received MAG and 44.2% received SAG, while 56.6% DM patients received MAG and 43.4% received SAG. The use of MAG compared with SAG was associated with lower 10-year mortality for both non-DM [17.7 vs. 21.0%, adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.72-1.06] and DM patients (21.5 vs. 29.9%, adjusted HR 0.65, 95% CI 0.48-0.89; P for interaction = 0.12). For both groups, the rate of 10-year MACE was also lower for MAG vs. SAG. Overall, deep sternal wound infections (DSWIs) were uncommon but more frequent in the MAG vs. SAG group in both non-DM (3.3 vs. 2.1%) and DM patients (7.9 vs. 4.8%). The highest rates of DSWI were in insulin-treated patients receiving MAG (9.6 vs. 6.3%, when compared with SAG).

CONCLUSION

In this post hoc analysis of the ART, MAG was associated with substantially lower mortality rates at 10 years after coronary artery bypass grafting in patients with DM. Patients with DM receiving MAG had a higher incidence of DSWI, especially if insulin dependent.

Long-term survival after coronary bypass surgery with multiple versus single arterial grafts

OBJECTIVES

This study sought to evaluate the long-term differences in survival between multiple arterial grafts (MAG) and single arterial grafts (SAG) in patients who underwent coronary artery bypass grafting (CABG) in the SYNTAX study.

METHODS

The present analysis included the randomized and registry-treated CABG patients (n = 1509) from the SYNTAX Extended Survival study (SYNTAXES). Patients with only venous (n = 42) or synthetic grafts (n = 1) were excluded. The primary end point was all-cause death at the longest follow-up. Multivariable Cox regression was used to adjust for differences in baseline characteristics. Sensitivity analysis using propensity matching with inverse probability for treatment weights was performed.

RESULTS

Of the 1466 included patients, 465 (31.7%) received MAG and 1001 (68.3%) SAG. Patients receiving MAG were younger and at lower risk. At the longest follow-up of 12.6 years, all-cause death occurred in 23.6% of MAG and 40.0% of SAG patients [adjusted hazard ratio (HR) 0.74, 95% confidence interval (CI) (0.55-0.98); P = 0.038], which was confirmed by sensitivity analysis. MAG in patients with the three-vessel disease was associated with significant lower unadjusted and adjusted all-cause death at 12.6 years [adjusted HR 0.65, 95% CI (0.44-0.97); P = 0.033]. In contrast, no significance was observed after risk adjustment in patients with the left main disease, with and without diabetes, or among SYNTAX score tertiles.

CONCLUSIONS

In the present post hoc analysis of all-comers patients from the SYNTAX trial, MAG resulted in markedly lower all-cause death at 12.6-year follow-up compared to a SAG strategy. Hence, this striking long-term survival benefit of MAG over SAG encourages more extensive use of multiple arterial grafting in selected patients with reasonable life expectancy.

TRIAL REGISTRATION

SYNTAXES ClinicalTrials.gov reference: NCT03417050; SYNTAX ClinicalTrials.gov reference: NCT00114972.

Ten-year improved survival in patients with multi-vessel coronary disease and poor left ventricular function following surgery: A retrospective cohort study

OBJECTIVE

Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] < 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients.

METHODS

We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI.

RESULTS

214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p < 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p < 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p < 0.001).

CONCLUSION

Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken.

Differences in Short- and Long-Term Mortality Associated With BMI Following Coronary Revascularization

BACKGROUND

The association between obesity and mortality risks following coronary revascularization is not clear. We examined the associations of BMI (kg/m2) with short-, intermediate-, and long-term mortality following coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with different coronary anatomy risks and diabetes mellitus status.

METHODS AND RESULTS

Data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry were analyzed. Using normal BMI (18.5-24.9) as a reference, multivariable-adjusted hazard ratios for all-cause mortality within 6 months, 1 year, 5 years, and 10 years were individually calculated for CABG and PCI with 4 prespecified BMI categories: overweight (25.0-29.9), obese class I (30.0-34.9), obese class II (35.0-39.9), and obese class III (≥40.0). The analyses were repeated after stratifying for coronary risks and diabetes mellitus status. The cohorts included 7560 and 30 258 patients for CABG and PCI, respectively. Following PCI, overall mortality was lower in patients with overweight and obese class I compared to those with normal BMI; however, 5- and 10-year mortality rates were significantly higher in patients with obese class III with high-risk coronary anatomy, which was primarily driven by higher mortality rates in patients without diabetes mellitus (5-year adjusted hazard ratio, 1.78 [95% CI, 1.11-2.85] and 10-year adjusted hazard ratio, 1.57 [95% CI, 1.02-2.43]). Following CABG, overweight was associated with lower mortality risks compared with normal BMI.

CONCLUSIONS

Overweight was associated with lower mortality following CABG and PCI. Greater long-term mortality in patients with obese class III following PCI, especially in those with high-risk coronary anatomy without diabetes mellitus, warrants further investigation.