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Importance: It has been reported that women undergoing coronary artery bypass have higher mortality and morbidity compared with men but it is unclear if the difference has decreased over the last decade., Objective: To evaluate trends in outcomes of women undergoing coronary artery bypass in the US from 2011 to 2020., Design, Setting, and Participants: This retrospective cohort study at hospitals contributing to the Adult Cardiac Surgery Database of the Society of Thoracic Surgeons included 1 297 204 patients who underwent primary isolated coronary artery bypass from 2011 to 2020., Exposure: Coronary artery bypass., Main Outcomes and Measures: The primary outcome was operative mortality. The secondary outcome was the composite of operative mortality and morbidity (including operative mortality, stroke, kidney failure, reoperation, deep sternal wound infection, prolonged mechanical ventilation, and prolonged hospital stay). The attributable risk (the association of female sex with coronary artery bypass grafting outcomes) for the primary and secondary outcomes was calculated., Results: Between 2011 and 2020, 1 297 204 patients underwent primary isolated coronary artery bypass grafting with a mean age of 66.0 years, 317 716 of which were women (24.5%). Women had a higher unadjusted operative mortality (2.8%; 95% CI, 2.8-2.9 vs 1.7%; 95% CI, 1.7-1.7; P < .001) and overall unadjusted incidence of the composite of operative mortality and morbidity compared with men (22.9%; 95% CI, 22.7-23.0 vs 16.7%; 95% CI, 16.6-16.8; P < .001). The attributable risk of female sex for operative mortality varied from 1.28 in 2011 to 1.41 in 2020, with no significant change over the study period (P for trend = 0.38). The attributable risk for the composite of operative mortality and morbidity was 1.08 in both 2011 and 2020 with no significant change over the study period (P for trend = 0.71)., Conclusions and Relevance: Women remain at significantly higher risk for adverse outcomes following coronary artery bypass grafting and no significant improvement has been seen over the course of the last decade. Further investigation into the determinants of operative outcomes in women is urgently needed.

Background: Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database., Methods: Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching., Results: We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories., Conclusions: The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The optimal role of radial artery grafts in coronary artery bypass grafting (CABG) remains uncertain. The purpose of this study was to examine angiographic and clinical outcomes following CABG among patients who received a radial artery graft., Methods: Patients in the angiographic cohort of the PREVENT-IV trial were stratified based upon having received a radial artery graft or not during CABG. Baseline characteristics and 1-year angiographic and 5-year clinical outcomes were compared between patients., Results: Of 1,923 patients in the angiographic cohort of PREVENT-IV, 117 received a radial artery graft. These patients had longer surgical procedures (median 253 vs 228 minutes, P < .001) and had a greater number of grafts placed (P < .0001). Radial artery grafts had a graft-level failure rate of 23.0%, which was similar to vein grafts (25.2%) and higher than left internal mammary artery grafts (8.3%). The hazard of the composite clinical outcome of death, myocardial infarction, or repeat revascularization was similar for both cohorts (adjusted hazard ratio 0.896, 95% CI 0.609-1.319, P = .58). Radial graft failure rates were higher when used to bypass moderately stenotic lesions (<75% stenosis, 37% failure) compared with severely stenotic lesions (≥75% stenosis, 15% failure)., Conclusions: Radial artery grafts had early failure rates comparable to saphenous vein and higher than left internal mammary artery grafts. Use of a radial graft was not associated with a different rate of death, myocardial infarction, or postoperative revascularization. Despite the significant potential for residual confounding associated with post hoc observational analyses of clinical trial data, these findings suggest that when clinical circumstances permit, the radial artery is an acceptable alternative to saphenous vein and should be used to bypass severely stenotic target vessels., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aims: Accurate risk prediction in patients undergoing revascularisation is essential. We aimed to assess the predictive performance of Society of Thoracic Surgeons (STS) risk models in patients with left main coronary artery disease (LMCAD) undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention with everolimus-eluting stents (PCI-EES)., Methods and Results: The predictive performance of STS risk models for perioperative mortality, stroke and renal failure was evaluated for their discriminative ability (C statistic) and calibration (Hosmer-Lemeshow goodness-of-fit-test; χ2 and p-values) among patients with LMCAD undergoing PCI-EES (n=935) and CABG (n=923) from the randomised EXCEL trial. STS risk scores, in CABG patients, showed good discrimination for 30-day mortality and average discrimination for stroke (C statistic 0.730 and 0.629, respectively) with average calibration. For PCI, STS risk scores had no discrimination for mortality (C statistic 0.507), yet good discrimination (C statistic 0.751) and calibration for stroke. The predictive performance for renal failure was good for CABG (C statistic 0.82), yet poor for PCI (C statistic 0.59)., Conclusions: In selected patients with LMCAD from the EXCEL trial, STS risk models showed good predictive performance for CABG yet lacked predictive performance for PCI for perioperative mortality and renal failure. The STS stroke risk model was surprisingly more discriminating in PCI compared to CABG. Improved and procedure-specific risk prediction instruments are needed to accurately estimate adverse events after LMCAD revascularisation by CABG and PCI. ClinicalTrials.gov Identifier: NCT01205776.

Background: International collaboration has an interest in health care quality evaluation. We compared characteristics and surgical outcomes between Asian patients in the United States and Japanese patients who undergo adult cardiac surgery., Methods: Using the Japan Adult Cardiovascular Surgery Database (JCVSD) and The Society of Thoracic Surgeons (STS) National Database, we compared Asian patients undergoing isolated coronary artery bypass graft surgery between 2013 and 2016 in Japan and the United States. The STS had 16,903 Asian patients among 573,823 patients of all races undergoing isolated coronary artery bypass graft surgery (2.95%); the JCVSD had 55,570 patients, almost all of whom are Japanese. Descriptive statistics were analyzed independently, then the data were aggregated for comparison., Results: The JCVSD patients were older (69 vs 65 years) with a smaller body surface area (1.65 m 2 vs 1.81 m 2 ) and body mass index (24 kg/m 2 vs 26 kg/m 2 ). The proportion of males (79% vs 78%), prevalence of chronic lung disease (82% vs 86%), and diabetes mellitus (54% vs 60%) were similar. The JCVSD had higher prevalence of renal disease requiring dialysis (11% vs 6%). The numbers of anastomoses were similar (3.1 vs 3.3); off-pump procedures and the usage of right internal mammary artery were more prevalent (60% vs 15% and 38% vs 7%, respectively) in the JCVSD. The unadjusted operative mortality was 2.7% in the JCVSD and 2.1% in the STS database., Conclusions: Comparisons of coronary artery bypass graft surgery characteristics and outcomes were conducted between the STS National Database and the JCVSD to illustrate the value of international collaboration on adult cardiac surgery databases., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Multi-arterial bypass grafting with bilateral internal thoracic (BITA-MABG) or radial (RA-MABG) arteries improves long-term survival, but its increased complexity raises perioperative safety concerns. We compared perioperative outcomes of RA-MABG and BITA-MABG using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD)., Methods: We analysed the 2004-2015 BITA-MABG and RA-MABG experience in STS-ACSD. Primary end points were operative mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios [AOR (95% confidence interval)] were derived via multivariable logistic regression. Sensitivity analyses were done in patient sub-cohorts and based on institutional BITA-utilization rates (<5%, 5-10%, 10-20%, 20-40% and >40%)., Results: Eighty-five thousand nine hundred five RA-MABG (82.5% men; 61 years) and 61 336 BITA-MABG (85.1% men; 59 years) patients were analysed; 41.6% of BITA-MABG and 27.3% of RA-MABG cases came from institutions with low MABG utilization rates (<10%). Unadjusted OM was equivalent for both techniques (BITA-MABG versus RA-MABG: 1.3% vs 1.2%, P = 0.79), while DSWI was lower for RA-MABG (1.0% vs 0.6%, P < 0.001). RA-MABG was associated with lower adjusted OM [AOR = 0.80 (0.69-0.96)] and DSWI [AOR = 0.39 (0.32-0.46)]. Sensitivity analyses confirmed robustness of these findings. Equivalent outcomes were observed at high BITA-use institutions where BITA cases comprised >20% of all cases for OM and ≥40% for DSWI., Conclusions: This analysis of the STS-ACSD showed that RA-MABG is a generally safer form of multi-arterial coronary artery bypass grafting surgery. However, this advantage is mitigated at institutions with substantial BITA experience., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Beginning in 2002, all 14 Massachusetts nonfederal cardiac surgery programs submitted Society of Thoracic Surgeons (STS) National Database data to the Massachusetts Data Analysis Center for mandatory state-based analysis and reporting, and to STS for nationally benchmarked analyses. We sought to determine whether longitudinal prevalences and trends in risk factors and observed and expected mortality differed between Massachusetts and the nation., Methods: We analyzed 2003 to 2014 expected (STS predicted risk of operative [in-hospital + 30-day] mortality), observed, and risk-standardized isolated coronary artery bypass graft mortality using Massachusetts STS data (N = 39,400 cases) and national STS data (N = 1,815,234 cases). Analyses included percentage shares of total Massachusetts coronary artery bypass graft volume and expected mortality rates of 2 hospitals before and after outlier designation., Results: Massachusetts patients had significantly higher odds of diabetes, peripheral vascular disease, low ejection fraction, and age ≥75 years relative to national data and lower odds of shock (odds ratio, 0.66; 99% confidence interval, 0.53-0.83), emergency (odds ratio, 0.57, 99% confidence interval, 0.52-0.61), reoperation, chronic lung disease, dialysis, obesity, and female sex. STS predicted risk of operative [in-hospital + 30-day] mortality for Massachusetts patients was higher than national rates during 2003 to 2007 (P < .001) and no different during 2008 to 2014 (P = .135). Adjusting for STS predicted risk of operative [in-hospital + 30-day] mortality, Massachusetts patients had significantly lower odds (odds ratio, 0.79; 99% confidence interval, 0.66-0.96) of 30-day mortality relative to national data. Outlier programs experienced inconsistent, transient influences on expected mortality and their percentage shares of Massachusetts coronary artery bypass graft cases., Conclusions: During 12 years of mandatory public reporting, Massachusetts risk-standardized coronary artery bypass graft mortality was consistently and significantly lower than national rates, expected rates were comparable or higher, and evidence for risk aversion was conflicting and inconclusive., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We evaluated the presence of an 'obesity paradox' in coronary artery bypass grafting (CABG) patients, determined its time course and ascertained whether it is associated with improved cardiovascular (CV) survival versus non-CV survival., Methods: A retrospective analysis of 3 prospectively collected databases was conducted. A fifteen-year Kaplan-Meier analysis in 7091 CABG patients was performed and repeated in 5 body mass index [BMI (kg/m2)] cohorts [Normal (18.5-24.99 kg/m2), Overweight (25-29.99 kg/m2), Obese I (30-34.99 kg/m2), Obese II (35-39.99 kg/m2) and Obese III (≥40 kg/m2)]. Mortality hazard ratios {HR [95% confidence interval (CI)]} were derived using comprehensive multivariable competing risk Cox regression, accounting for BMI categories for overall (0-15), Early (0-1), Intermediate (1-8) and Late (8-15) postoperative years, to relax the proportional hazards assumption. The regression was repeated using BMI as a continuous variable. Mortality was classified into any, CV and non-CV., Results: Obese patients were younger with more comorbidities. Fifteen-year survival was improved in the Overweight and Obese I groups (P < 0.001). Adjusted 15-year mortality was reduced in the Overweight [HR (95% CI) = 0.88 (0.79-0.98)] and Obese I [HR = 0.88 (0.78-0.99)] groups driven by improved CV and non-CV survival. This trend was noted in the early (Overweight) and intermediate postoperative periods (Overweight and Obese I) with no significance in the late period. Higher mortality in the Obese III [HR = 1.28 (1.06-1.55)] group was driven by a decreased CV survival. Using BMI as a continuous variable, a BMI of 29 kg/m2 was associated with optimal survival., Conclusions: We identified a protective partial obesity paradox in the early and intermediate postoperative periods among Overweight and mildly obese (Obese I) patients with improved CV and non-CV survival. The morbidly obese (the Obese III group) had higher early and late CV mortality.

Background: We investigated whether extended arterial grafting with three or more arterial grafts in patients with a left internal thoracic artery to left anterior descending artery graft improves survival in coronary artery bypass graft surgery patients and whether its effects will depend on the extent of coronary artery disease; specifically three-vessel disease (3VD) versus two-vessel disease (2VD)., Methods: Fifteen-year mortality was analyzed in 11,931 patients with multivessel disease and primary isolated left internal thoracic artery to left anterior descending artery coronary artery bypass graft surgery with 2 or more grafts. Patients were aged 64.3 ± 10.5 years; 3,484 (29.2%) were women; 2,532 (21.2%) had 2VD and 9,399 (78.8%) had 3VD. Patients were grouped into one single-artery group (n = 6,782, 56.9%; reference group), and two multiple artery groups: two arteries (n = 3,678, 30.8%) and three arteries (n = 1,471, 12.3%). Long-term survival was compared by Kaplan-Meier estimates. Risk-adjusted mortality hazard ratio (HR) with 95% confidence interval (CI) were derived by covariate adjusted Cox regression to quantify multiple artery effects versus one artery in the overall cohort and separately among patients with 2VD and 3VD., Results: Radial artery (94%) and right internal thoracic artery (6%) conduits were used for additional arterial grafts. For the entire multivessel cohort, increasing number of arterial grafts was associated with incrementally improved 15-year survival (two arteries HR 0.85, 95% CI: 0.78 to 0.92; three arteries HR 0.75, 95% CI: 0.65 to 0.85). The three arteries versus two arteries comparison was consistent, even if not significant (HR 0.89, 95% CI: 0.77 to 1.03). The benefits derived from additional arterial grafts were more pronounced in case of 3VD (two arteries HR 0.84 95% CI: 0.76 to 0.92; three arteries HR 0.73, 95% CI: 0.63 to 0.84), without survival benefit with 2VD., Conclusions: Our results support the use of extended arterial grafting to maximize long-term coronary artery bypass graft surgery patient survival, especially for 3VD patients., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Incomplete coronary revascularization is associated with suboptimal outcomes. We investigated the long-term effects of Incomplete, Complete, and Supra-complete revascularization and whether these effects differed in the setting of single-arterial and multi-arterial coronary artery bypass graft (CABG)., Methods: We analyzed 15-year mortality in 7157 CABG patients (64.1 ± 10.5 years; 30% women). All patients received a left internal thoracic artery to left anterior descending coronary artery graft with additional venous grafts only (single-arterial) or with at least one additional arterial graft (multi-arterial) and were grouped based on a completeness of revascularization index (CRI = number of grafts minus the number of diseased principal coronary arteries): Incomplete (CRI ≤ -1 [N = 320;4.5%]); Complete (CRI = 0 [N = 2882;40.3%]; reference group); and two Supra-complete categories (CRI = +1[N = 3050; 42.6%]; CRI ≥ + 2 [N = 905; 12.6%]). Risk-adjusted mortality hazard ratios (AHR) were calculated using comprehensive propensity score adjustment by Cox regression., Results: Incomplete revascularization was rare (4.5%) but associated with increased mortality in all patients (AHR [95% confidence interval] = 1.53 [1.29-1.80]), those undergoing single-arterial CABG (AHR = 1.27 [1.04-1.54]) and multi-arterial CABG (AHR = 2.18 [1.60-2.99]), as well as in patients with 3-Vessel (AHR = 1.37 [1.16-1.62]) and, to a lesser degree, with 2-Vessel (AHR = 1.67 [0.53-5.23]) coronary disease. Supra-complete revascularization was generally associated with incrementally decreased mortality in all patients (AHR [CRI = +1] = 0.94 [0.87-1.03]); AHR [CRI ≥ +2] = 0.74 [0.64-0.85]), and was driven by a significantly decreased mortality risk in single-arterial CABG (AHR [CRI = +1] = 0.90 [0.81-0.99]; AHR [CRI ≥ +2] = 0.64 [0.53-0.78]); and 3-Vessel disease patients (AHR [CRI = +1] = 0.94 [0.86-1.04]; and AHR [CRI ≥ +2] = 0.75 [0.63-0.88]) with no impact in multi-arterial CABG (AHR [CRI = +1] = 1.07 [0.91-1.26]; AHR [CRI ≥ +2] = 0.93 [0.73-1.17])., Conclusions: Incomplete revascularization is associated with decreased late survival, irrespective of grafting strategy. Alternatively, supra-complete revascularization is associated with improved survival in patients with 3-Vessel CAD, and in single-arterial but not multi-arterial CABG., (© 2018 Wiley Periodicals, Inc.)

Objectives: Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting. Although transient, POAF is linked to increased late mortality. We hypothesized that POAF increases late cerebrovascular (CeV) and composite cerebrovascular/cardiovascular/vascular (CV* = CeV + CV + Other-V) but not non-cardiovascular (Non-CV) mortality., Methods: We analysed 8807 non-salvage coronary artery bypass grafting patients (1994-2011). Fifteen-year and time-segmented (early, 0-1 year; intermediate, 1-6 years and late, 6-15 years) all-cause and cause-specific mortality were compared for POAF versus No-POAF patients. Corresponding POAF versus No-POAF adjusted hazard ratios [AHRs (95% confidence interval, CI)] were derived using the competing risk Cox regression., Results: POAF occurred in 1992 (23%) patients. Complications other than POAF occurred in 1875 (21%) patients but were more frequent among POAF patients (31% vs 18%; P < 0.001). Overall mean follow-up was 9 ± 4 years. POAF patients had a higher 15-year unadjusted mortality (53% vs 39%; P < 0.001) and were consequently associated with higher adjusted all-cause [AHR (95% CI) = 1.23 (1.14-1.33)] and composite cardiovascular [CV*: AHR (95% CI) = 1.15 (1.02-1.30)] mortality. The trends towards a higher 15-year CeV [AHR (95% CI) = 1.34 (0.94-1.91)] and Non-CV [AHR (95% CI) = 1.12 (0.99-1.26)] mortality were not significant. Time-segmented analyses showed that (i) POAF increased all-cause mortality early, and this persisted in the intermediate and late periods and (ii) CeV [AHR (95% CI) = 2.14 (1.14-4.04)] and CV* [AHR (95% CI) = 1.31 (1.06-1.62)] mortality rates were increased in the intermediate but not in the early or late periods. Non-CV mortality was similar in POAF and No-POAF for all time intervals. These findings were corroborated in propensity-matched sub-cohorts and in sensitivity analyses in patients free of any other complication., Conclusions: POAF is associated with worse long-term survival principally driven by increased intermediate-term cerebrovascular and cardiovascular mortality, while Non-CV mortality was similar.

Background: The multiarterial grafting survival advantage noted in the overall population undergoing coronary artery bypass grafting is not well defined in the obese. We investigated the early to late survival effects of the radial artery in left internal thoracic artery-based multiarterial bypass grafting (radial artery-multiarterial bypass grafting) versus single arterial bypass grafting (left internal thoracic artery-single arterial bypass grafting) in obese patients., Methods: We analyzed 15-year Kaplan-Meier survival in 6102 patients receiving primary, left internal thoracic artery-based coronary artery bypass grafting with 2 or more grafts divided into body mass index groups: nonobese (<30 kg/m 2 ) and all-obese, comprised of mildly obese (30-35 kg/m 2 ) and morbidly obese (>35 kg/m 2 ). Risk-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of radial artery-multiarterial bypass grafting versus left internal thoracic artery-single arterial bypass grafting were derived via Cox regression and applied separately for early (<0.5 years), intermediate (0.5-5 years), and late (5-15 years) follow-up in each body mass index cohort. Propensity score matching between radial artery-multiarterial bypass grafting and left internal thoracic artery-single arterial bypass grafting cohorts within the body mass index groups was performed as a corroborating analysis., Results: Radial artery-multiarterial bypass grafting was more frequently used in obese patients who were younger (62 ± 10 years; mild/morbid: 45.4%/54.4% radial artery-multiarterial bypass grafting) compared with nonobese patients (66 ± 10 years; 37.4% radial artery-multiarterial bypass grafting). Unadjusted 15-year survival was significantly better for radial artery-multiarterial bypass grafting in all body mass index groups. Multivariate analysis showed a survival benefit of radial artery-multiarterial bypass grafting over the entire 0- to 15-year study period in the all-obese cohort (HR, 0.85; 95% CI, 0.74-0.98) and was more pronounced in the mildly obese (HR, 0.79; 95% CI, 0.66-0.96) versus morbidly obese (HR, 0.88; 95% CI, 0.69-1.13). The radial artery-multiarterial bypass grafting survival benefit was realized between 0.5 and 5 years postoperatively and was comparable for all-obese (HR, 0.69; 95% CI, 0.51-0.94) and nonobese (HR, 0.68; 95% CI, 0.52-0.88) groups. Propensity score matching was confirmatory., Conclusions: Radial artery-multiarterial bypass grafting confers a long-term survival advantage in both obese and nonobese patients., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Multiarterial coronary grafting with two arterial grafts leads to improved survival compared with conventional single artery based on left internal thoracic artery to left anterior descending artery and saphenous vein grafts. We investigated whether extending arterial grafting to three or more arterial grafts further improves survival, and whether such a benefit is modified by diabetes mellitus., Methods: We analyzed 15-year coronary artery bypass graft surgery mortality data in 11,931 patients (age 64.3 ± 10.5 years; 3,484 women [29.2%]; 4,377 [36.7%] with diabetes mellitus) derived from three US institutions (1994 to 2011). All underwent primary isolated left internal thoracic artery to left anterior descending artery grafting with at least two grafts: one artery (n = 6,782; 56.9%); two arteries (n = 3,678; 30.8%); or three or more arteries (n = 1,471; 12.3%). Long-term survival was estimated by Kaplan-Meier methods. Propensity score matching and comprehensive covariate adjustment (Cox regression) were used to derive long-term risk-adjusted hazard ratio (HR) with 95% confidence interval (CI) for increasing number of arterial grafts in the overall cohort and for diabetes and no-diabetes cohorts., Results: Radial artery (94%) and right internal thoracic artery (6%) were used as additional arterial grafts. Multivariate analysis in all patients showed that diabetes was associated with decreased survival (HR 1.43, 95% CI: 1.34 to 53), whereas increasing number of arterial grafts was associated with decreased mortality (one artery HR 1.0 [reference]; two arteries HR 0.87, 95% CI: 0.80 to 0.95; and three arteries HR 0.83, 95% CI: 0.72 to 0.95). Pairwise comparisons also showed an incremental benefit of additional arterial grafts: two arteries versus one artery, HR 0.89 (95% CI: 0.80 to 0.98); and three arteries versus one artery, HR 0.80 (95% CI: 0.68 to 0.94). A three-artery versus two-artery survival advantage trend was also noted, but was not significant in either the overall study cohort (HR 0.90, 95% CI: 0.75 to 1.07), the diabetes cohort (HR 0.79, 95% CI: 0.60 to 1.03), or the no-diabetes cohort (HR 01.00, 95% CI: 0.79 to 1.26). Among diabetes patients, the survival advantage of two arteries versus one artery was modest (HR 0.96, 95% CI: 0.72 to 1.11), whereas it was significant for three arteries versus one artery (HR 0.74, 95% CI: 0.58 to 0.96). Analyses of propensity matched subcohorts were also consistent., Conclusions: Increasing number of arterial grafts improves long-term survival and supports extended use of arterial grafts in coronary artery bypass graft surgery, irrespective of diabetes status., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This meta-analysis was designed to assess whether center experience affects the short- and long-term results and the relative benefits of bilateral internal thoracic artery grafting (BITA) for coronary artery bypass grafting., Methods and Results: MEDLINE and EMBASE were searched to identify all articles reporting the outcome of BITA in patients undergoing coronary artery bypass grafting. The BITA center experience was gauged according to the percentage use of BITA in the institutional overall coronary artery bypass grafting population (%BITA). The primary outcome was long-term all-cause mortality. Secondary outcomes were operative mortality, perioperative myocardial infarction, perioperative stroke, deep sternal wound infections (DSWIs), and major postoperative adverse event. The rates of the primary and secondary outcomes were calculated after adjusting for %BITA. Primary and secondary outcomes were also compared between the BITA and the single internal thoracic artery arms in the adjusted studies. Meta-regression was used to evaluate the effect of %BITA on the primary and secondary outcomes. Thirty-four studies (27 894 patients undergoing BITA) were included. In the pooled analysis, the incidence rate for long-term mortality was 2.83% (95% confidence interval, 2.21%-3.61%). %BITA was significantly and inversely associated with long-term mortality and the rate of DSWI. In the pairwise comparison, %BITA was significantly and inversely associated with the risk of long-term mortality and DSWI in the group undergoing BITA., Conclusions: BITA series with higher %BITA report significantly lower long-term mortality and DSWI rate as well as higher long-term survival advantage and lower relative risk of DSWI in their BITA cohort. These findings suggest that a specific volume-outcome relationship exists for BITA grafting., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting., (© 2018 Wiley Periodicals, Inc.)

Background: More than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe., Methods: We analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (n = 73,054) and RA-MABG (n = 97,623) vs SABG (n = 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate., Results: SABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p < 0.001) and RA-MABG (1.19%, p < 0.001). DSWI was higher among BITA-MABG (1.08%, p < 0.001) and similar for RA-MABG (0.71%, p = 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; p = 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p < 0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; p = 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; p = 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (<5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p < 0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; p = 0.049) BITA use., Conclusions: MABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Recent evidence shows that multi-arterial coronary artery bypass grafting (MABG) based on bilateral internal thoracic (BITA) or left internal thoracic (LITA) and radial artery (RA) improves long-term outcomes compared with single arterial coronary artery bypass grafting (SABG) (LITA + saphenous vein graft). How this evidence affected the worldwide use of MABG, if at all, is not well defined. Accordingly, we report 10-year temporal trends of MABG utilization from 2 continents. A study population of 1,683,434 non-emergent, primary, isolated LITA-based coronary artery bypass grafting (CABG) (≥2 grafts) patients was derived from the Society of Thoracic Surgeons (STS) (1,307,528 (79.5%) of 1,644,388 isolated CABG; total 1179 centers) and the Australia New Zealand Cardiothoracic (ANZ) Databases (34,213 (87%) of 39,046 isolated CABG; 24 centers) between 2004 and 2014. Patients were excluded based on the following: (1) no LITA, (2) if arterial grafts were other than RA or ITA, or (3) if grafting data were missing. The 3 MABG groups were LITA + RA, BITA, and BITA + RA, each with or without supplemental vein grafts. Grafting trends and their associated patient demographics were analyzed. SABG (89.3% STS, 51.4% ANZ) was the most common grafting strategy. MABG was most frequently accomplished by LITA + RA: (STS: 6.1%; ANZ: 42.6%), followed by BITA: (STS: 4.1%; ANZ: 4.3%), while ≥3 (BITA + RA) was rare in the STS (0.5%), but more common in ANZ (5.9%). In the STS, between 2004 and 2014, SABG rates systematically increased from 85.2% to 91.7%, BITA grafting was essentially unchanged from 3.6% to 4.3%, while RA use decreased systematically from 10.5% to 3.7%. In the ANZ, SABG rates increased from 17.3% to 51.4%, BITA grafting decreased from 6.3% to 3.6%, while RA grafting decreased from 65.8% to 39.0%. Compared with SABG patients, BITA patients were younger (STS: median age 59 vs 66, P < 0.001; ANZ: mean age 62 vs 68, P < 0.001), predominately male (STS: 84% vs 73%, P < 0.001; ANZ: 86% vs 79%, P < 0.001), less obese (body mass index >30 kg/m 2 ) in STS (37% vs 42%, P < 0.001), more obese in ANZ (33% vs 32%, P = 0.001), and less diabetic (STS: 26% vs 43%, P < 0.001; ANZ: 25% vs 37%, P < 0.001), whereas RA patients were intermediate in age (STS: 61; ANZ: 65), in male sex (STS: 82%; ANZ: 81%), in the prevalence of diabetes (STS: 40%; ANZ: 34%), and were most obese (STS: 47%; ANZ: 34%). A decade-long analysis of STS data reveals a counterintuitive decline in the use (driven by decreasing RA use) of MABG: a potentially superior grafting strategy compared with SABG. In contra distinction, the smaller but growing ANZ data document a distinctly different CABG practice pattern, with a higher MABG utilization rate, but a similarly declining RA use. The reasons for these practice patterns and declining MABG are likely diverse and require further assessment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: It is not clear whether radial artery (RA), right internal thoracic artery (RITA), or saphenous vein (SV) is the preferred second bypass graft during coronary artery bypass graft surgery using the left internal thoracic artery (LITA) in patients aged less or greater than 70 years., Methods: Late survival data were collected for 13,324 consecutive, isolated, primary coronary artery bypass graft surgery patients from three hospitals. Cox regression analysis was performed on all patients grouped by age., Results: Adjusted Cox regression showed overall better RA versus SV survival (hazard ratio [HR] 0.82, p < 0.001) and no difference in RITA versus SV survival (HR 0.95, p = 0.35). However, the survival benefit of RA versus SV was seen only in patients aged less than 70 years (HR 0.77, p < 0.001); and RITA patients aged less than 70 years also had a survival benefit compared with SV (HR 0.86, p = 0.03). There was no difference in survival for RA versus RITA across all ages., Conclusions: For patients aged less than 70 years, the optimal grafting strategy is using either RA or RITA as the second preferred graft. In patients aged 70 years or more, RA and RITA grafting should be used selectively. Multiple arterial grafting using either RA or RITA should be more widely utilized during coronary artery bypass graft surgery for patients less than 70 years of age., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We currently have an incomplete understanding of which postoperative complications after coronary artery bypass grafting (CABG) are associated with long-term death. The purpose of this study was to find the associations between complications and attributable death., Methods: Prospectively collected data on patient characteristics, risk factors, and complications of patients undergoing isolated CABG with 20-year follow-up were analyzed with a Cox regression model to calculate the overall hazard of dying associated with each postoperative complication. An individual's age and hazard of dying from each complication were then used to calculate years of life lost to each complication., Results: The postoperative mortality rate was 0.79% (69 of 8,773) at 30 days, 2.85% (250 of 8,773) at 180 days, and 6.38% (560 of 8,773) at 2 years. At a median follow-up of 9.8 years, 1,891 patients (21.6%) had died. Postoperative complications occurred in 3,438 patients (39.2%). Cardiac arrest (hazard ratio, 2.153), reoperation (hazard ratio, 1.679), and new dialysis (hazard ratio, 1.64) were the complications with the greatest hazard of death. After adjusting for complication incidence and patient age, cardiac arrest (703 years), reoperation (544 years), atrial fibrillation (470 years), and prolonged mechanical ventilation (371 years) were associated with the greatest number of years of life lost., Conclusions: Acute cardiac arrest, reoperation for other cardiac reasons, new dialysis, atrial fibrillation, and prolonged mechanical ventilation are associated with the largest increase in attributable deaths. Prevention and treatment of these complications may improve mortality rates after cardiac operations., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Red blood cell transfusion after coronary artery bypass graft surgery has been associated with increased late all-cause death. Yet, whether this association is, first, independent of the packed red blood cells and perioperative morbidity association, and second, of a cardiac versus noncardiac etiology remains unknown., Methods: We analyzed patients undergoing coronary artery bypass graft surgery at two Ohio hospitals (n = 6,947) from 1994 to 2007. Salvage operations and patients with preoperative renal failure were excluded. Long-term outcomes and leading cause of death (cardiac, noncardiac, all cause) were derived from the US Social Security Death Index and later from Ohio Department of Health Death Index. Fifteen-year mortality cumulative incidence functions were compared for transfusion groups (yes, n = 2,540; no, n = 4,806) overall, and then stratified based on perioperative complications status (yes, n = 2,638; no, n = 4,708). Comprehensive, 32 covariates, risk-adjusted transfusion effects were estimated by competing risk regression. Results were confirmed by propensity score adjusted analysis., Results: Perioperative transfusions and complications occurred in 33.9% and 35.2% of patients, respectively. In all, 3,108 deaths (48.1%) have been documented (median time to death, 7.43 years). Both transfusion rates (25.6% versus 49.1%, p < 0.001) and deaths (58.2% versus 38.5%, p < 0.001) were more frequent among complications patients. Red blood cells transfusion increased intermediate to late mortality risk overall (15-year adjusted hazard ratio [AHR] 1.21, 95% confidence interval [CI]: 1.11 to 1.31), and for complications (AHR 1.24, 95% CI: 1.11 to 1.39) and no complications (AHR 1.16, 95% CI: 1.03 to 1.31). The increased mortality was true for cardiac and noncardiac etiologies (AHR 1.19, 95% CI: 1.03 to 1.36, and AHR 1.14, 95% CI: 1.01 to 1.29, respectively). Red blood cell transfusion increased mostly cardiac deaths (AHR 1.38, 95% CI: 1.14 to 1.66) among the complications group, and noncardiac mortality (AHR 1.24, 95% CI: 1.05 to 1.47) for the no complications group. A parallel propensity matched sensitivity analysis confirmed these findings., Conclusions: Perioperative red blood cells transfusion is associated with significant adverse late death effects among both complicated patients and noncomplicated patients, principally seen between 0 and 5 years postoperatively, and is driven by both increased cardiovascular and noncardiovascular mortality. Further studies are needed to elucidate the mechanisms behind these findings, including their potential dose dependence., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Multiple arterial coronary artery grafting (MABG) improves long-term survival compared with single arterial CABG (SABG), yet the best second arterial conduit to be used with the left internal thoracic artery (LITA) remains undefined. Outcomes in patients grafted with radial artery (RA-MABG) versus right internal thoracic artery (RITA-MABG) as the second arterial graft were compared with SABG., Methods: Multi-institutional, retrospective analysis of non-emergent isolated LITA to left anterior descending coronary artery CABG patients was performed using institutional Society of Thoracic Surgeon National Adult Cardiac Surgery Databases. 4484 (54.5%) SABG [LITA ± saphenous vein grafts (SVG)], 3095 (37.6%) RA-MABG (RA ± SVG) and 641 (7.9%) RITA-MABG (RITA ± SVG) patients were included. The RITA was used as a free (68%) or in situ (32%) graft. RA grafts were principally anastomosed to the ascending aorta. Long-term survival was ascertained from US Social Security Death Index and institutional follow-up. Triplet propensity matching and covariate-adjusted multivariate logistic regression were used to adjust for baseline differences between study cohorts., Results: Compared with the SABG cohort, the RITA-MABG cohort was younger (58.6 ± 10.2vs65.9 ± 10.4, P < 0.001), had a higher prevalence of males (87% vs 65%, P < 0.001) and was generally healthier (MI: 36.7% vs 56.7%, P < 0.001, smoking: 56.8% vs 61.1%, IDDM: 3.0% vs 14.4%, CVA: 2.6% vs 10.0%). The RA-MABG cohort was generally characterized by a risk profile intermediate to that of SABG and RlTA-MABG. Unadjusted 5-, 10- and 15-year survival rates were best in RITA-MABG (95.2%, 89% and 82%), intermediate in RA-MABG (89%, 74%, 57%) and worst in SABG (82%, 61% and 44%) cohorts (all P < 0.001). Propensity matching yielded 551 RA-MABG, RITA-MABG and SABG triplets, which showed similar 30-day mortality. Late survival (16 years) was equivalent in the RA-MABG and RITA-MABG cohorts [68.2% vs 66.7%, P = 0.127, hazard ratio (HR) = 1.28 (0.96-1.71)] and both significantly better than SABG (61.1%). The corresponding SABG versus RITA-MABG and SABG versus RA-MABG HRs (95% confidence interval) were 1.52 (1.18-1.96) and 1.31 (1.01-1.69) with P < 0.002 and P = 0.038, respectively., Conclusions: RA-MABG or RITA-MABG equally improve long-term survival compared with SABG and thus should be embraced by the Heart Team as the therapy of choice in LITA-based coronary artery bypass surgery., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES)., Objectives: This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG)., Methods: We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts., Results: BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001)., Conclusions: Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Left internal thoracic artery (LITA) and radial artery (RA) multi-arterial CABG (MABG) is generally associated with improved long-term survival compared with traditional LITA and saphenous vein single arterial CABG (SABG). We examined the hypothesis that this multi-arterial survival advantage persists irrespective of left ventricular ejection fraction (LVEF)., Methods: We retrospectively analyzed the primary, non-salvage multi-graft CABG experience (n = 11,261; 64.4 ± 10.4 years, 70.4% men) from 2 institutions (1995 to 2011). Risk-adjusted 15-year survival was pairwise compared for the MABG versus SABG grafting approaches within 3 LVEF subcohorts (>0.50, n = 4,833 [44% MABG]; 0.36 to 0.50, n = 4,465 [39% MABG]; and ≤ 0.35, n = 1,963 [35% MABG]) using propensity-matched and covariate adjusted Cox regression (all patients) comparisons., Results: Propensity matching yielded 1,317 (LVEF > 0.50), 1,179 (LVEF, 0.36 to 0.50), and 470 (LVEF ≤ 0.35) well-matched grafting method pairs. Acute perioperative mortality was equivalent between MABG and SABG within each LVEF group, but increased with decreasing LVEF. MABG was uniformly associated with better 15-year survival compared with SABG for all LVEF categories. The associated matched-adjusted hazard ratios (95% confidence intervals) were consistent across EF groups at 0.79 (0.68 to 0.93), 0.80 (0.69 to 0.93), and 0.82 (0.66 to 1.0), respectively. Covariate adjusted HR in all patients concurred with matched results., Conclusions: MABG results in significantly enhanced long-term survival compared with LITA/SVG SABG regardless of the degree of LV dysfunction. These results favor MABG as the therapy of choice in patients with LV dysfunction., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Recent studies have indicated that coronary artery bypass grafting (CABG) outcomes in patients with prior stents are suboptimal. We aimed to study the impact of prior percutaneous coronary intervention (PCI) with stenting (PCI-S) on late CABG mortality in diabetic patients with triple-vessel disease., Methods: We reviewed the primary nonemergency CABG experience from a single U.S. institution (n = 7005; 1996-2007, Toledo, Ohio). Diabetics with triple-vessel disease (n = 1583) were identified and divided into 2 groups: (1) prior PCI-S (n = 202); and (2) no prior PCI (No-PCI [n = 1381]). Hierarchic Cox proportional hazards models were used to assess the effect of prior PCI-S on 5-year mortality after CABG. A propensity score for PCI-S and No-PCI patients was derived using a nonparsimonious logistic regression and used to generate a 1:1 (PCI-S to No-PCI) matched cohort., Results: In model 1, after adjusting for preoperative clinical characteristics, medications, off-pump surgery, and isolated CABG surgery status, prior PCI-S was associated with a 39% increased risk of mortality (hazard ratio [HR] = 1.39, with 95% confidence interval [CI; 1.02, 1.90]; P = .04). Further adjustment for date of surgery (model 2) (HR = 1.39, with 95% CI [1.02, 1.91]; P = .04) or operative parameters (model 3) (HR = 1.38, with 95% CI [1.01, 1.88]; P = .046) did not alter the association. The 1:1 matched-cohort analysis confirmed the increased risk associated with PCI-S (HR = 1.61, with 95% CI [1.03, 2.51]; P = .037)., Conclusions: Patients who have both diabetes and triple-vessel disease, and have undergone prior PCI-S, have poorer long-term outcomes after CABG compared with those who have had no prior PCI-S., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Packed red blood cell (RBC) transfusions are associated with increased mortality after coronary artery bypass grafting (CABG) but not after cardiac valve operations. Transfusions are associated with increased strokes and deep venous thromboses after cardiac operations as well as increased peripheral vascular graft thrombosis. The purpose of this study was to determine if RBC transfusions were associated with a greater hazard of an occluded graft developing after CABG., Methods: Patients who underwent symptom-driven coronary artery angiography after CABG were analyzed using Cox models and propensity scoring to compare outcomes based on the RBC transfusion status during their index CABG hospitalization., Results: We analyzed 940 patients. We found that patients who received transfusions were more likely to have occluded grafts on angiography (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.03-1.50; p = 0.02). After adjusting for other factors, we found that RBC transfusion was associated with about a 20% increased hazard of graft occlusion (HR, 1.21; 95% CI,1.07-1.37; p = 0.003)., Conclusions: Perioperative RBC transfusion is associated with graft occlusion after CABG at both the patient and graft levels. These results add to the growing body of evidence that homologous RBC transfusion is not risk free but is associated with a variety of adverse effects including midterm graft failure., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The association of new-onset postoperative atrial fibrillation (POAF) and late death after coronary artery bypass grafting (CABG) has been confounded by the frequent concomitant serious complications that co-occur with POAF. We aimed to define the magnitude and time dependence of the effect of isolated POAF on late survival after uncomplicated CABG to comprehensively account for comorbidity and perioperative confounding factors., Methods: Nonsalvage CABG patients with no history of AF, no concomitant aortic or valvular surgery, and no perioperative complications other than POAF were studied (n=6305). Patients were divided into AF (n=1211, 68 years old, 72% male) and no-AF (n=5094, 63 years old, 70% male) groups. Propensity matching was done using 55 patient variables, including coronary grafts, completeness of revascularization, and transfusion data. The AF effect was quantified using time-segmented hazard ratios by Cox regression analysis., Results: Single (1-to-1), double (1-to-2), and triple (1-to-3) propensity matching of the AF and no-AF was achieved for 1196, 993, and 719 cases, respectively. The AF group showed significantly worse, yet time-varying, 0- to 18-year survival: 0 to 1 year, HR, 1.18 (95% confidence interval, 0.77-1.81); 1 to 6 years, HR, 1.37 (95% confidence interval, 1.12 to 1.67); and 6 to 17 years, HR, 1.25 (95% confidence interval, 1.05 to 1.49)., Conclusions: Isolated POAF was associated with a time-varying increase in mortality after CABG. Given these findings and the high incidence of POAF, efforts to reduce POAF should be pursued to potentially improve resource usage, morbidity, and mortality., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: studies have shown that elevated hemoglobin A1c levels are associated with worse short-term outcomes after cardiac surgery. However, the effect on readmission has not been studied. The primary purpose of this study was to determine the independent effect of hemoglobin A1c level on the readmission rate after cardiac surgery. The secondary purpose was assess its effect on complications and mortality., Methods: consecutive patients undergoing coronary artery bypass surgery between April 2007 and August 2010 were divided into 3 groups based on preoperative hemoglobin A1c levels. Outcomes were controlled for demographics, comorbidities, and surgery., Results: 300 (34%) patients had normal hemoglobin A1c levels (<6.0%), 305 (35%) had mildly elevated levels (6.0%-6.9%), and 275 (31%) had markedly elevated levels (≥ 7.0%). Postoperative glucose levels were similar among all 3 hemoglobin A1c groups. Compared to patients with normal hemoglobin A1c levels, those with higher levels were more likely to be readmitted: adjusted odds ratio 2.091 (95% confidence interval: 1.074-4.069, p = 0.036) for hemoglobin A1c 6.1%-6.9%; and adjusted odds ratio 2.089 (95% confidence interval: 1.050-4.155, p = 0.036) for hemoglobin A1c ≥ 7.0. Overall, 381 (43%) patients suffered complications, and hemoglobin A1c levels were similar in those with and without complications (6.8% ± 1.6% vs. 6.9% ± 1.7%, p = 0.837). Mortality was equivalent in all 3 hemoglobin A1c groups., Conclusions: elevated preoperative hemoglobin A1c levels are associated with an increased risk of readmission but not complications., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: A survival benefit of radial artery use versus saphenous vein grafting in coronary artery bypass grafting (CABG) has been reported. We aimed to elucidate the relative radial artery survival benefit as a function of time after surgery from two independent CABG series., Methods: We compared 0- to 15-year survival with radial artery versus saphenous vein grafting in isolated, nonsalvage primary CABG with left internal thoracic artery to left anterior descending from two institutions: Ohio (radial artery [n=2,361; 61 years]; saphenous vein [n=2,547; 67 years]), and New York (radial artery [n=1,970; 58 years]; saphenous vein [n=2,974; 69 years]). Separate multivariate radial artery-use propensity models based on demographic, preoperative factors, intraoperative variables, and completeness of revascularization data were computed and used to derive propensity- and sex-matched CABG cohorts (1,799 [Ohio] and 995 [New York] pairs). A three-phase (early and late) mortality model was fit to Kaplan-Meier mortality estimates and used to derive relative radial artery versus saphenous vein hazard functions., Results: Radial artery use patterns and patient risk profiles differed substantially for New York and Ohio, with the New York radial artery cohort significantly younger and more male. Within-institution matched graft-type cohorts were well matched. Cumulative mortality was significantly better for radial artery at both institutions (p < 0.001 both). All mortality-time data were well described by the three-phase model, and the derived relative hazard functions were qualitatively and quantitatively similar for New York and Ohio, exhibiting maximal benefit between 0.5 and 5 years., Conclusions: Despite substantial differences in radial artery use patterns during a 15-year period, our analysis in large propensity-matched radial artery and saphenous vein cohorts yielded remarkably similar, time-varying radial artery to saphenous vein survival benefit at both institutions. These converging findings based on two independent patient series extend currently available objective evidence in support of a radial artery survival advantage in CABG., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Both anemia and transfusions (Tx) are associated with mortality after cardiac operations. However, the relative contributions of anemia and Tx and their interaction on late mortality have not been determined., Methods: 922 patients who underwent isolated coronary artery bypass grafting (CABG) were retrospectively studied. Anemia (A+) was defined as hemoglobin<12 g/dL for men and <11 g/dL for women. Patients who received (Tx+) and did not receive (Tx-) transfusions were compared; patient characteristics were controlled for by the use of Cox analysis and then by matching Tx+ to Tx- patients based on identical hemoglobin levels at admission and by propensity matching., Results: 5.3% of Tx- patients died, compared with 11% of Tx+ patients (p=0.001). The interaction of anemia and Tx was associated with a greater hazard of dying. In particular, A+Tx+ (anemic, received transfusion) patients had a threefold hazard of death (2.918, 95% confidence interval=1.512-5.633, p=0.001) compared with A-Tx- (nonanemic, no transfusion) patients. A+Tx+ patients had twice the hazard of dying as did A+Tx- (anemic, no transfusion) (hazard ratio=2.087, 95% confidence interval=1.004-4.336, p=0.049). In populations matched by preoperative hemoglobin levels or by propensity scores, similar results were seen: a significant interaction between anemia and transfusion of red blood cells. A+Tx+ patients fared significantly worse than did the other three groups. Although there was no difference in mortality between A- patients who did or did not receive transfusions, A+T+ patients had triple the risk as A+T- patients, whereas A+Tx- patients had a similar risk of late mortality as A-Tx- patients., Conclusions: The anemia-transfusion interaction was associated with an increased hazard of late mortality., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether the use of the radial artery (RA) vs the saphenous vein (SV) as the second grafting conduit with the internal thoracic artery (ITA) confers a late-survival advantage in diabetes mellitus (DM)., Methods: We reviewed our 1996-2007 DM coronary artery bypass grafting (CABG) experience. Study patients (N = 2281) included all primary, non-salvage multigraft CABG discharged alive and receiving ≥1 ITA graft. Bilateral ITA, ITA-only grafts or concomitant valve/aortic surgery patients were excluded. A non-parsimonious, RA use propensity model (42 variables) was derived excluding five factors [gender, vessel disease, insulin, renal failure and left ventricular (LV) dysfunction] that were always strictly matched for all pairs. Greedy matching resulted in well-matched ITA/RA and ITA/SV cohorts (N = 578 each). The late follow-up was truncated at 16 years, and survival comparisons were done by Kaplan-Meier analysis., Results: RA grafting was used in 933 (41%) DM patients and was more frequent for non-insulin (513/1348; 49.1%) compared with insulin (271/784; 34.6%) dependent patients. Relatively fewer insulin ITA/RA (169; 62%) could be matched vs non-insulin (469; 71%). Late survival was significantly better for ITA/RA overall [hazard ratio, HR (95% confidence interval) = 0.78 (0.65-0.95); P = 0.012], but this was primarily due to the non-insulin sub-cohort [HR = 0.72 (0.56-0.91); P = 0.007] as opposed to no effect for insulin [HR = 0.92 (0.68-1.26); P = 0.61]. Sub-cohort analysis revealed a significant ITA/RA survival advantage in males, preserved LV function and three-vessel disease. No sub-cohorts were associated with superior ITA/SV survival., Conclusion: Our analysis indicated that RA grafting confers a significant late-survival advantage and, thus, supports its liberal use in DM patients undergoing multivessel CABG.

As many as 14 % of patients undergoing coronary artery bypass surgery are readmitted within 30 days. Readmission is usually the result of morbidity and may lead to death. The purpose of this study is to develop and compare statistical and genetic programming models to predict readmission. Patients were divided into separate Construction and Validation populations. Using 88 variables, logistic regression, genetic programs, and artificial neural nets were used to develop predictive models. Models were first constructed and tested on the Construction populations, then validated on the Validation population. Areas under the receiver operator characteristic curves (AU ROC) were used to compare the models. Two hundred and two patients (7.6 %) in the 2,644 patient Construction group and 216 (8.0 %) of the 2,711 patient Validation group were re-admitted within 30 days of CABG surgery. Logistic regression predicted readmission with AU ROC = .675 ± .021 in the Construction group. Genetic programs significantly improved the accuracy, AU ROC = .767 ± .001, p < .001). Artificial neural nets were less accurate with AU ROC = 0.597 ± .001 in the Construction group. Predictive accuracy of all three techniques fell in the Validation group. However, the accuracy of genetic programming (AU ROC = .654 ± .001) was still trivially but statistically non-significantly better than that of the logistic regression (AU ROC = .644 ± .020, p = .61). Genetic programming and logistic regression provide alternative methods to predict readmission that are similarly accurate.

Background: We aimed to determine whether the reported late survival benefit of radial artery (RA) versus saphenous vein (SV) grafting in the general coronary artery bypass graft surgery (CABG) population is maintained in elderly patients aged 70 years or older., Methods: We reviewed our 1996 to 2007 experience in 2,120 elderly patients (RA, n = 607; SV, n = 1,513) who underwent primary, nonsalvage CABG with multiple completed grafts including at least one internal thoracic artery (ITA) graft. Patients were excluded in case of single-vessel disease, bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery. Kaplan-Meier 12-year survival estimates were compared for 1-to-1 matched ITA/RA and ITA/SV cohorts based on a nonparsimonious RA use propensity model (48 variables)., Results: The ITA/RA and ITA/SV cohorts (both, aged 75 ± 4yrs and 3.5 ± 0.8 grafts) were well matched and had identical operative mortality (2.3%; 11 of 480 each). Late survival was superior ITA/RA versus ITA/SV (p < 0.001), estimated at 85.1% versus 70.6% and 70.9% versus 50.5% for 5 and 10 years, respectively. Late survival risk ratios (95% confidence interval) for RA versus SV grafting was 0.47 (0.36 to 0.61), and the relative SV to RA death hazard was greater than 1 between 1 and 144 months., Conclusions: The late survival results suggest that elderly (≥70 years) primary multivessel CABG patients benefit substantially when RA is used as the second conduit in combination with ITA. Indeed, compared with previously published comparisons including all age groups, the derived risk ratio indicates that the benefit for the elderly may exceed that for younger patients in the initial decade after CABG. Use of RA should not be avoided in the elderly., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study aimed to compare the survival benefit derived from using radial artery (RA) as a second arterial conduit in combination with internal thoracic artery (ITA), as opposed to ITA plus saphenous vein (SV) in men and women., Methods: We reviewed the 1996 to 2007 primary, nonsalvage coronary artery bypass graft surgery (CABG) experience at Mercy Saint Vincent Medical Center (n = 6,384; 69% men, 31% women). Study subjects had two or more completed grafts including one ITA graft. Patients with bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery were excluded. Separate sex nonparsimonious propensity models for RA grafting based on 47 preoperative and intraoperative factors were used to identify matched ITA/RA and ITA/SV cohorts. Kaplan-Meier and Cox regression analyses were then applied to assess sex-specific 12-year survival risk ratios of RA versus SV grafting., Results: Patient variables for the RA and SV cohorts were well-matched in both men (n = 1,416 each; median age 62 years) and women (n = 567 each; median age 66 years). Thirty-day mortality was similar for ITA/RA versus ITA/SV in men (1.3% versus 1.2%; p = 1.0) and women (1.4% versus 1.9%; p = 0.664). Late mortality (1 to 144 months) was significantly better for ITA/RA in men (risk ratio 0.65, 95% confidence interval: 0.54 to 0.79; p < 0.001) and women (risk ratio 0.75, 95% confidence interval: 0.57 to 0.99; p = 0.045)., Conclusions: Late survival results suggest that male and female CABG patients benefit appreciably from use of RA as a second arterial conduit in combination with ITA. Yet, the late survival advantage derived from RA use was relatively less for women. This sex variance in benefit likely reflects differences in risk profiles of male and female CABG patients., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The use of ketorolac, a potent cyclooxygenase-1 inhibitor, for analgesia after cardiac operations has been limited by concerns of increased cardiovascular events. However, a recent study found that its use after coronary artery bypass grafting was associated with improved survival., Methods: This was a retrospective study of patients who received coronary arteriograms for symptoms suggestive of recurrent ischemic heart disease. Patients who received postoperative ketorolac were matched with nonusers by propensity scores. Graft occlusion rates were compared, and their association with ketorolac use was compared using Cox proportional hazard modeling., Results: Although the rate of graft occlusion was similar in the two groups, in 184 of the 303 propensity-matched patients (61%) who received ketorolac vs 202 of the 303 patients (67%) who did not (p=0.13), there was a longer time to angiographically proven occlusion in the patients who received ketorolac (2.80±2.19 vs 2.04±1.63 years; p<0.001). Cox modeling to control for the other variables and the longer time to angiography in the ketorolac group showed that ketorolac use was associated with nearly a halving of the hazard ratio (0.561; 95% confidence interval, 0.454 to 0.692; p<0.001) for any graft occlusion., Conclusions: The use of ketorolac after coronary artery bypass grafting was associated with a lower rate of angiographically proven graft closure and suggests a mechanistic (improved graft patency) explanation for the previously reported survival benefit of ketorolac., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: We investigated whether use of radial artery versus saphenous vein grafts during coronary artery bypass grafting reoperations is associated with a significant long-term survival benefit., Methods: We reviewed a series of 347 consecutive coronary artery bypass grafting reoperations (1996-2007; 270 [78%] male patients; age, 65.3 +/- 9.2 years). Internal thoracic artery grafts were used in 248 (71%) patients at the time of the first coronary artery bypass grafting operation and in 154 (44%) patients at reoperation. Patients were grouped based on whether a functional radial artery graft was present after coronary artery bypass grafting reoperation (radial artery cohort, n = 203 [59%]) or not (saphenous vein cohort, n = 144 [41%]). Median time to reoperation was similar for the radial artery (10.3 years) and saphenous vein (10.1 years) cohorts (P = .55). Angiographic data were used to ascertain the number and type of grafts that remained functional from initial coronary artery bypass grafting. Survival data (< or = 12 years) were time segmented based on multiphase hazard modeling at 90 days, and late survival was then analyzed by using proportional hazard Cox regression, with risk adjustment based on a radial artery-use propensity score computed from 48 covariates, including time to reoperation, month of surgical intervention, and total arterial and vein grafts after reoperation. Propensity-matched and propensity quintile comparisons were also done., Results: Follow-up was similar for the radial artery versus saphenous vein cohorts (5.7 +/- 3.4 vs 5.8 +/- 4.0 years, P = .86), and 112 (50 in the radial artery and 62 in the saphenous vein cohorts) deaths were documented. Early mortality (< or = 90 days) did not differ for the radial artery (7.4%) and saphenous vein (12.5%) cohorts (P = .14). Unadjusted late outcomes were superior for the radial artery versus saphenous vein cohorts, with survival of 97.3% versus 92.9%, 84.9% versus 77.2%, and 74.1% versus 60.3% at 1, 5, and 10 years, respectively. Propensity-adjusted radial artery survival was superior, with a hazard ratio of 0.58 (P = .04), and this result was confirmed in a propensity-matched comparison., Conclusions: We conclude that the use of radial artery as opposed to saphenous vein grafting for reoperative coronary artery bypass grafting, either with or without concomitant internal thoracic artery grafts, is associated with a substantial improvement in late survival. This benefit is likely derived from the increased overall number of arterial grafts., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Ischemic preconditioning has been shown to attenuate the rise in creatine kinase-myocardial band levels that occur with coronary artery bypass surgery (CABG). Recently, concerns have been raised that some sulfonylureas particularly glibenclamide may block ischemic preconditioning. The purpose of this study was to determine the effect of various diabetic medicines on creatine kinase-myocardial band levels after CABG. In this retrospective study of 799 patients undergoing CABG, patients continued their routine diabetic medicines up to the day of surgery. Intra-operatively and postoperatively, tight glycemic control was maintained with an insulin infusion. Anesthesia was maintained with isoflurane supplemented by fentanyl. Creatine kinase-myocardial band levels were determined the day after surgery at 05:00 h and the mean levels compared between diabetics and non-diabetics and further compared by type of diabetic medicine. After univariable comparisons, linear regression was used to determine the statistically significant predictors of creatine kinase-myocardial band levels. After correction for other factors, none of the diabetic medicines was a statistically significant predictor of creatine kinase-myocardial band levels. We found that the use of glibenclamide or other diabetic medications had no effect on creatine kinase-myocardial band levels the morning after patients underwent CABG.

Background: Increasing the number of arterial grafts for coronary artery bypass grafting (CABG) has been linked to improved late survival. Currently, it is not known if these long-term benefits are also true when sequential radial artery (RA) grafts are the primary means to maximizing arterial revascularization., Methods: We compared late survival of 532 consecutive patients receiving sequential RA grafts (sequential RA group: 438 men; 462 with three-vessel disease) with that of a 4,131 contemporaneous internal thoracic artery (ITA) with saphenous vein (SV) multivessel CABG cohort (conventional group). Graft failure rates were determined from symptom-driven repeat angiography films in 122 sequential RA patients performed 2 to 4,317 days after surgery. Median survival sequential RA follow-up was 5.3 years (range, 0.5 to 12.3)., Results: The sequential RA patients received a total of 1,181 RA grafts (538 sequential [30 triple] and 75 single) along with 636 SV and 533 ITA. Overall RA graft failure (80 of 272; 29%) was intermediate to that for ITA (7 of 121; 5.8%; p < 0.001) and vein (54 of 133, 41.6%; p = 0.032) grafts. Sequential versus nonsequential RA failure did not differ (77 of 252 [31%] versus 3 of 20 [15%]; p = 0.202), while failure of the proximal (36 of 123; 29%) and distal (40 of 129; 31%) components of sequential RA grafts were essentially identical. A total of 69 deaths (6 operative; 1.1%) have occurred in the sequential RA cohort. Unadjusted 10-year sequential RA cohort survival was 76.2% overall, and 79.0% for the 454 primary isolated CABG subgroup. The risk-adjusted 10-year survival using a logit propensity score was substantially better for the sequential RA cohort versus the conventional CABG cohort (risk ratio [95% confidence interval] 0.61 [0.44 to 0.85]; p = 0.003)., Conclusions: Sequential RA grafting is a safe method for maximizing arterial revascularization and is associated with excellent 10-year survival that seems to be superior to conventional or ITA/SV CABG results. Also, the similar proximal and distal sequential RA patency mitigates concerns of a clinically significant effect of increased vasoreactivity of distal segments of RA conduits.

Background: Studies in patients undergoing coronary artery bypass grafting (CABG) have shown an increased long-term mortality rates associated with perioperative blood transfusions. However, some studies in other patient populations have shown no effect on death or even a lowered mortality rate in patients receiving blood transfusions, which suggests that the effects of blood transfusion may be disease-dependent., Methods: Data of all patients who underwent valve operations with or without associated CABG between October 2, 1991, and November 14, 2007, were obtained from the department's database and analyzed using logistic regression for 30-day and Cox models for long-term mortality to determine the effects of transfusion on death. To control for the potential interaction between transfusion and complications and sicker patients being more likely to receive blood, we separately analyzed the data for the different valve populations and used propensity analysis to control for sicker patients being more likely to receive blood., Results: Of 1823 patients who underwent valve operations, the operation was isolated in 993 and combined with CABG in 830. By 30 days, 125 patients (6.9%) had died, and 717 (39%) were dead at follow-up. After controlling for type of operation and factors that influenced the transfusion decision, transfusion was associated with increased death only in patients who had combined valve and CABG, and not in isolated valve operations., Conclusions: Transfusion had no effect on the mortality rate after isolated valve operations but was associated with increased mortality when valve operations were combined with CABG.

Background: Diabetes mellitus has become a major health issue in the United States and contributes to morbidity and mortality from coronary artery disease. Despite lifestyle changes and medications that have been shown to decrease complications and death, many persons have poor glycemic control. The purpose of this study is to determine the prevalence of elevated Hemoglobin A1c levels, a marker of glycemic control in patients presenting for coronary artery bypass surgery, and to determine if risk factors for diabetes mellitus could identify those patients with an elevated hemoglobin A1c., Methods: All patients undergoing coronary artery bypass surgery had hemoglobin A1c levels determined immediately preoperatively. Proportions were used to describe the number of patients with elevated levels. Linear regression and receiver operator characteristic curves were used to evaluate the accuracy of risk factors to identify patients with elevated levels., Results: 83 of 87 (95%) diabetic patients had elevated A1c levels (>or= 6.0%), with 55 of 87 (63%) having inadequate control - A1c levels >or= 7.0. 93 of 163 (57%) non-diabetic patients had elevated A1c levels (>or= 6.0%), with 19 (12%) having levels >or= 7.0%. Risk factors for diabetes mellitus poorly predicted which patient had elevated A1c levels., Conclusion: The prevalence of elevated hemoglobin levels in patients undergoing coronary artery bypass surgery is high and routine measurement should be done to permit institution of lifestyle modifications and medication changes that decrease complications and death from diabetes mellitus.