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Background: Transcatheter aortic valve replacement (TAVR) has become the standard of care for a wide spectrum of patients with severe aortic stenosis. However, there are wide variations in access to TAVR among jurisdictions. It is unknown if such variation is associated with differences in postprocedural outcomes. Our objective was to determine whether differences in health care delivery in jurisdictions with high vs low access of care to TAVR translate to differences in postprocedural outcomes., Methods: In this observational, retrospective cohort study, we identified all Ontario and New York State residents greater than 18 years of age who received TAVR from January 1, 2012, to December 31, 2018. Our primary outcomes were post-TAVR 30 day in-hospital mortality and all-cause readmissions. Using indirect standardization, we calculated the observed vs expected outcomes for New York patients, had they been treated in Ontario., Results: Our cohort consisted of 16,814 TAVR patients at 36 hospitals in New York State and 5007 TAVR patients at 11 hospitals in Ontario. In Ontario, TAVR access rates increased from ∼18.2 TAVR per million in 2012 to 87.4 TAVR per million in 2018, whereas for New York State, the rates increased from 31.9 to 220.4 TAVR per million. For 30-day mortality, 3.1% of Ontario TAVR patients had an in-hospital death, compared with 2.5% of New York patients. With adjustment, this translated to an observed-expected ratio of 0.70 (95% confidence interval [CI], 0.54-0.92) for New York patients., Conclusions: Having greater access to TAVR may be associated with improved outcomes, potentially because of intervention earlier in the trajectory of the disease., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Randomized trials have compared percutaneous coronary intervention and coronary artery bypass grafting (CABG) in patients with left main coronary artery disease undergoing nonemergent revascularization. However, there is a paucity of real-world contemporary observational studies comparing percutaneous coronary intervention (PCI) and CABG., Objectives: The purpose of this study was to compare the long-term clinical outcomes of CABG versus PCI in patients with left main coronary disease., Methods: Clinical and administrative databases for Ontario, Canada, were linked to obtain records of all patients with angiographic evidence of left main coronary artery disease (≥50% stenosis) treated with either isolated CABG or PCI from 2008 to 2020. Emergent, cardiogenic shock, and ST-segment elevation myocardial infarction patients were excluded. Baseline characteristics of patients were compared and 1:1 propensity score matching was performed. Late mortality and major adverse cardiac and cerebrovascular events were compared between the matched groups using a Cox proportional hazard model., Results: After exclusions, 1,299 and 21,287 patients underwent PCI and CABG, respectively. Prior to matching, PCI patients were older (age 75.2 vs 68.0 years) and more likely to be women (34.6% vs 20.1%), although they had less CAD burden. Propensity score matching on 25 baseline covariates yielded 1,128 well-matched pairs. There was no difference in early mortality between PCI and CABG (5.5% vs 3.9%; P = 0.075). Over 7-year follow-up, all-cause mortality (53.6% vs 35.2%; HR: 1.63; 95% CI: 1.42-1.87; P < 0.001) and major adverse cardiac and cerebrovascular events (66.8% vs 48.6%; HR: 1.77; 95% CI: 1.57-2.00) were significantly higher with PCI than CABG., Conclusions: CABG was the most common revascularization strategy in this real-world registry. Patients undergoing PCI were much older and of higher risk at baseline. After matching, there was no difference in early mortality but improved late survival and freedom from major adverse cardiac and cerebrovascular events with CABG., Competing Interests: Funding Support and Author Disclosures This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. This study also received funding from a Foundation grant from the Canadian Institutes of Health Research (grant FDN 148446) and the Ted Rogers Centre for Heart Research. The authors acknowledge that the clinical registry data used in this analysis are from participating hospitals through CorHealth Ontario, which serves as an advisory body to the Ontario Ministry of Health, is funded by the MOH, and is dedicated to improving the quality, efficiency, access, and equity in the delivery of the continuum of adult cardiac and stroke care in Ontario, Canada. Dr Lee has served as the Ted Rogers Chair in Heart Function Outcomes, University Health Network, University of Toronto. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Objective: Multiple arterial grafting (MAG) in coronary artery bypass grafting (CABG) is associated with higher survival and freedom from major adverse cardiac and cerebrovascular events (MACCEs) in observational studies of mostly men. It is not known whether MAG is beneficial in women. Our objectives were to compare the long-term clinical outcomes of MAG versus single arterial grafting (SAG) in women undergoing CABG for multivessel disease., Methods: Clinical and administrative databases for Ontario, Canada, were linked to obtain all women with angiographic evidence of left main, triple or double vessel disease undergoing isolated non-emergent primary CABG from 2008 to 2019. 1:1 propensity score matching was performed. Late mortality and MACCE (composite of stroke, myocardial infarction, repeat revascularisation and death) were compared between the matched groups with a stratified log-rank test and Cox proportional-hazards model., Results: 2961 and 7954 women underwent CABG with MAG and SAG, respectively, for multivessel disease. Prior to propensity-score matching, compared with SAG, those who underwent MAG were younger (66.0 vs 68.9 years) and had less comorbidities. After propensity-score matching, in 2446 well-matched pairs, there was no significant difference in 30-day mortality (1.6% vs 1.8%, p=0.43) between MAG and SAG. Over a median and maximum follow-up of 5.0 and 11.0 years, respectively, MAG was associated with greater survival (HR 0.85, 95% CI 0.75 to 0.98) and freedom from MACCE (HR 0.85, 95% CI 0.76 to 0.95)., Conclusions: MAG was associated with greater survival and freedom from MACCE and should be considered for women with good life expectancy requiring CABG., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There remains a paucity of real-world observational evidence comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with diabetes and multivessel coronary artery disease (CAD)., Objectives: This study compared early and long-term outcomes of PCI versus CABG in patients with diabetes., Methods: Clinical and administrative databases in Ontario, Canada were linked to obtain records of all patients with diabetes with angiographic evidence of 2- or 3-vessel CAD who were treated with either PCI or isolated CABG from 2008 to 2017. A 1:1 propensity score match was performed to account for baseline differences. All-cause mortality and the composite of myocardial infarction, repeat revascularization, stroke, or death (termed major cardiovascular and cerebrovascular events [MACCEs]) were compared between the matched groups using a stratified log-rank test and Cox proportional hazards model., Results: A total of 4,519 and 9,716 patients underwent PCI and CABG, respectively. Before matching, patients who underwent CABG were significantly younger (age 65.7 years vs. 68.3 years), were more likely to be men (78% vs. 73%) and had more severe CAD. Propensity score matching based on 23 baseline covariates yielded 4,301 well-balanced pairs. There was no difference in early mortality between PCI and CABG (2.4% vs. 2.3%; p = 0.721) after matching. The median and maximum follow-ups were 5.5 and 11.5 years, respectively. All-cause mortality (hazard ratio [HR]: 1.39; 95% CI: 1.28 to 1.51) and overall MACCEs (HR: 1.99; 95% CI: 1.86 to 2.12) were significantly higher with PCI compared with CABG., Conclusions: In patients with multivessel CAD and diabetes, CABG was associated with improved long-term mortality and freedom from MACCEs compared with PCI., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: The optimal conduits for coronary artery bypass grafting (CABG) remain controversial in multivessel coronary artery disease., Objective: To compare the long-term clinical outcomes of total arterial revascularization (TAR) vs non-TAR (CABG with at least 1 arterial and 1 saphenous vein graft) in a multicenter population-based study., Design, Setting, and Participants: This multicenter population-based cohort study using propensity score matching took place from October 2008 to March 2017 in Ontario, Canada, with a mean and maximum follow-up of 4.6 and 9.0 years, respectively. Individuals with primary isolated CABG were identified, with at least 1 arterial graft. Exclusion criteria were individuals from out of province and younger than 18 years. Patients undergoing a cardiac reoperation or those in cardiogenic shock were also excluded because these conditions would potentially bias the surgeon toward not performing TAR. Analysis began April 2019., Exposures: Total arterial revascularization., Main Outcomes and Measures: Primary outcome was time to first event of a composite of death, myocardial infarction, stroke, or repeated revascularization (major adverse cardiac and cerebrovascular events). Secondary outcomes included the individual components of the primary outcome., Results: Of 49 404 individuals with primary isolated CABG, 2433 (4.9%) received TAR, with the total number of bypasses being 2, 3, and 4 or more vessels in 1521 (62.5%), 865 (35.6%), and 47 individuals (1.9%), respectively. The mean (SD) age was 61.2 (10.4) years and 1983 (81.5%) were men. After propensity score matching, 2132 patient pairs were formed, with equal total number of bypasses (mean [SD], 2.4 [0.5]) but with more arterial grafts in the TAR group (mean [SD], 2.4 [0.5] vs 1.2 [0.4]; P < .01). In-hospital death (15 [0.7%] vs 21 [1.0%]; P = .32) did not differ between TAR vs non-TAR groups after propensity score matching. Throughout 8 years, TAR was associated with improved freedom from major adverse cardiac and cerebrovascular events (hazard ratio, 0.78; 95% CI, 0.68-0.89), death (hazard ratio, 0.80; 95% CI, 0.66-0.97), and myocardial infarction (hazard ratio, 0.69; 95% CI, 0.51-0.92). There was no difference in stroke and repeated revascularization., Conclusions and Relevance: Total arterial revascularization was associated with improved long-term freedom from major adverse cardiac and cerebrovascular events, death, and myocardial infarction and may be the procedure of choice for patients with reasonable life expectancy requiring CABG.

Objectives: The aim of this study was to compare early and late outcomes between redo surgical aortic valve replacement (AVR) and valve-in-valve (ViV) transcatheter AVR., Background: Published studies to date comparing redo surgical AVR (RS) with ViV transcatheter AVR for failed biological prostheses have been small and limited to early outcomes., Methods: Clinical and administrative databases for Ontario, Canada's most populous province, were linked to obtain patients undergoing ViV and RS for failed previous biological prostheses. Propensity score matching was performed to account for differences in baseline characteristics. Early outcomes were compared using the McNemar test. Late mortality was compared between the matched groups using a Cox proportional hazards model., Results: A total of 558 patients undergoing intervention for failed biological prostheses between March 31, 2008, and September 30, 2017, at 11 Ontario institutions (ViV, n = 214; RS, n = 344) were included. Patients who underwent ViV were older and had more comorbidities. Propensity matching on 27 variables yielded similar groups for comparison (n = 131 pairs). Mean time from initial AVR to RS or ViV was 8.6 ± 4.4 years and 11.3 ± 4.5 years, respectively. Thirty-day mortality was significantly lower with ViV compared with RS (absolute risk difference: -7.5%; 95% confidence interval: -12.6% to -2.3%). The rates of permanent pacemaker implantation and blood transfusions were also lower with ViV, as was length of stay. Survival at 5 years was higher with ViV (76.8% vs. 66.8%; hazard ratio: 0.55; 95% confidence interval: 0.30 to 0.99; p = 0.04)., Conclusions: ViV TAVR was associated with lower early mortality, morbidity, and length of hospital stay and with increased survival compared with RS and may be the preferred approach for the treatment of failed biological prostheses., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Observational studies have shown better survival in patients undergoing coronary artery bypass grafting (CABG) with 2 arterial grafts compared with 1. However, whether a third arterial graft is associated with incremental benefit remains uncertain. We sought to analyze the outcomes of 3 versus 2 arterial grafts during CABG. As a secondary objective, we compared CABG with 2 or 3 arterial grafts (multiple arterial grafts [MAG]) with CABG using a single arterial graft (SAG)., Methods: Retrospective cohort analyses of all patients undergoing primary isolated CABG in Ontario, Canada, from October 2008 to March 2016. Propensity score matching was performed between patients with 3 arterial grafts (3Art group) versus 2 (2Art group). The primary outcome was time to first event of a composite of death, myocardial infarction, stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events). Additional analyses were performed to evaluate the association between MAG versus SAG and long-term outcomes using propensity score matching., Results: Fifty thousand, two hundred thirty patients underwent isolated CABG during our study period; 3044 (6.1%) and 8253 (16.4%) patients had 3 and 2 arterial grafts, respectively, resulting in 2789 propensity score matching pairs for the primary analyses. Mean and maximum follow-up was 4.2 and 8.5 years, respectively. Radial artery grafting was more common in the 3Art versus 2Art group (79.3% versus 65.6%, P<0.01). In-hospital outcomes were not significantly different, including death (3Art 0.8% versus 2Art 0.5%, P=0.26). Up to 8 years, there were no differences in major adverse cardiac and cerebrovascular events (3Art 27%, 95% confidence interval [CI], 24% to 30% versus 2Art 25%, 95% CI, 22% to 28%; hazard ratio [HR], 1.08, 95% CI, 0.94-1.25), death (HR, 1.08; 95% CI, 0.90-1.29), myocardial infarction (HR, 1.15; 95% CI, 0.87-1.51), stroke (HR, 1.39; 95% CI, 0.95-2.06), or repeat revascularization (HR, 1.04; 95% CI, 0.82-1.32). When evaluating MAG versus SAG, 8629 patient pairs were formed using propensity score matching. At 8 years, cumulative incidences of major adverse cardiac and cerebrovascular events (HR, 0.82, 95% CI, 0.77-0.88), survival (HR, 0.80; 95% CI, 0.73-0.88), repeat revascularization (HR, 0.79; 95% CI, 0.69-0.90), and myocardial infarction (HR, 0.83; 95% CI, 0.72-0.97) were superior in the MAG group., Conclusions: CABG with 3 arterial grafts was not associated with increased in-hospital death nor with better clinical outcomes at 8-year follow-up, compared with CABG with 2 arterial grafts. MAG was associated with superior outcomes compared with SAG.