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Impact of the Interplay among Number of Grafts, Pump Status and Conduit Selection on 15-Year Survival in Patients Undergoing CABG: A Propensity Matched Study in 2012 Patients.
Juan B. Grau, MD1, Christopher K. Johnson, BS1, Giovanni Ferrari, PhD2, Richard E. Shaw, PhD1, Mariano E. Brizzio, MD1, Daniel J. Flores1, Bruce Mindich, MD1, Alex Zapolanski, MD1.
1Valley-Columbia Heart Center, Ridgewood, NJ, USA, 2University of Pennsylvania, Philadelphia, PA, USA.

OBJECTIVE: We have shown that optimal survival after CABG is achieved when bilateral internal mammary arteries (BIMAs) are used as conduits. However, the effect of number of grafts and pump status on the long-term outcomes of BIMA use remains unknown. To determine the impact of these variables on 15-year survival after CABG, we analyzed a cohort of 2012 propensity-matched patients.
METHODS: From 1994-2013, 6,666 patients had CABG at our institution. These patients were matched by developing a propensity score for having BIMA using 22 preoperative factors and the nearest-neighbor-matching algorithm with Greedy 5-1 Digit Matching. This resulted in two patient cohorts (BIMA and Single IMA (SIMA)) of 1,006 patients each. These groups were further stratified by the number of grafts (<4 vs. ≥4) performed and pump status (off- vs. on-pump) to form 8 groups. Late mortality was determined using the Social Security Death Index. Cox Proportional Hazards Regression analysis was used to control for baseline factors.
RESULTS: Table 1 demonstrates that the highest survival was found in patients who had BIMA off-pump when ≥4 grafts used (86%). For patients having BIMA with <4 grafts placed, survival was higher when the operation was performed on-pump (78% vs. 69%). Secondary analysis of BIMA off-pump <4 grafts patients demonstrated that the majority of those patients were under-revascularized and off-pump may have not been the best strategy for these patients. On the other hand, patients with SIMA and <4 grafts used demonstrated higher survival when the off-pump strategy was used (75% vs. 67%).
CONCLUSIONS: If patients require ≥4 grafts, survival is highest if the BIMAs are utilized via the off-pump approach. For SIMA with ≥4grafts, survival is significantly lower than for BIMA and pump status has no survival advantage. Therefore, 15-year survival after CABG is influenced by not only conduit selection, but also by the interplay between the number of grafts used and pump status. These findings provide guidance in determining the ideal surgical approach for isolated CABG.
Results of Cox Proportional Hazards Regression
GroupNSurvival (%)Adjusted HR (95% CI) vs. Group 1p-value
1 BIMA off pump ≥4 grafts30386%--
2 BIMA on pump ≥4 grafts24783%1.260 (0.778 - 2.042)0.348
3 BIMA on pump <4 grafts26778%1.583 (1.008 - 2.487)0.046
4 SIMA off pump <4 grafts27375%1.804 (1.114 - 2.919)0.016
5 SIMA off pump ≥4 grafts21972%2.013 (1.209 - 3.353)0.007
6 SIMA on pump ≥4 grafts22672%1.957 (1.246 - 3.074)0.004
7 BIMA off pump <4 grafts18969%2.277 (1.378 - 3.763)0.001
8 SIMA on pump <4 grafts28867%2.472 (1.601 - 3.816)0.0001


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