Total Arterial Myocardial Revascularization Among Elder Patients - 10 Years Survival Analysis
Jacek Piatek, Anna Kedziora, Radoslaw Litwinowicz, Piotr Mazur, Krzysztof Bryniarski, Boguslaw Kapelak, Janusz Konstanty-Kalandyk
John Paul II Hospital, Kraków, Poland
BACKGROUND: According to the current ESC/EACTS Myocardial Revascularization Guidelines, left internal mammary artery (LIMA) should always be implanted to graft left anterior descending (LAD), but an additional arterial graft should be considered in appropriate patients undergoing coronary artery bypass grafting (CABG). In spite of inconclusive 10-year results from the Arterial Revascularization Trial (ART), observational studies underline the superior arterial grafts patency. Nevertheless, based on the data published by the Society of Thoracic Surgeons (STS), bilateral internal mammary grafts are implanted as few as 5% of CABG cases, and the usage of the radial artery (RA) has declined by approximately 33% within the last decade. However, comorbidities and limited life expectancy may potentially abolish the survival benefit from arterial revascularization in older patients. Data on the arterial revascularization in octogenarians is sparse, and arterial revascularization trials omitted this age group, as the mean age of patients enrolled into two most prominent trials (ART and RADIAL) was below 70 years old.
METHODS: Between 2004 and 2010, 205 patients aged 80 years or older at the time of surgery underwent isolated CABG. Of them, 7/205 (3.4%) received TAMR. No patients were excluded from the analysis. Out of 205 patients aged 80 years old or older at the time of surgery, who underwent isolated CABG within the same period of time, we matched two groups of 7 patients (LIMA to LAD combined with venous grafts and venous grafts only). Data for long-term mortality was obtained from the population registration office. Life expectancy was estimated for each patient individually and based on the data from the Polish Central Statistical Office. RESULTS: In the TAMR group, there were no perioperative MIs or mortalities, and the predicted mortality rate was lower than predicted both by the EuroSCORE II (0 % vs 2.3 %; p=0.018) and the STS score (0 % vs 1.4 %; p=0.018). In April 2020, after a median follow-up of 10 years, five (71.4 %) patients remained alive. Postoperative survival was better when compared to estimated life expectancy (p=0.005) and to LIMA(LAD) combined with venous grafts group (p=0.026) (Figure 1).
CONCLUSIONS: Total arterial myocardial revascularization can be performed safely among low-risk octogenarians and improved survival is observed, in comparison with life expectancy and other surgical revascularization strategies. 