Bobby Yanagawa1, Subodh Verma2, Amine Mazine2, Derrick Y Tam2, Peter Jüni3, John D Puskas4, Shamini Murugavel2, Jan O Friedrich5. 1. Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. Electronic address: yanagawab@smh.ca. 2. Division of Cardiac Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 3. Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada. 4. Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA. 5. Critical Care and Medicine Departments, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Abstract
OBJECTIVES: This meta-analysis compares total arterial revascularization (TAR) versus conventional coronary artery bypass and additionally to two arterial grafts. METHODS: We searched MEDLINE and EMBASE Databases from 1996-to-2016 for studies comparing TAR versus non-TAR for multi-vessel surgical revascularization. Data were extracted by 2 independent investigators. Meta-analysis used random effects, which incorporates heterogeneity. RESULTS: There were 4 smaller shorter follow-up randomized controlled trials (RCTs), plus 15 matched/adjusted and 6 unmatched/unadjusted larger longer follow-up observational studies that met inclusion criteria (N=130.305 patients; mean follow-up range: 1-15years). There were no differences in perioperative stroke, myocardial infarction or mortality. However, TAR was associated with lower long term all-cause mortality in observational studies matched/adjusted for confounders (incident rate ratio 0.85, 95% CI: 0.81-0.89, p<0.0001; I2=0%) and unmatched/unadjusted (incident rate ratio 0.67, 95% CI: 0.59-0.76, p<0.0001; I2=67%) for TAR. Decreases in major cardiovascular outcomes and revascularization did not achieve statistical significance. There were greater sternal complications with TAR in the matched/adjusted studies (pooled risk ratio 1.21, 95% CI: 1.03-1.42, p=0.02; I2=0%). When compared to patients with two arterial grafts, TAR was still associated with reduced long-term all-cause mortality (incident rate ratio 0.85, 95% CI: 0.73-0.99, p=0.04) with minimal heterogeneity (I2=5%). CONCLUSIONS: Data from primarily observational studies suggest that TAR may improve long-term survival compared with conventional coronary bypass by 15-20% even when compared with two arterial grafts. Prospective randomized trials of TAR with long term follow-up are needed.
OBJECTIVES: This meta-analysis compares total arterial revascularization (TAR) versus conventional coronary artery bypass and additionally to two arterial grafts. METHODS: We searched MEDLINE and EMBASE Databases from 1996-to-2016 for studies comparing TAR versus non-TAR for multi-vessel surgical revascularization. Data were extracted by 2 independent investigators. Meta-analysis used random effects, which incorporates heterogeneity. RESULTS: There were 4 smaller shorter follow-up randomized controlled trials (RCTs), plus 15 matched/adjusted and 6 unmatched/unadjusted larger longer follow-up observational studies that met inclusion criteria (N=130.305 patients; mean follow-up range: 1-15years). There were no differences in perioperative stroke, myocardial infarction or mortality. However, TAR was associated with lower long term all-cause mortality in observational studies matched/adjusted for confounders (incident rate ratio 0.85, 95% CI: 0.81-0.89, p<0.0001; I2=0%) and unmatched/unadjusted (incident rate ratio 0.67, 95% CI: 0.59-0.76, p<0.0001; I2=67%) for TAR. Decreases in major cardiovascular outcomes and revascularization did not achieve statistical significance. There were greater sternal complications with TAR in the matched/adjusted studies (pooled risk ratio 1.21, 95% CI: 1.03-1.42, p=0.02; I2=0%). When compared to patients with two arterial grafts, TAR was still associated with reduced long-term all-cause mortality (incident rate ratio 0.85, 95% CI: 0.73-0.99, p=0.04) with minimal heterogeneity (I2=5%). CONCLUSIONS: Data from primarily observational studies suggest that TAR may improve long-term survival compared with conventional coronary bypass by 15-20% even when compared with two arterial grafts. Prospective randomized trials of TAR with long term follow-up are needed.
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