Multiarterial grafting: The answer to that question

Central MessageThe true value of multiarterial grafting remains an open question. Future research needs to provide more precise information regarding optimal patient selection.This Invited Expert Opinion provides a perspective on the following paper: J Am Coll Cardiol. 2019;74(18):2238-2248. https://doi.org/10.1016/j.jacc.2019.08.1043. The selection. This I wish had answer that because I'm tired answering question.—Yogi BerraIs there benefit for (MAG) in patients undergoing coronary artery bypass surgery multivessel disease? question, which appeared have been clearly answered logical and evidentiary grounds, has re-emerged as unanswered. well-established superior patency arterial grafts compared with those constructed from saphenous veins would intuitively suggest goal supplying myocardium improved perfusion be better served graft. Internal mammary (IMA) tend excess 90%, relatively stable over time, whereas vein graft disease is progressive, occluding than one third by 10 years.1Sabik J.F. Lytle B.W. Blackstone E.H. Houghtaling P.L. Cosgrove D.M. Comparison internal thoracic system.Ann Thorac Surg. 2005; 79: 544-551Abstract Full Text PDF PubMed Scopus (282) Google Scholar Perhaps occlusion subject variations harvesting technique2Samano N. Geijer H. Liden M. Fremes S. Bodin L. Souza D. no-touch maintains patency, after 16 years, comparable left artery: randomized trial.J Cardiovasc 2015; 150: 880-888Abstract (135) antiplatelet lipid-lowering therapy.3Sun J.C. Don C. Kulik A. Verrier E. Aldea G. Clopidogrel combined aspirin improves surgery: results systematic review meta-analysis.J 2013; 61: E1204Crossref Scholar,4Margaritis Channon K.M. Antoniades Statins failure surgery.Curr Opin Pharmacol. 2012; 12: 172-180Crossref (19) Early concerns radial appear resolved through appropriate selection high-grade lesions harvesting/management protocols, carefully performed prospective trials demonstrating grafts.5Gaudino Benedetto U. Biondi-Zoccai Sedrakyan Puskas J.D. et al.for RADIAL InvestigatorsRadial-artery or saphenous-vein coronary-artery surgery.N Engl Med. 2018; 378: 2069-2077Crossref (244) Validation theory reside multiple meta-analyses actual survival advantage bilateral versus single IMA grafting,6Weiss A.J. Zhao Tian D.H. Taggart D.P. Yan T.D. A meta-analysis comparing grafting.Ann Cardiothorac 2: 390-400PubMed Scholar, 7Yi Shine B. Rehman Altman D.G. Effect long-term survival: approach.Circulation. 2014; 130: 539-545Crossref (192) 8Takagi Goto S.N. Watanabe T. Mizuno Y. Kawai Umemoto adjusted hazard ratios 20 observational studies grafting.J 148: 1282-1290Abstract (70) 9Buttar Ya Long-term short-term outcomes using grafting: meta-analysis.Heart. 2017; 103: 1419-1426Crossref (99) well emerging literature support use second conduit.10Tatoulis J. Schwann T.A. Long term surgery.Ann 7: 636-643Crossref (6) Indeed, professional guidelines become increasing supportive MAG, especially younger (whose life expectancy sufficient realize benefit) who undergo (CABG) surgery.11Hillis L.D. Smith P.K. Anderson J.L. Bittl J.A. Bridges C.R. Byrne J.G. al.American College Cardiology FoundationAmerican Heart Association Task Force Practice GuidelinesAmerican Thoracic SurgerySociety Cardiovascular AnesthesiologistsSociety Surgeons2011 ACCF/AHA guideline surgery. report American Foundation/American task force practice guidelines. Developed collaboration Surgery, Society Anesthesiologists, Surgeons.J 2011; 58: e123-e210Crossref (552) 12Neumann F.J. Sousa-Uva Ahlsson Alfonso F. Banning A.P. al.ESC Scientific Document Group2018 ESC/EACTS myocardial revascularization.Eur 2019; 40: 87-165Crossref (2276) 13Aldea G.S. Bakaeen F.G. Pal Head S.J. Sabik al.The Surgeons clinical conduits 2016; 101: 801-809Abstract (211) And yet, profession, surgeons generally remain remarkably unimpressed. While nationally representative (STS) Adult Cardiac Surgery Database currently records frequency usage 99% range (especially since added anterior descending quality metric their composite measures), (BIMA) meager 5.7%, recorded only 6.8% cases isolated CABG MAG national databases despite evidence actually even declined time.14Schwann Tatoulis Bonnell Kurlansky P. al.Worldwide trends multi-arterial 2004-2014: tale 2 continents.Semin 29: 273-280Abstract (47) reasons this apparent discrepancy are multifactorial. Much emphasis surgical outcome cardiac evaluated relates perioperative events. Mandatory state emphasize risk-adjusted mortality length stay, STS star ratings, although perhaps circumspect, include mortality, complications, process measures15Shahian He X. Jacobs J.P. P.A. Badhwar V. Cleveland Jr., measure individual surgeon performance adult measurement force.Ann 100: 1315-1324Abstract (51) Scholar—all these metrics, important appropriate, focus immediate period. tends technically demanding, may require increased operative specific patient-management requirements challenging. BIMA grafting, without tedious skeletonized approach harvesting, increases risk dreaded complication sternal wound infection. though not any institutional retrospective studies, slight receiving (SIMA), when less-experience hands.16Schwann Habib R.H. Wallace Shahian O'Brien al.Operative multiple-arterial single-arterial 105: 1109-1119Abstract (68) Why then complex, time-consuming, potentially deleterious no recognized gain? absence metrics area active investigation, projects merge Centers Medicare & Medicaid Services Disease Control Prevention death registries, but worthy yet integrated into profession assesses quality.17Jacobs Edwards F.H. Prager R.L. Wright C.D. al.Successful linking database social security data examine operations.Ann 92: 32-37Abstract (72) In addition, cannot underestimate technical subtleties techniques required success—nuances practices readily known all teaching programs. Lastly, until provocative findings Arterial Revascularization Trial (ART), it was argued were control supprt MAG.18Taggart Gerry Gray A.M. Lees al.Arterial InvestigatorsBilateral internal-thoracic-artery at years.N 380: 437-446Crossref (186) Although criticism valid, its application reason reluctance adopt somewhat illogical, embraced arguably much less-compelling evidence. virtually Class recommendation, level same B MAG. Into somewhat-confusing arena enters analysis New Jersey recently published Chikwe colleagues.19Chikwe Sun Hannan E.L. Itagaki Lee Adams Egorova N.N. Outcomes surgery.J 74: 2238-2248Crossref (37) reacting, might reasonably wonder, supporting do we really need confirmation registry? With negative controlled ART, data? similar other further glean? each questions resounding YES. First, should noted methodologic care sophistication merged analyzed exemplary and, itself, stand out examples how advanced statistical modeling can meaningful insight data. To summarize, careful successful merging mandatory 3 mandated recording inpatient episodes, catheterizations, mortalities yielded 26,124 nonemergent, first-time patients, whom 3647 (14%) underwent After thorough adjustment baseline differences, associated lower 10-year 3588 propensity-score matched pairs (15.1% vs 17.3%, P = .01), infarction (hazard ratio [HR], 0.81, confidence interval [CI], 0.69-0.65) reintervention (HR, CI 0.67-0.99). Multiple SIMA ostensibly consistent HR around 0.80 favoring group.6Weiss However, many (and authors) analyses overlap another. Moreover, inspection demonstrates variability outcome. marked difference among centers technique also prevalence applied—20% Cleveland,20Lytle Loop F.D. Arnold J.H. Akhrass R. al.Two one.J 1999; 117: 855-872Abstract (733) 48% Miami,21Kurlansky Traad E.A. Dorman M.J. Galbut D.L. Zucker Ebra Thirty-year follow-up defines propensity-matched groups.Ann 2010; 90: 101-108Abstract (166) 73% Calgary22Kieser T.M. Curran H.J. Rose M.S. Norris C.M. Graham M.M. balance between incomplete complete revascularization: series 1000 consecutive 98% grafts.J 147: 75-83Abstract (24) Scholar—suggesting differences criteria. funnel plots fully overcome publication bias inherent advocacy—surgeons success. Individual-center therefore reflection what accomplished rather accomplished. registry data, contrast, clearer broad spectrum reality. It surprising find moderate 0.86 experience. Even if accept comprehensive reality, interpret light recent ART? Despite accepted mantra represent greatest evidence, caution exercised analyzing results. inclusion exclusion criteria design limit interaction confounding variables lead study population represents small proportion present care. confounded variable consent, site enrollment efficiency, little-recognized overwhelming feature trials—lack equipoise. Surgical particular expertise, such adequately evaluate technique, researchers must identify sufficiently proficient reliably perform operation. necessarily standard, most likely so specifically they believe preferable. Therefore, definition, equipoise consequently unwilling enter trial feel preferred approach. They chose marginal perceived benefit, thereby biasing toward null. One possible solution adopted CORONARY23Lamy Devereaux P.J. Prabhakaran Hu Straka Z. CORONARY InvestigatorsFive-year off-pump on-pump grafting.N 375: 2359-2368Crossref (209) investigators, on- both techniques; randomization, assigned experienced approach, eliminating point entry. Unfortunately, ART reports disclose percentage eligible enrolled. What did emerge trial, however, challenge studying approach—technique competence uniform across sites; indeed, 13.9% receive treatment assigned, huge sites worse greater crossover. Because permitted per-surgeon preference, 21.8% received graft; as-treated supported (adjusted HR, 0.81). contrast older historical adjunctive medical therapy compliance quite high (75%-90%), ameliorating groups, medication shown dramatic impact surgery.24Kurlansky Herbert Prince Mack Coronary percutaneous intervention: meds matter: adherence comparative outcomes.Circulation. 134: 1238-1246Crossref (31) Of note 2.2%—ART (powered 5% absolute 20% relative difference) underpowered finding. fact, York, included some authors study, reported benefits 7-year acute infarction, stroke 20.2% 22.8%, 0.88 (CI, 0.83-0.93).25Samadashvili Sundt Wechsler al.Multiple disease.J 1275-1285Crossref (35) end nearly identical 0.90 trial; sample less conclusion reverse. importance balancing emphasized examination considerable characteristics found study: body mass index 28 34, diabetes 24% 47%, hypertension 77% 92%, peripheral vascular 7% 17%, previous 3% 8%, intervention 16% 24%. We will spare reader values, begin recognize closer our practices. enthusiasm tenacity ROMA investigators greatly admired,26Taggart role CABG: roads Rome.J 2249-2253Crossref (2) extremely valuable emerge, nonetheless familiar compass size. Lastly available California,27Goldstone A.B. Chiu Baiocchi Wang Lingala Boyd Woo Y.J. Second venous California.Circulation. 137: 1698-1707Crossref York State,25Samadashvili province Ontario28Rocha R.V. Tam D.Y. Karkhanis Nedadur Fang Tu J.V. patients.Circulation. 138: 2081-2090Crossref (36) British Columbia,29Pu Ding Shin Skarsgard Wong D.R. Bozinovski al.Long-term population-based Columbia, Canada.JAMA 1187-1196Crossref (29) data-entry requirements, additional gleaned another report. first interest is, time periods, MAG: 9.9% California, 14.0% Jersey, 19.9% 22.5% Ontario, 27.8% Columbia. None registries adjustment; varied 0.84 0.79, 0.80, 0.79 latter series. Subtle selection, patterns, public reporting, analytical (all studies) account effect. conservative estimate colleagues 2.2% years MAG—with number needed treat 40, major longer whether rather, derive benefit. sets us along path observed >70 age, nor ejection fraction ≤30%. Issues conduit risk, frailty, self-care, difficult tease large fact reliable skillfully certainly inform investigation. future merger direct artificial intelligent environment help granular Unlike hapless prophet baseball lore, am trying author conflicts interest. Journal policy requires editors reviewers decline handling reviewing manuscripts conflict article