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Eur J Cardiothorac Surg 2006;30:311-317
© 2006 Elsevier Science NL

Left main coronary artery stenosis no longer a risk factor for early and late death after coronary artery bypass surgery — an experience covering three decades

Anders Jönssona,*, Niklas Hammarb,c, Tobias Nordquistd, Torbjörn Iverta

a Department of Thoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
b Department of Epidemiology; Institute of Environmental Medicine, Sweden
c Department of Epidemiology, AstraZeneca R&D, Mölndal, Sweden
d Department of Epidemiology, Stockholm Centre of Public Health, Stockholm, Sweden

Received 21 March 2006; accepted 15 May 2006.

* Corresponding author. Address: Department of Cardiothoracic Surgery, Karolinska University Hospital, S-171 76 Stockholm, Sweden. Tel.: +46 8 517 70832; fax: +46 8 331931. (Email: anders.l.jonsson{at}karolinska.se).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 
Objective: To analyse early and late mortality after coronary artery bypass grafting (CABG) in patients with and without left main coronary artery (LMCA) stenosis during the 30-year period 1970–1999. Methods: A total of 1888 of 10,647 patients (18%) who underwent a first isolated CABG at the Karolinska Hospital in Stockholm, Sweden, during 1970–1999 had significant left main coronary artery stenosis. The Swedish National Cause of Death Register was used to determine mortality up to five years after the operation. Results: The proportion of patients with LMCA stenosis of all CABG patients increased from 7% during the 1970s to 26% in 1999. During 1970–1984 early mortality was 5.8% in patients with LMCA stenosis compared with 1.5% in patients without LMCA stenosis (odds ratio (OR) 3.7 (95% confidence interval (CI) 1.8–7.6)). The corresponding rates during 1995–1999 were 2.0% versus 2.2% (OR 0.8 (95% CI 0.5–1.5)), respectively. The increased risk of early death in patients with LMCA stenosis was neutralised in males during 1985–1994 and in females during 1995–1999. Five-year survival in males was 88% after operations performed during 1994–1999 compared with 82% after CABG performed during 1970–1984. Five-year mortality, exclusive of early deaths, during 1970–1984 was higher in patients with LMCA stenosis (12.8%) than in those without (8.4%) (relative risk 1.7 (95% CI 1.1–2.5)). An increased risk of late mortality in patients with LMCA stenosis was neutralised in males during 1985–1994 and in females during 1995–1999. Conclusions: During 1970–1999 there was a decrease of early and five-year mortality in patients with LMCA stenosis after CABG despite increase of patient age and risk factors. There were gender differences so that the risk of death in patients with compared with in those without LMCA stenosis was neutralised in males during 1985–1994 and in females during 1994–1999. The continuous decline of mortality during three decades most likely reflects improvement of the peri- and postoperative management of patients undergoing CABG during this period.

Key Words: Left main coronary artery • Mortality • Coronary artery bypass grafting


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 References
 
Studies during the 1970s and 1980s showed significant survival benefit in patients with left main coronary artery (LMCA) stenosis randomised to coronary artery bypass grafting (CABG) compared with medical therapy [1–3]. Surgical revascularisation is, therefore, the preferred treatment for patients with LMCA stenosis. LMCA stenosis has been recognised as a risk factor for early death among patients undergoing CABG [4–6]. In a report from the Clevelands Clinics in 1982, left main disease was neutralised as an independent risk factor for operative mortality after CABG [7]. In agreement with this report, several centres have recorded early survival in patients with LMCA stenosis compared with that in other patients undergoing CABG [8–11]. There are reports of similar long-term survival after CABG regardless of LMCA stenosis [10,11]. In the CASS Registry experience and also in young patients undergoing CABG, the presence of LMCA stenosis increased the risk of late death [12,13].

The purpose of this study was to compare early and late mortality after CABG in patients with and without LMCA stenosis, respectively, after operations performed during three decades from 1970 up to 1999.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 References
 
2.1 Patients
From the first patient in Sweden undergoing CABG in 1970 up to 1999, a total of 10,647 patients underwent primary isolated CABG at the Karolinska Hospital in Stockholm, 1888 (18%) of whom had significant LMCA stenosis. Demographic variables and clinical characteristics were extracted by retrospective review of medical records. The study was approved by the Ethics Committee. Patients with LMCA stenosis were older, had more frequently hyperlipidaemia, unstable angina and peripheral vascular disease and less often a history of myocardial infarction and a normal left ventricular function (LVF). They also had more grafts placed at the operation and more internal mammary artery grafts utilised than patients without LMCA stenosis (Table 1 ).


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  		Table 1. Characteristics of 10,647 patients undergoing coronary artery bypass surgery during 1970–1999 in relation to presence of left main coronary artery stenosis
 
2.2 Operative technique
Owing to the long time period covered by this study, there were major changes over time of the operative technique. All operations except 126 off-pump procedures during the late 1990s were performed via a median sternotomy with the aid of cardiopulmonary bypass. Bubble oxygenators replaced initially used disc oxygenators in 1975 and were completely discarded in favour of membrane oxygenators in 1988. Intermittent aortic cross clamping was used up to 1976. Subsequently the most common method of myocardial protection was cold crystalloid modified St. Thomas’ cardioplegia with procainamide 5 mmol/l given antegrade into the aortic root. During the 1990s, cold diluted blood cardioplegia was administered either antegrade into the aorta or in patients with high-grade proximal coronary artery obstruction retrograde into the coronary sinus or various combinations of these two techniques were used. The distal anastomoses were constructed first with a continuous running 7-0 polypropylene suture and the proximal vein anastomoses to the aorta sutured over a partially occluding clamp while reperfusing the heart and rewarming the patient. Six patients had direct surgical angioplasty of the LMCA and no additional bypass grafts. Antiplatelet therapy consisting of 160 mg acetylsalicylic acid was given routinely after the operation from 1983. During the 1990s additional antithrombotic treatment of dalteparin (Fragmin®, Pharmacia & Upjohn, Stockholm, Sweden) 5000 U was administered once daily subcutaneously until discharge from hospital.

2.3 Definitions
Body mass index (BMI) was calculated by dividing weight in kilograms by the square of height in meters. Patients were defined as hypertensive if taking antihypertensive medication as having diabetes on admission if they were treated with insulin or oral hypoglycaemic agents or on diet regimen and as having hyperlipidaemia if taking lipid-lowering drugs. A patient was classified as having unstable angina if admitted to the hospital because of angina at rest, new onset or accelerated angina within four weeks of the operation or angina within two weeks of an AMI. Peripheral vascular disease was defined as a history of exertional claudication and/or prior revascularisation to the legs. Any coronary artery stenosis was considered haemodynamically significant if the luminal diameter was reduced at least 50% in two projections, assessed visually by the physician performing the coronary angiography. A significant LMCA stenosis was defined from the report of the physician performing the angiography and the surgeon's assessment before the operation. In 13 of the 1888 patients (0.7%) classified in this report as with LMCA stenosis, the main stem was in fact completely occluded. LMCA stenosis was considered as two-vessel disease obstructing coronary flow to both the left anterior descending coronary artery and to the circumflex coronary artery. Left ventricular function was assessed by preoperative contrast ventriculography or echocardiography and categorised as normal, reduced or severely reduced according to the assessment of the cardiac surgeon or the physician performing the ventriculography or the echocardiography. Early mortality was defined as death within 30 days of the operation.

2.4 Statistical analysis
Every person living in Sweden has a unique identification number that was used for record linkage to the National Cause of Death Register. Early mortality was compared in patients with and without LMCA stenosis crude and adjusted by odds ratios (ORs) obtained from logistic regression analyses. Kaplan–Meier estimates of survival up to 5 years after surgery in females and males were calculated. The relative risk (RR) of late death was estimated crude and in multivariate analysis using Cox's proportional hazards regression. In the multivariate analysis, adjustment was made for age and other prognostic factors associated with the outcome. Variables that did not influence the point estimate of RR more than 0.1 when adjusted for in the multivariate analysis were excluded from the final model. Estimates of RR were accompanied by asymptotic 95% confidence intervals (CIs). Differences in means between patient groups were evaluated using analysis of variance or the Student's t-test. The chi-square test was used in the analyses of proportions for categorical variables. In the multivariate analysis, age was included in the models as a continuous variable and others as dichotomous variables representing presence or absence of the characteristic. Year of surgery was subdivided into the categories 1970–1984, 1985–1994 and 1995–1999. Left ventricular function was categorised as normal, reduced or severely reduced.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 References
 
There was a continuous increase of the number of operations performed during the 30-year study period. The proportion of patients with LMCA stenosis among all CABG procedures also increased from 7% (46/694 patients) during the 1970s to 26% of the operations performed in 1999 (171/647 patients) (Fig. 1 ). During the study period the average age of patients with LMCA stenosis undergoing CABG increased by nine years (Table 2 ). There was a concomitant increase of the proportion of women, patients with diabetes, hyperlipidaemia, unstable angina, severely reduced left ventricular function, use of the internal mammary artery graft and placement of three or more grafts at the operation.


Figure 1
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  		Fig. 1. Number of isolated coronary artery bypass operations per year performed during 1970 up to 1999. Patients operated on for left main coronary artery stenosis are marked with filled columns.

 

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  		Table 2. Characteristics of 1888 patients with left main coronary artery obstruction undergoing coronary artery bypass surgery during 1970–1999
 
3.1 Early mortality
Early mortality after CABG in patients with LMCA stenosis was 7% during 1975–1979 with a marked reduction after 1984 to 2% during 1995–1999 (Fig. 2 ). During 1970 through 1984 the risk of early death was almost four times higher in patients with LMCA stenosis than in those without LMCA stenosis (5.8% vs 1.5%) (Table 3 ). This elevated risk remained after multivariate correction for possible confounders (OR 3.7 (95%CI 1.8–7.6)). Early mortality in patients with LMCA stenosis was high in both genders during this period but there were few women. The increased risk of early death after CABG in patients with LMCA stenosis was neutralised in males during 1985–1994 and in females during 1995–99.


Figure 2
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  		Fig. 2. Average early mortality during five 5-year periods from 1975 through 1999 in patients with left main coronary artery stenosis undergoing coronary artery bypass grafting.

 

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  		Table 3. Early death in relation to presence of left main coronary artery obstruction among 10,647 patients undergoing isolated coronary artery bypass surgery during 1970–1999 for females and males during three time periods
 
3.2 Late morality
Five-year survival in males was superior after operations performed during 1985–1999 than in earlier years (Fig. 3 ). An improvement in five-year survival was seen in women after operations performed during 1995–1999 and possibly already in 1985–1994 up to three years after the operation. Average lengths of follow-up were 4.8 years, 4.8 years and 3.3 years for patients undergoing CABG during 1970–1984, 1985–1994 and 1995–1999, respectively.


Figure 3
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  		Fig. 3. Five-year survival after coronary artery bypass grafting, inclusive of early deaths, in relation to time period of surgery in males (a) and females (b) with left main coronary artery stenosis. The Y-axis starts at 50% to emphasise differences between groups.

 
Mortality up to five years, exclusive of early deaths, in the group who had CABG during 1970–1984 was higher in patients with LMCA stenosis (12.8%) than in those without LMCA stenosis (8.4%) (Table 4 ). This increased late mortality remained after multivariate adjustment (RR 1.7 (95%CI 1.1–2.5)). Five-year mortality after CABG performed during 1985–1994 in males and during 1995–1999 in females was similar in patients with and without LMCA stenosis. Five-year mortality among the relatively few females operated on during 1985–1994 was higher in those with than in those without LMCA stenosis (RR 1.7 (95%CI 1.0–2.9)).


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  		Table 4. Late deaths from 30 days up to five years after isolated coronary artery bypass surgery and relative risk (RR) in relation to presence of left main coronary artery obstruction for females and males during three time periods
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
References
 
This study could be performed because of a complete register of patients undergoing CABG from the very first operation in 1970 through a 30-year period. All patients operated on during this period could be followed with respect to early and late mortality through the Swedish National Cause of Death Register. This register is complete with regard to deaths in Swedish citizens and we regard the ascertainment of deaths as highly reliable and comparable throughout the study period.

During the time period of our study increasingly older patients with more comorbidities were referred for CABG in accordance with findings in other reports [14–16]. Despite documented increase of patients’ risk factors over time others and we have observed a progressively declining hospital mortality [15–19]. The results of CABG in patients with LMCA stenosis presented in this report were comparable with other reports of an early mortality in the range of 2–5% [10,11].

The reasons for the observed marked increase of the proportion of LMCA stenosis among all CABG procedures during the late 1990s compared with that of the 1970s were multifactorial. Many patients with high-grade LMCA stenosis were probably never diagnosed before death during the 1970s because of poor availability of angiography and long waiting times for surgery. The progressively elderly patient population admitted for surgery had more advanced coronary artery disease and more often LMCA lesions than younger patients in agreement with findings in other reports [5,20–22]. With time the indications for coronary angiography widened and waiting times were shortened dramatically. As angiography was performed emergently in patients with unstable coronary syndromes critical high-grade LMCA stenosis were diagnosed and operated on early. There was a rapid expansion of the number of percutaneous coronary interventions (PCI) particularly from 1990. This resulted in reduced referral to surgery of patients with single-, double- and sometimes three-vessel disease in favour of PCI leaving a higher proportion of angina patients with LMCA stenosis for CABG.

There was a pronounced decrease of the risk of both early and late death during the three decades in patients with LMCA undergoing CABG. During this long time period there were major improvements within almost all fields regarding perioperative management of patients undergoing open heart surgery such as technical development of pumps and oxygenators, shorter operative times, less cooling, refined careful surgical technique and handling of grafts, methods of myocardial protection with use of supplemental retrograde cardioplegia in case of high-grade coronary obstructions, anaesthesiological and intensive care monitoring and practices to deal with heart and renal failure in addition to the understanding and introduction of effective antithrombotic regimens. These cumulative beneficial effects of continuous advancement in operative, anaesthetic and medical management all contributed to the improved survival [15,23].

We preferred to analyse late outcome exclusive of early mortality as causes of late deaths are other than those related to perioperative events. In our experience there was neutralisation of LMCA stenosis as a risk factor for both early and late death during the 1990s regardless of gender and despite increase of patient age and risk factors. The observed reduced risk of late death in patients with LMCA stenosis may be secondary to a more complete revascularisation, more frequent use of IMA grafts and the results of improved medical management [24]. Survival benefit over time after CABG ascribed to continuing improvement of surgical techniques has been confirmed in other reports [15,23].

In patients with LMCA stenosis, female gender seemed to be associated with an increased early mortality. Smaller coronary vessels could explain the delay of complete neutralization of survival observed in females as compared with that in males [25]. Refined surgical technique may have improved graft patency. A better understanding of coronary artery disease in women and enhanced medical management possibly contributed to improved survival during the 1990s.

Limitations of this study include the retrospective collection of information on patient characteristics, incomprehensive information on when changes of surgical techniques took place and lack of clinical follow-up to evaluate the effect of improved medical care. Patients with unstable coronary syndromes and diabetes are presently put on statin treatment increasing the proportion of patients defined by us as having hyperlipidaemia. Similar increases of patients with unstable angina and acute myocardial infarctions were to a certain degree due to altered definitions.

We conclude that during the 30-year period 1970–1999 there was a decrease of early and five-year mortality in patients with LMCA stenosis after CABG despite increases of patient age and risk factors. An increased risk of early and late deaths after CABG in patients with LMCA stenosis compared with patients without LMCA stenosis in the 1970s and 1980s was neutralised during the 1990s. This most likely reflects improvement of the peri- and postoperative management of patients undergoing CABG during this time period.


   Acknowledgments
 
The study was supported by a grant from Stockholm County Council (EXPO 95). We are grateful to Anders Giesecke, Susanne Hylander, Anna Olofsson, Henrik Overödder, Björn Törnkvist and Christian Unge for scrutinizing medical record data.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 References
 

  1. Yusuf S, Zucker D, Peduzzi P, Fisher LD, Takaro T, Kennedy JW, Davis K, Killip T, Passamani E, Norris R. Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the Coronary Artery Bypass Graft Surgery Trialists Collaboration. Lancet 1994;344:563-570.[CrossRef][Medline]
  2. Chaitman BR, Fisher LD, Bourassa MG, Davis K, Rogers WJ, Maynard C, Tyras DH, Berger RL, Judkins MP, Ringqvist I, Mock MB, Killip T. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease. Report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol 1981;48:765-777.[CrossRef][Medline]
  3. Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H, Taylor HA, Chaitman BR. Comparison of surgical and medical group survival in patients with left main coronary artery disease. Long-term CASS experience. Circulation 1995;91:2325-2334.[Abstract/Free Full Text]
  4. Hannan EL, Kilburn Jr. H, O’Donnell JF, Lukacik G, Shields EP. Adult open heart surgery in New York State. An analysis of risk factors and hospital mortality rates. J Am Med Assoc 1990;264:2768-2774.[Abstract/Free Full Text]
  5. Davierwala PM, Maganti M, Yau TM. Decreasing significance of left ventricular dysfunction and reoperative surgery in predicting coronary artery bypass grafting-associated mortality: a twelve-year study. J Thorac Cardiovasc Surg 2003;126:1335-1344.[Abstract/Free Full Text]
  6. Jones RH, Hannan EL, Hammermeister KE, Delong ER, O’Connor GT, Luepker RV, Parsonnet V, Pryor DB, The Working Group Panel on the Cooperative CABG Database Project Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. J Am Coll Cardiol 1996;28:1478-1487.[Abstract]
  7. Cosgrove DM, Loop FD, Lytle BW, Baillot R, Gill CC, Golding LA, Taylor PC, Goormastic M. Primary myocardial revascularization. Trends in surgical mortality. J Thorac Cardiovasc Surg 1984;88:673-684.[Abstract]
  8. Gol MK, Ozsoyler I, Sener E, Goksel S, Saritas A, Tasdemir O, Bayazit K. Is left main coronary artery stenosis a risk factor for early mortality in coronary artery surgery?. J Card Surg 2000;15:217-222.[Medline]
  9. Corbineau H, Lebreton H, Langanay T, Logeais Y, Leguerrier A. Prospective evaluation of coronary arteries: influence on operative risk in coronary artery surgery. Eur J Cardiothorac Surg 1999;16:429-434.[Abstract/Free Full Text]
  10. Ellis SG, Hill CM, Lytle BW. Spectrum of surgical risk for left main coronary stenoses: benchmark for potentially competing percutaneous therapies. Am Heart J 1998;135:335-338.[CrossRef][Medline]
  11. d’Allonnes FR, Corbineau H, Le Breton H, Leclercq C, Leguerrier A, Daubert C. Isolated left main coronary artery stenosis: long term follow up in 106 patients after surgery. Heart 2002;87:544-548.[Abstract/Free Full Text]
  12. Myers WO, Blackstone EH, Davis K, Foster E.D., Kaiser GC. CASS Registry long term surgical survival. Coronary Artery Surgery Study. J Am Coll Cardiol 1999;33:488-498.[Abstract/Free Full Text]
  13. Graziosi GC, Wolterbeek DW, Kappetein AP, Huysmans HA. Risk factors in coronary artery bypass surgery for patients 40 years of age and younger. Thorac Cardiovasc Surg 1994;42:259-263.[Medline]
  14. Sadeghi N, Sadeghi S, Mood ZA, Karimi A. Determinants of operative mortality following primary coronary artery bypass surgery. Eur J Cardiothorac Surg 2002;21:187-192.[Abstract/Free Full Text]
  15. Abramov D, Tamariz MG, Fremes SE, Guru V, Borger MA, Christakis GT, Bhatnagar G, Sever JY, Goldman BS. Trends in coronary artery bypass surgery results: a recent, 9-year study. Ann Thorac Surg 2000;70:84-90.[Abstract/Free Full Text]
  16. Noyez L, Janssen DP, van Druten JA, Skotnicki SH, Lacquet LK. Coronary bypass surgery: what is changing? Analysis of 3834 patients undergoing primary isolated myocardial revascularization. Eur J Cardiothorac Surg 1998;13:365-369.
  17. Christakis GT, Ivanov J, Weisel RD, Birnbaum PL, David TE, Salerno TA. The changing pattern of coronary artery bypass surgery. Circulation 1989;80:I151-I161.
  18. Hannan EL, Kilburn Jr. H, Racz M, Shields E, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York State. J Am Med Assoc 1994;271:761-766.[Abstract/Free Full Text]
  19. Ghali WA, Ash AS, Hall RE, Moskowitz MA. Statewide quality improvement initiatives and mortality after cardiac surgery. J Am Med Assoc 1997;277:379-382.[Abstract/Free Full Text]
  20. Disch DL, O’Connor GT, Birkmeyer JD, Olmstead EM, Levy DG, Plume SK. Changes in patients undergoing coronary artery bypass grafting: 1987–1990. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg 1994;57:416-423.[Abstract]
  21. Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: the Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 1994;57:12-19.[Abstract]
  22. Ferguson Jr. TB, Coombs LP, Peterson ED. Preoperative beta-blocker use and mortality and morbidity following CABG surgery in North America. J Am Med Assoc 2002;287:2221-2227.[Abstract/Free Full Text]
  23. Pryor DB, Harrell Jr. FE, Rankin JS, Lee KL, Muhlbaier LH, Oldham HN, Hlatky MA, Mark DB, Reves JG, Califf RM. The changing survival benefits of coronary revascularization over time. Circulation 1987;76:V13-V21.
  24. Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
  25. Hammar N, Sandberg E, Larsen FF, Ivert T. Comparison of early and late mortality in men and women after isolated coronary artery bypass graft surgery in Stockholm, Sweden, 1980 to 1989. J Am Coll Cardiol 1997;29:659-664.[Abstract]



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