Circulation, Vol 86, 446-457, Copyright © 1992 by American Heart Association
MR Bell, BJ Gersh, HV Schaff, DR Holmes Jr, LD Fisher, EL Alderman, WO Myers, LS Parsons and GS Reeder
BACKGROUND. Complete revascularization after coronary artery bypass surgery
is a logical goal and improves symptomatic outcome and survival. However,
the impact of complete revascularization in patients with three-vessel
coronary disease with varying severities of angina and left ventricular
dysfunction has not been clearly defined. METHODS AND RESULTS. The study
was performed as a retrospective analysis of 3,372 nonrandomized surgical
patients from the Coronary Artery Surgery Study (CASS) Registry who had
three-vessel coronary disease. Group 1 (894 patients) had class I or II
angina (Canadian Cardiovascular Society criteria) and group 2 (2,478
patients) had class III or IV angina. In group 1, adjusted cumulative
4-year survivals according to the number of vessels bypassed were 85% (one
vessel), 94% (two vessels), 96% (three vessels), and 96% (more than three
vessels) (log rank, p = 0.022). Adjusted event-free survival (death,
myocardial infarction, definite angina, or reoperation) was not influenced
by the number of vessels bypassed, nor was the anginal status among
patients remaining alive after 5 years. In group 2, adjusted cumulative
5-year survivals were 78% (one vessel), 85% (two vessels), 90% (three
vessels), and 87% (more than three vessels) (log rank, p = 0.074). Adjusted
event-free survivals after 6 years were 23% (one vessel), 23% (two
vessels), 29% (three vessels), and 31% (more than three vessels) (p =
0.025); at 5 years, those with more complete revascularization were more
likely to be asymptomatic or free of severe angina. Among group 2 patients
with ejection fractions less than 0.35, 6-year survival was 69% for those
with grafts to three or more vessels versus 45% for those with grafts to
two vessels (p = 0.04). Placing grafts to three or more vessels was
independently associated with improved survival and event-free survival in
group 2 but not group 1 patients. The case-fatality rates among 529
patients experiencing a myocardial infarction during follow-up was
significantly higher for patients with less complete revascularization.
CONCLUSIONS. Complete revascularization (grafts to three or more vessels)
in patients with three-vessel coronary disease appears to most benefit
those with severe angina and left ventricular dysfunction.
ARTICLES
Effect of completeness of revascularization on long-term outcome of patients with three-vessel disease undergoing coronary artery bypass surgery. A report from the Coronary Artery Surgery Study (CASS) Registry
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905.
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