title: Completeness of coronary revascularization and survival: Impact of age and off-pump surgery.
abstract: OBJECTIVE
  We conducted a multicenter observational cohort study of the effect of completeness of revascularization on long-term survival after coronary artery bypass grafting. We also investigated the impact of age and off-pump surgery.
  
  
  METHODS
  The Veterans Affairs Continuous Improvement in Cardiac Surgery Program was used to identify all patients (N=41,139) with left main and 3-vessel coronary artery disease who underwent nonemergency coronary artery bypass grafting from October 1997 to April 2011. The primary outcome measure, all-cause mortality, was compared between patients with complete revascularization and patients with incomplete revascularization. Survival functions were estimated with the Kaplan-Meier method and compared by using the log-rank test. Propensity scores calculated for each patient were used to match 5509 patients undergoing complete revascularization to 5509 patients undergoing incomplete revascularization. A subgroup analysis was performed in patients aged at least 70 years and patients who underwent off-pump coronary artery bypass grafting.
  
  
  RESULTS
  In the unmatched groups, several risk factors were more common in the incomplete revascularization group, as was off-pump coronary artery bypass grafting. In the matched groups, risk-adjusted mortality was higher in the incomplete revascularization group than in the complete revascularization group at 1 year (6.96% vs 5.97%; risk ratio [RR], 1.17; 95% confidence interval [CI], 1.01-1.34), 5 years (18.50% vs 15.96%; RR, 1.16; 95% CI, 1.07-1.26), and 10 years (32.12% vs 27.40%; RR, 1.17; 95% CI, 1.11-1.24), with an overall hazard ratio of 1.18 (95% CI, 1.09-1.28; P<.0001). The hazard ratio for patients aged 70 years or more was 1.125 (95% CI, 1.001-1.263; P=.048). The hazard ratio was 1.47 (95% CI, 1.303-1.655) for the unmatched off-pump coronary artery bypass grafting group and 1.156 (95% CI, 1.000-1.335) for the matched off-pump coronary artery bypass grafting group.
  
  
  CONCLUSIONS
  Incomplete revascularization is associated with decreased long-term survival, even in elderly patients. Surgeons should consider these findings when choosing a revascularization strategy, particularly if off-pump coronary artery bypass grafting is contemplated.
authors: Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex. Electronic address: Shuab.Omer@bcm.edu.
authors: Shuab
authors: S
authors: Omer
authors: Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
authors: Lorraine D
authors: LD
authors: Cornwell
authors: Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
authors: Todd K
authors: TK
authors: Rosengart
authors: Division of Cardiothoracic Surgery, University of Minnesota and Minneapolis Veterans Affairs Medical Center, Minneapolis, Minn.
authors: Rosemary F
authors: RF
authors: Kelly
authors: Division of Cardiothoracic Surgery, University of Minnesota and Minneapolis Veterans Affairs Medical Center, Minneapolis, Minn.
authors: Herbert B
authors: HB
authors: Ward
authors: Department of Cardiothoracic Surgery, University of Alabama and Birmingham Veterans Medical Center, Birmingham, Ala.
authors: William L
authors: WL
authors: Holman
authors: Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
authors: Faisal G
authors: FG
authors: Bakaeen
mesh_terms: D000367:Age Factors; D000465:Algorithms; D047549:Coronary Artery Bypass, Off-Pump / Q000401:mortality; D003324:Coronary Artery Disease / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D014728:Veterans