Patients and Definitions
A review was undertaken of all patients who underwent myocardial
revascularization at our institution between January 2009 and December
2016. Of these patients, those who had intervention for TVD were
selected for analysis.
We used the same definitions for stroke and myocardial infarction
(long-term) as the SYNTAX trial (1). However, for periprocedural
myocardial infarction (short-term outcome) we only included Type 1 MI
(using the Third Universal Definition of Myocardial Infarction) that
occurred on index hospital admission, which explains our low event rate
(11). New-onset renal failure was defined as a non-dialysis dependent
patient requiring one or more hemodialysis sessions post-procedure.
Target vessel revascularization was defined as a repeat intervention for
a prior stented lesion, either within the stent itself or within 5 mm of
the stent, and/or a repeat procedure for a lesion that was previously
surgically bypassed. We also included major adverse cardiovascular
events (MACE) as a long-term clinical endpoint. Our definition of MACE
denotes a composite end-point encompassing death, repeat
revascularization and/or myocardial infarction. We did not include major
adverse cardiovascular and cerebrovascular evens (MACCE) as a long-term
clinical outcome. Instead we included stroke as a short-term clinical
endpoint, as we felt that stroke 30 days post-revascularization is
unlikely related to the revascularization method. For patients that
underwent HCR, length of stay included the total hospital stay for both
the MIDCAB and PCI. Our preferred method is to perform a MIDCAB-first
approach, followed by interval PCI, typically within 4 to 6 weeks of
surgery. However, select situations require a PCI-first approach. Among
the PCI cohort in which revascularization was often performed on
separate admissions, we defined length of stay as the days admitted for
all hospitalizations combined. All clinical events were adjudicated by
an independent clinical event committee (involving a cardiothoracic
surgeon and interventional cardiologist).
The relative contraindications to HCR were the need for emergency
revascularization, and/or severe pulmonary disease rendering the patient
unable to tolerate single-lung ventilation. Patients with high BMI have
been regarded by some investigators as being unsuitable for HCR; we did
not withhold HCR from these patients, and, indeed, our experience with
minimally-invasive direct coronary artery bypass (MIDCAB) in this
patient population has been reported previously (12).
We analyzed propensity-matched patients who underwent HCR, CABG, or
multi-vessel PCI for triple-vessel disease. Any patients who required
concomitant non-coronary surgery, in addition to their revascularization
procedure, were also excluded, as were patients who required emergency
or salvage intervention, as well as patients who had prior cardiac
and/or thoracic surgery.