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CASS registry

Long term surgical survival

William O. Myers, MD, FACC^a, Eugene H. Blackstone, MD, FACC^*, Kathryn Davis, PhD, FACC, Eric D. Foster, MD, FACC and George C. Kaiser, MD, FACC

^a Department of Thoracic and Cardiovascular Surgery, Marshfield Clinic, Marshfield, Wisconsin, USA
^* Department of Surgery, University of Alabama, Birmingham, Alabama, USA
Coordinating Center for Collaborative Studies in Coronary Artery Surgery, University of Washington, Seattle, Washington, USA
Department of Surgery, Albany Medical College of Union University, Albany, New York, USA
Department of Surgery, St. Louis University Medical Center, St. Louis, Missouri, USA

View larger version (22K): [in a new window]   Figure 1 Risk-unadjusted survival after coronary artery bypass grafting (CABG). (A) Survival: Overall survival according to the Kaplan-Meier life table estimates. Confidence limits are one standard error. The numbers in parentheses represent the number of patients at risk entering each two-year interval. The fine dash-dot-dash line is an age-sex-race matched U.S. population life table. (B) Hazard: The instantaneous risk of death (hazard function) is depicted enclosed within confidence limits equivalent to one standard error. The rapidly declining early phase of hazard gives way to a steadily rising hazard phase after about nine months. The fine dash-dot-dash line is an age-sex-race matched U.S. population hazard function. Only at its nadir does the curve drop below that of the U.S. population for about a year.

View larger version (38K): [in a new window]   Figure 2 Association of age at CABG with survival. The depiction is a nomogram (solution to the equation) of the multivariable hazard function. The solid curves enclosed by their dashed confidence limits represent, from top to bottom, 30-day, 3-year, 10-year and 15-year survival. Superimposed on the nomograms is a corresponding depiction of the U.S. population life table for each time frame. The following values for risk factor variables were used: male patient, weight 77 kg, body surface area 1.95 m2, Canadian Heart Class III angina, no use of digitalis nor diuretics, one previous myocardial infarct, LV wall motion score 7, LV end diastolic pressure 12 mm Hg, three coronary systems diseased, no left main or proximal left anterior descending (LAD) coronary disease, no inferior wall jeopardy, no history of diabetes, hypertension or smoking, elective operation with use of only vein grafts. This, in a 55-year-old patient, represents the median values for individual variables in Appendix A.

View larger version (25K): [in a new window]   Figure 3 Association of gender with survival. Time-related survival (hazard function shown) after CABG according to patient gender. The depiction is as in Figure 2, except that the information has been displayed across time. In addition, the risk factors have been set to the median value for males and females in the data set, respectively. The fine dot-dash-dot line is an age-race-sex matched depiction for a similarly aged female population, while the double-dot-dashed line depicts a male population.

View larger version (24K): [in a new window]   Figure 4 Association of use of digitalis at CABG with survival. Hazard function after CABG for a patient with and one without use of digitalis. All other risk factors were held at median values.

View larger version (25K): [in a new window]   Figure 5 Association of coexisting diabetes at CABG with survival. Hazard function after CABG for a patient with and one without diabetes. All other risk factors were held at the median values as defined for Figure 2.

View larger version (23K): [in a new window]   Figure 6 Association of hypertension at CABG with survival. Hazard function after CABG for one patient with and one patient without hypertension. All other risk factors were held at the median values.

View larger version (30K): [in a new window]   Figure 7 Association of smoking with survival. Hazard function after CABG for a patient who never smoked, previously smoked, or is a current smoker at the time of CABG. All other risk factors were held at median values.

View larger version (23K): [in a new window]   Figure 8 Association of use of at least one IMA at CABG with survival. Hazard function after CABG for a patient receiving all venous grafts and one receiving at least one IMA (generally to the left anterior coronary artery). All other risk factors were held at the median values. The hazard function curve is below that of the general U.S. population for a dozen years for patients with one IMA.

View larger version (18K): [in a new window]   Figure 9 Hazard function components and their influence. The time-scale of the hazard function is expanded to emphasize the first five years of follow-up. Hazard Components. The vertical axis is the instantaneous risk of death. The dashed line is the overall hazard function. It is the sum of two components shown in solid lines: an early declining and a late rising hazard phase component. Note that the two curves cross about 9 months after operation, and this nearly corresponds to the lowest value of the overall hazard function.