Concomitant Mitral Regurgitation in Patients Undergoing Surgical Aortic Valve Replacement for Aortic Stenosis: A Systematic Review.

BACKGROUND: Concomitant mitral regurgitation (MR) is frequently seen in patients undergoing surgical aortic valve replacement (AVR) for severe aortic stenosis (AS). When the severity of MR is moderate or less, the decision to undertake simultaneous mitral valve intervention can be challenging. METHODS: A systematic search of Medline, PubMed (NCBI), Embase and Cochrane Library was conducted to qualitatively assess the current evidence for concomitant mitral valve intervention for MR in patients with AS undergoing AVR. The primary outcome for this systematic review was the postoperative change in the severity of MR and other outcomes of interest included factors that predict improvement or persistence of MR and long-term impacts of residual MR. RESULTS: A total of 17 studies were included. The percentage of patients demonstrating improvement in MR severity following AVR ranged from 17.2% to 72%; the studies that exclusively included patients with moderate functional MR and reported longer term echocardiographic follow-up of greater than 12 months demonstrated an improvement in MR severity of 45% to 72%. CONCLUSION: This systematic review demonstrates that a proportion of patients can exhibit an improvement in MR following isolated surgical AVR, but whether this confers any long-term morbidity and mortality benefit remains unclear.

Sustained subcutaneous delivery of secretome of human cardiac stem cells promotes cardiac repair following myocardial infarction.

AIMS: To establish pre-clinical proof of concept that sustained subcutaneous delivery of the secretome of human cardiac stem cells (CSCs) can be achieved in vivo to produce significant cardioreparative outcomes in the setting of myocardial infarction. METHODS AND RESULTS: Rats were subjected to permanent ligation of left anterior descending coronary artery and randomized to receive subcutaneous implantation of TheraCyte devices containing either culture media as control or 1 × 106 human W8B2+ CSCs, immediately following myocardial ischaemia. At 4 weeks following myocardial infarction, rats treated with W8B2+ CSCs encapsulated within the TheraCyte device showed preserved left ventricular ejection fraction. The preservation of cardiac function was accompanied by reduced fibrotic scar tissue, interstitial fibrosis, cardiomyocyte hypertrophy, as well as increased myocardial vascular density. Histological analysis of the TheraCyte devices harvested at 4 weeks post-implantation demonstrated survival of human W8B2+ CSCs within the devices, and the outer membrane was highly vascularized by host blood vessels. Using CSCs expressing plasma membrane reporters, extracellular vesicles of W8B2+ CSCs were found to be transferred to the heart and other organs at 4 weeks post-implantation. Furthermore, mass spectrometry-based proteomic profiling of extracellular vesicles of W8B2+ CSCs identified proteins implicated in inflammation, immunoregulation, cell survival, angiogenesis, as well as tissue remodelling and fibrosis that could mediate the cardioreparative effects of secretome of human W8B2+ CSCs. CONCLUSIONS: Subcutaneous implantation of TheraCyte devices encapsulating human W8B2+ CSCs attenuated adverse cardiac remodelling and preserved cardiac function following myocardial infarction. The TheraCyte device can be employed to deliver stem cells in a minimally invasive manner for effective secretome-based cardiac therapy.

Rhythm disturbances following rapid-deployment aortic valve replacement.

OBJECTIVES: There have been reports of postoperative conduction disturbances after rapid-deployment aortic valve replacement. Our objective was to assess electrocardiogram changes in patients undergoing this procedure and review the literature on this topic. METHODS: In this retrospective case series, clinical data were extracted from patient records at St Vincent's Hospital Melbourne and the Australia New Zealand Society of Cardiac and Thoracic Surgeons database. Electrocardiogram data were obtained at baseline and postoperatively on day 5 and at week 6 and reviewed for rhythm disturbances and intracardiac conduction problems. Pacemaker status was also recorded. RESULTS: From 2013 to 2017, 100 consecutive patients underwent rapid-deployment aortic valve replacement with 1 valve type at our institution. Three patients were excluded because of paced rhythm preoperatively, leaving 97 patients (mean age 74.7 ± 8.12 years; 56.7% male) for analysis. Some 18.6% of patients developed new left bundle branch block at 5 days postoperatively and only 4.1% of patients found with persistent left bundle branch block at 6-week follow-up compared with preoperatively. No significant changes were observed in the frequencies of atrial fibrillation, first-degree heart block, and right bundle branch block. However, there was evidence of increases in paced rhythm and subsequent need for a permanent pacemaker. A total of 14 patients (14.4%) had a permanent pacemaker implanted at an average of 11.1 ± 2.9 days postoperatively. CONCLUSIONS: Rhythm disturbances and conduction abnormalities are noted with the rapid-deployment aortic valves used at our institution, but appear comparable to other rapid-deployment aortic valve replacement bioprostheses. These abnormalities may be related to the effect of the sub-annular stent frame of the valve system and implantation technique.

Effects of Preoperative Angiotensin-Converting Enzyme Inhibitor Therapy on Postoperative Renal Function in Cardiac Surgery.

A Best Evidence Topic in cardiac surgery was written according to a structured protocol. The question addressed was-"In patients who undergo cardiac surgery, is preoperative angiotensin-converting enzyme inhibitor therapy associated with postoperative renal dysfunction?" Altogether, 339 papers were found using the reported search. Ten (10) were chosen which best answered the clinical question. The papers were evaluated for bias and heterogeneity using validated tools and the collected results analysed qualitatively. Evidence in the current literature is inconclusive that preoperative administration of angiotensin-converting enzyme inhibitor therapy affects postoperative renal dysfunction in patients undergoing cardiac surgery.

Preoperative Platelet-to-Lymphocyte Ratio Is Not Associated With Postoperative Atrial Fibrillation.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) and is associated with increased short-term and long-term mortality. While the precise etiology of POAF remains unclear, inflammation is a known contributing factor. Preliminary studies have suggested that an elevated preoperative platelet-to-lymphocyte ratio (PLR), an inexpensive and readily available novel inflammatory biomarker, may be associated with increased incidence of POAF after CABG. This study sought to further investigate this hypothesis. METHODS: The study cohort included all patients undergoing isolated CABG, with no prior history of arrhythmia, who were operated on between August 1, 2010, and December 31, 2018, at a major Australian tertiary center (n = 1457). Patients were divided into low (<86) or high (≥86) PLR groups based on an optimal cutoff derived from receiver-operating characteristic curve analysis. The incidence of POAF was then compared. Categorical variables were analyzed using the chi-square test and continuous variables using logistic regression. RESULTS: Of 1457 patients, 495 (34.0%) developed POAF. There was no statistically significant difference in the incidence of POAF between patients in the high-PLR and low-PLR groups (34.8% vs 31.0%; P = .22). Using multivariable logistic regression analysis, high PLR was not independently associated with POAF (odds ratio, 1.04; P = .78). CONCLUSIONS: Elevated preoperative PLR is not independently associated with POAF in patients undergoing isolated CABG. The findings of this study differ from those of 2 previous smaller studies.

Bleeding After Cardiac Surgery Is Associated With an Increase in the Total Cost of the Hospital Stay.

BACKGROUND: Cardiac surgery results in complications for some patients that lead to a longer hospital stay and higher costs. This study identified the presurgery characteristics of patients that were associated with the cost of their hospital stay and estimated how much of that cost could be attributed to a bleeding event, defined as requiring 3 units or more of packed red blood cells or returning to the operating room for bleeding. We also identified the presurgery characteristics that were associated with the bleeding event. METHODS: This prospective cohort of patients (n = 1459) underwent cardiac surgery at 3 tertiary referral hospitals in Australia during 2014 and 2015. Clinical data included the variables held by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry. Cost data were collected as part of a state-level hospital data collection. RESULTS: Many of the baseline patient characteristics were associated with the total cost of cardiac surgery. After adjusting for these characteristics, the cost of cardiac surgery was 1.76 (confidence interval, 1.64-1.90) times higher for patients who had a bleeding event (P < .001), thus resulting in a median increase in costs (in Australian dollars) of $33,338 (confidence interval, $21,943-$38,415). Several baseline characteristics were strongly associated with a bleeding event. CONCLUSIONS: The impact of a bleeding event on the cost of cardiac surgery is substantial. This study identified a set of risk factors for bleeding that could be used to identify patients for discussion at the heart team level, where measures to minimize the risk of transfusion may be initiated.

Vein Graft Patency Rates With Aspirin Plus Clopidogrel Following Coronary Artery Bypass Grafting.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, "In patients who have undergone Coronary Artery Bypass Grafting, does aspirin plus clopidogrel postoperatively improve vein graft patency when compared to aspirin alone?" Altogether, 165 papers were found using the reported search, of which five represented the best evidence to answer the clinical question. Overall analysis of these papers demonstrated similar rates of vein graft patency between the two groups. There was no difference between the groups with regard to mortality, adverse bleeding-related outcomes, or composite vascular events.

Do patients with the centrifugal flow HeartMate 3 or HeartWare left ventricular assist device have better outcomes compared to those with axial flow HeartMate II?

A best evidence topic was written according to a structured protocol. The question addressed was 'Do patients with centrifugal flow HeartMate 3 (HM3) or HeartWare left ventricular assist device (HVAD) have better outcomes compared to those with the axial flow HeartMate II (HMII)?' Altogether 1791 papers were found using the reported search, of which 21 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In publications reporting on MOMENTUM 3 randomized control trial (RCT), HM3 had better outcomes compared to HMII with a lower rate of pump thrombosis (1.1% vs 15.7%), stroke events (10.1% vs 19.2%) and ischaemic stroke (6.3% vs 13.4%) at 2-year follow-up. Markers of quality of life and functional capacity were comparable between the 2 devices at 6 months. In publications reporting on ENDURANCE RCTs, compared to HMII, patients with HVAD had poorer outcomes with an increased rate of sepsis (23.6% vs 15.4%), stroke (29.7% vs 12.1%) and right heart failure (38.5% vs 26.8%) postoperatively. Outcomes were improved for the HVAD group in a more recent RCT where strict blood pressure control was instigated postoperatively. Outcomes from retrospective studies comparing HMII with HVAD varied, with some publications reporting higher rates of right ventricular assist device use (29% vs 15%), gastrointestinal bleeding (30% vs 0%), cerebrovascular accident (44% vs 10%), transient ischaemic attack (5% vs 2%) and higher cumulative risk of infection and haemorrhagic cerebrovascular accident with HVAD. This is not consistent across these studies, and 9 studies including a systematic review reported no difference in any outcomes. In conclusion, patients with centrifugal flow HM3 have better outcomes than those with axial flow HMII. Although there is some variability in outcomes in retrospective studies, patients with centrifugal flow HeartWare HVAD have similar outcomes to those with axial flow HMII when strict blood pressure control is instigated postoperatively. By inference, centrifugal flow HM3 would appear to be the superior device, although all conclusions are based on 1 large (industry-sponsored) RCT.

Management of atrial fibrillation after cardiac surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol addressing the question 'for post-cardiac surgery atrial fibrillation (AF), do clinical outcomes differ between rate or rhythm control strategies?' Altogether, 2174 papers were found using the reported searches, of which 5 represented the best evidence to answer the clinical question. Hospital length of stay ranged from 5.0 to 13.2 days for rate control and 5.2 to 10.3 days for rhythm control. Freedom from AF at follow up was achieved in 84.2-91 and 84.2-96% in rate and rhythm control groups respectively. Minimal serious adverse events were noted in all studies analysed and there was no difference between rate and rhythm control groups. We conclude that in the management of post-cardiac surgery, AF, rate control and rhythm control are equivalent in terms of hospital length of stay, freedom from arrhythmia at follow up and complication rates.

Levosimendan Following Cardiac Surgery.

A best evidence topic was written to address if perioperative levosimendan improves mortality following cardiac surgery. Fourteen papers represented the best available evidence. An older meta-analysis summarising 11 of these trials concluded that there were fewer deaths in the levosimendan group compared to the control group (OR 0.41, p <0.001) however, this was driven by the results of three included trials by the same author. Three larger and more recent randomised controlled trials failed to demonstrate significant differences in mortality. We conclude that levosimendan lacks robust evidence to substantiate claims of mortality benefit in cardiac surgery patients and should not be used routinely in such patients.

Does minimally invasive coronary artery bypass improve outcomes compared to off-pump coronary bypass via sternotomy in patients undergoing coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing off-pump coronary artery bypass grafting, for single or multivessel disease, does minimally invasive direct coronary artery bypass (MIDCAB) or off-pump coronary artery bypass (OPCAB) provide the superior outcome including a reduction in morbidity and mortality?'. A total of 187 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, date, journal and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. It was found that compared to OPCAB, MIDCAB surgery can offer decreased intensive care unit length of stay (4.5-57.4 h vs 5.2-52.7 h) and total hospital length of stay (4.5-8.5 days vs 5.2-12 days), with 1 paper showing a decrease in mortality at 1 year (3% vs 14%). However, there were several papers that showed significant risks with MIDCAB surgery in patients with either single or multivessel disease. These include increased risk of incomplete revascularization (29% vs 0%), significant early complications (22.5 vs 0%), urgent reintervention (16% vs 0%), repeat revascularization events (12.2% vs 3.7%), progression of native disease (4.8% vs 0.9%), rehospitalization by 3 months (20% vs 2%) and postoperative infarction (2.9% vs 1.45%). These risks did not translate to an increase in early mortality (0-1% vs 0-1.6%) or late mortality (0-3% vs 0-14%) in papers that included mid-term follow up. However, they do represent significant potential risks that cannot be overlooked when considering the use of MIDCAB. We conclude that MIDCAB is associated with greater morbidity and reintervention compared to OPCAB via sternotomy, but both techniques are equivalent in terms of operative and mid-term mortality.

Platelet transfusion is not associated with increased mortality or morbidity in patients undergoing cardiac surgery.

BACKGROUND: Transfusion of platelets is common in cardiac surgery, and while there are guidelines for their use, there are concerns about potential risks. We aimed to assess the impact of platelet transfusion on mortality, thrombosis, and infection in this patient group. STUDY DESIGN AND METHODS: A retrospective cohort study of all patients at St Vincent's Hospital Melbourne who underwent a first cardiac surgery procedure from June 2001 to June 2014 was conducted. A propensity-weighted analysis was performed to examine the association between intraoperative platelet transfusion and outcomes. RESULTS: A total of 5233 patients met inclusion criteria, and 531 (10.15%) received intraoperative platelet transfusion (median two platelet doses, interquartile range, 1-17). Patients receiving platelets were older, had higher body mass index, lower rates of diabetes and dyslipidemia, higher rates of infective endocarditis, recent myocardial infarction and unstable angina, and exposure to aspirin or clopidogrel. On univariable analysis, platelet transfusion was associated with increased 30-day mortality (2.4% vs. 10.55%, p < 0.001), return to theatre for bleeding (3.23% vs. 13.37%, p < 0.001), and rates of any infection (9.26% vs. 19.17%, p < 0.001). After adjusting for confounders, platelet transfusion was not associated with increased risk of 30-day mortality or infective complications. Platelet transfusion was associated with higher rates of return to theatre (relative risk [RR], 2.46; confidence interval [CI], 1.42, 4.04; p = 0.001) and decreased risk of thromboembolic events (RR, 0.28; CI, 0.15, 0.51; p < 0.001). CONCLUSION: Platelet transfusion was not associated with increased mortality or infective complications following first cardiac surgery. Further prospective studies are required to identify patients most likely to benefit from platelet transfusion.

Biologically active constituents of the secretome of human W8B2+ cardiac stem cells.

The benefits of adult stem cells for repair of the heart have been attributed to the repertoire of salutary paracrine activities they appear to exert. We previously isolated human W8B2+ cardiac stem cells (CSCs) and found they powerfully influence cardiomyocytes and endothelial cells to collectively promote cardiac repair and regeneration. Here, the complexity of the W8B2+ CSC secretomes was characterised and examined in more detail. Using ion exchange chromatography to separate soluble proteins based on their net surface charge, the secreted factors responsible for the pro-survival activity of W8B2+ CSCs were found within the low and medium cation fractions. In addition to the soluble proteins, extracellular vesicles generated from W8B2+ CSCs not only exhibited pro-survival and pro-angiogenic activities, but also promoted proliferation of neonatal cardiomyocytes. These extracellular vesicles contain a cargo of proteins, mRNA and primary microRNA precursors that are enriched in exosomes and are capable of modulating collectively many of the cellular pathways involved in protein metabolism, cell growth, as well as cellular responses to stress and organisation of the extracellular matrix. Thus the W8B2+ CSC secretome contains a multitude of bioactive paracrine factors we have now characterised, that might well be harnessed for therapeutic application for cardiac repair and regeneration.

Rapid-Deployment Versus Conventional Bio-Prosthetic Aortic Valve Replacement.

BACKGROUND: The use of rapid-deployment aortic valve replacement (RD-AVR) has burgeoned in recent years. There are few studies comparing RD-AVR to conventional aortic valve replacement (cAVR) and no studies where both were inserted via full sternotomy. As such, we reviewed our experience and compared the two approaches. METHODS: From 2008 to 2015, 597 patients underwent isolated aortic valve replacement ± coronary artery bypass grafting (CABG) at a single centre. During this period, 41 (7%) patients received RD-AVR and 556 (93%) received cAVR. Of those receiving RD-AVR, surgical access was via full median sternotomy in 40 (98%). Propensity score matching yielded 41 matched pairs. Perioperative outcomes were compared. RESULTS: After propensity score matching, the RD-AVR group had shorter aortic cross clamp (X-clamp) (RD-AVR: 71±33min vs. cAVR: 106±42min, p<0.01) and cardiopulmonary bypass (CPB) times (95±42min vs. 134±47min, p<0.01). There was no difference in 30-day mortality (RD-AVR: 2% vs. cAVR: 2%, p>0.99). RD-AVR patients required shorter mean ventilation (17±25 vs. 63±131hrs, p<0.01) and intensive care unit (ICU) stay (51±45 vs. 108±157hrs, p=0.03) times. RD-AVR also had reduced rates of new postoperative atrial arrhythmias (8% vs. 20%, p=0.02). Total length of postoperative hospital stay was similar. Haemodynamic performance for the RD-AVR was within acceptable limits. CONCLUSIONS: The use of RD-AVR results in shorter X-clamp and CPB times and is associated with reductions in perioperative morbidity. RD-AVR is becoming a valuable component of the surgeon's armamentarium in selected patients. Long-term follow-up will reveal the full potential of these devices.

Transcatheter versus Surgical Aortic Valve Replacement in High-risk Patients: A propensity-score matched analysis.

BACKGROUND: There is limited data from Australia and New Zealand comparing transcatheter aortic valve implantation (TAVI) with conventional surgical aortic valve replacement (sAVR). METHODS: Between 2009 and 2015, 64 patients underwent TAVI and 669 underwent sAVR at a single centre. Patients' peri-operative details were analysed and compared between groups. Propensity-score matching was performed for risk adjustment. RESULTS: Patients receiving TAVI were older (mean age in years TAVI: 83.9±4.6 vs. sAVR: 71±9.9, P<0.001), and were more likely to be female (TAVI: 67%, 43/64, vs. sAVR: 32%, 217/669, P <0.001). Unadjusted 30-day mortality was comparable between groups (2/64, 3% vs. 22/669, 3%, P >0.99). The matched analysis revealed comparable 30-day mortality (TAVI: 2/44, 5% vs. sAVR: 2/44, 5%, P > 0.99). New atrial arrhythmia occurred more frequently within the sAVR cohort (TAVI: 1/44, 2% vs. sAVR 18/44, 41%, P <0.001). Complete heart block requiring permanent pacemaker was more frequent amongst the TAVI cohort (TAVI: 10/44, 23% vs. sAVR 2/44, 5%, P=0.039). At two years, survival was comparable between groups (TAVI: 74±1.7 vs. sAVR: 80±0.1%, P=0.65). CONCLUSION: This single centre experience suggests that TAVI is a valuable treatment option for high-risk surgical patients with comparable survival.

The Benefits and Pitfalls of the Use of Risk Stratification Tools in Cardiac Surgery.

Risk assessment tools are increasingly used in surgery. In cardiac surgery, risk models are used for patient counselling, surgical decision-making, performance benchmarking, clinical research, evaluation of new therapies and quality assurance, among others. However, they have numerous disadvantages which need to be considered. This article evaluates the utility of risk assessment tools in cardiac surgery including a discussion of their advantages and disadvantages.

Is a third arterial conduit necessary? Comparison of the radial artery and saphenous vein in patients receiving bilateral internal thoracic arteries for triple vessel coronary disease.

OBJECTIVES: The use of bilateral internal thoracic arteries (BITAs) is associated with improved long-term survival after coronary artery bypass grafting (CABG). However, it is unclear whether the addition of a radial artery (RA) in patients already receiving BITA confers any additional survival benefit over that of a saphenous vein (SV). As such, we reviewed our multicentre experience and compared both strategies. METHODS: From 1995 to 2010, 1497 patients underwent primary isolated CABG for three-vessel coronary disease using BITAs. An SV was used as a third conduit in 460 (31%) patients and an RA in 1037 (69%). A total of 1258 distal anastomoses were performed using RAs and these were to the diagonal territory in 169, the circumflex in 454 and the right coronary in 635. Survival data were obtained using the National Death Index and propensity-score matching was used for risk-adjustment. RESULTS: The overall cohort was young (mean age 61 ± 9 years). Patients receiving RAs were more likely to be younger, and were less likely to have experienced a prior myocardial infarction. At 30 days, mortality was similar (BITA + SV: 5, 1.1% vs BITA + RA: 9, 0.9%, P = 0.77). At 15 years, BITA + RA patients experienced improved unadjusted survival (BITA + SV: 67 ± 4.6% vs BITA + RA: 82 ± 3.2%, P < 0.0001). Multivariable Cox regression in the entire cohort also showed the BITA + RA group to be associated with better survival (HR 0.58, 95% CI 0.44-0.75, P < 0.001). After propensity-score matching of 262 patient-pairs, BITA + RA experienced similar 30-day mortality (BITA + SV: 3, 1.1% vs BITA + RA: 3, 1.1%, P > 0.99). However, at 15 years, BITA + RA patients experienced improved risk-adjusted survival (BITA + SV: 72 ± 6.0% vs BITA + RA: 82 ± 5.2%, P = 0.021). The RA was associated with better risk-adjusted survival for grafting of the right coronary and its branches (148 matched pairs; SV-RCA: 74 ± 7.8% vs RA-RCA: 86 ± 6.5%, P = 0.0046 at 15 years). CONCLUSIONS: The addition of an RA graft even in patients already receiving BITAs is associated with a survival benefit. In younger patients with a reasonable long-term life expectancy, surgeons should strive to achieve total arterial revascularization with BITAs and radial arteries.

Is the radial artery associated with improved survival in older patients undergoing coronary artery bypass grafting? An analysis of a multicentre experience†.

OBJECTIVES: Studies suggest that the radial artery (RA) may exhibit superior patency compared with the saphenous vein (SV). It is unclear whether older patients undergoing coronary artery bypass grafting (CABG) derive any survival benefit from the use of RAs. We sought to evaluate this using a multicentre database. METHODS: From 1995 to 2010, 6059 patients with three-vessel coronary artery disease underwent primary isolated CABG at 8 centres. A study cohort of 4006 patients was formed with 3220 (80%) receiving at least 1 RA to supplement a single in situ internal thoracic artery (RA group) while 786 (20%) received only veins to supplement a single ITA (SV group). In the RA group, bilateral RAs were used in 1418 (44%) cases, while total arterial revascularization was achieved in 1859 (58%). RAs were mostly grafted to the left circumflex and right coronary territories. Survival data were obtained using the National Death Index and propensity-score matching was used for risk adjustment. Separate propensity-score analyses were conducted for the 2149 patients (1645 RA, 504 SV) who were 70 years or older. RESULTS: Patients receiving RAs were younger (mean age in years RA: 68 ± 9.7 vs SV: 71 ± 7.9, P < 0.001) and less likely to have cerebrovascular disease, obstructive airways disease, myocardial infarction within 7 days and left-main coronary disease. At 30 days, RA patients experienced reduced unadjusted mortality (49 of 3220, 1.5% vs 25 of 786, 3.2%, P = 0.004). At 15 years, the RA group showed superior unadjusted survival (51 ± 1.1 vs 35 ± 1.9%, P < 0.001). After propensity-score matching of 507 patient pairs, there was comparable 30-day mortality between groups (RA: 9, 1.8 vs SV: 14, 2.8%, P = 0.41). However, at 15 years, the RA group still showed superior survival (42 ± 2.6 vs 35 ± 2.5%, P = 0.008). Among those 70 years and older (327 matched pairs), despite similar 30-day mortality (RA: 6, 1.8% vs SV: 10, 3.1%, P = 0.42), RA patients again exhibited improved survival (35 ± 3.3 vs 22 ± 2.8%, P = 0.004) at 15 years. CONCLUSIONS: This multicentre analysis suggests that the use of an RA is associated with a survival benefit in older patients undergoing CABG.