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Original research
Multiple arterial coronary bypass grafting is associated with greater survival in women
  1. Derrick Y Tam1,
  2. Rodolfo V Rocha1,
  3. Jiming Fang2,
  4. Maral Ouzounian3,
  5. Joanna Chikwe4,
  6. Jennifer Lawton5,
  7. Dennis T Ko2,6,
  8. Peter C Austin2,
  9. Mario Gaudino7,
  10. Stephen E Fremes1
  1. 1Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  2. 2ICES, Toronto, Ontario, Canada
  3. 3Division of Cardiac Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
  4. 4Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
  5. 5Division of Cardiac Surgery, John Hopkins Hospital, Baltimore, Maryland, USA
  6. 6Division of Cardiology, Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  7. 7Cardiothoracic Surgery, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
  1. Correspondence to Dr Stephen E Fremes, University of Toronto, Toronto, ON M5S, Canada; Stephen.Fremes{at}


Objective Multiple arterial grafting (MAG) in coronary artery bypass grafting (CABG) is associated with higher survival and freedom from major adverse cardiac and cerebrovascular events (MACCEs) in observational studies of mostly men. It is not known whether MAG is beneficial in women. Our objectives were to compare the long-term clinical outcomes of MAG versus single arterial grafting (SAG) in women undergoing CABG for multivessel disease.

Methods Clinical and administrative databases for Ontario, Canada, were linked to obtain all women with angiographic evidence of left main, triple or double vessel disease undergoing isolated non-emergent primary CABG from 2008 to 2019. 1:1 propensity score matching was performed. Late mortality and MACCE (composite of stroke, myocardial infarction, repeat revascularisation and death) were compared between the matched groups with a stratified log-rank test and Cox proportional-hazards model.

Results 2961 and 7954 women underwent CABG with MAG and SAG, respectively, for multivessel disease. Prior to propensity-score matching, compared with SAG, those who underwent MAG were younger (66.0 vs 68.9 years) and had less comorbidities. After propensity-score matching, in 2446 well-matched pairs, there was no significant difference in 30-day mortality (1.6% vs 1.8%, p=0.43) between MAG and SAG. Over a median and maximum follow-up of 5.0 and 11.0 years, respectively, MAG was associated with greater survival (HR 0.85, 95% CI 0.75 to 0.98) and freedom from MACCE (HR 0.85, 95% CI 0.76 to 0.95).

Conclusions MAG was associated with greater survival and freedom from MACCE and should be considered for women with good life expectancy requiring CABG.

  • coronary artery disease surgery

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  • Contributors All authors participated in (1) conception and design or analysis and interpretation of data, or both; (2) drafting of the manuscript or revising it critically for important intellectual content; and (3) final approval of the manuscript submitted.

  • Funding DYT is supported by CIHR Fellowship Award. SEF is supported by the Bernard S. Goldman Chair in Cardiovascular Surgery (Toronto, Ontario). This study was supported by the Bernard S. Goldman Grant for Cardiovascular Surgery. PA and DK are supported by a Mid-Career Award from the Heart and Stroke Foundation. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

  • Disclaimer The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. The dataset from this study is held securely in coded form at ICES. While data sharing agreements prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access (available at The full dataset creation plan and underlying analytic code are available from the authors on request, understanding that the computer programs may rely on coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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