Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Disease

Hybrid Revascularization: A Review

Hybrid coronary revascularization (HCR) combines surgical bypass with percutaneous coronary intervention (PCI) performed either during the same procedure or in a staged approach within 60 days. Coronary artery bypass grafting using the left internal mammary artery (LIMA) has shown excellent long-term patency with improved patient survival. It remains the gold standard treatment for the majority of patients with multivessel coronary artery disease. However, saphenous vein grafts have poor long-term patency. Advances in stent technology have resulted in reduced rates of thrombosis and restenosis, making PCI a viable alternative to coronary surgery in selected patients. HCR is attractive as a less invasive method of coronary revascularization which preserves the benefits of the LIMA performed with less invasive surgical techniques with the efficacy of newer generation stents.

Nucleolin mediated pro-angiogenic role of Hydroxysafflor Yellow A in ischaemic cardiac dysfunction: Post-transcriptional regulation of VEGF-A and MMP-9

Hydroxysafflor Yellow A (HSYA), a most representative ingredient of Carthamus tinctorius L., had long been used in treating ischaemic cardiovascular diseases in China and exhibited prominently anticoagulant and pro-angiogenic activities, but the underlying mechanisms remained largely unknown. This study aimed to further elucidate the pro-angiogenic effect and mechanism of HSYA on ischaemic cardiac dysfunction. A C57 mouse model of acute myocardial infarction (AMI) was firstly established, and 25 mg/kg HSYA was intraperitoneally injected immediately after operation and given once, respectively, each morning and evening for 2 weeks. It was found that HSYA significantly improved ischaemia-induced cardiac haemodynamics, enhanced the survival rate, alleviated the myocardial injury and increased the expressions of CD31, vascular endothelial growth factor-A (VEGF-A) and nucleolin in the ischaemic myocardium. In addition, HSYA promoted the migration and tube formation of human umbilical vein endothelial cells (HUVECs), enhanced the expressions of nucleolin, VEGF-A and matrix metalloproteinase-9 (MMP-9) in a dose- and time-dependent manner. However, down-regulation of nucleolin expression sharply abrogated the effect mentioned above of HSYA. Further protein-RNA coimmunoprecipitation and immunoprecipitation-RT-PCR assay showed that nucleolin binded to VEGF-A and MMP-9 mRNA and overexpression of nucleolin up-regulated the mRNA expressions of VEGF-A and MMP-9 in the HUVECs through enhancing the stability of VEGF-A and MMP-9 mRNA. Furthermore, HSYA increased the mRNA expressions of VEGF-A and MMP-9 in the extract of antinucleolin antibody-precipitated protein from the heart of AMI mice. Our data revealed that nucleolin mediated the pro-angiogenic effect of HSYA through post-transcriptional regulation of VEGF-A and MMP-9 expression, which contributed to the protective effect of HSYA on ischaemic cardiac dysfunction.

Percutaneous coronary intervention with drug-eluting stent versus coronary artery bypass grafting: A meta-analysis of patients with left main coronary artery disease

BACKGROUND

The relative efficacy and safety of percutaneous coronary intervention (PCI) with drug-eluting stents (DES), in comparison to coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) remains controversial.

METHODS

We performed a meta-analysis of randomised studies comparing patients with LMCAD treated with PCI with DES versus those treated with CABG, with respect to clinical outcomes at 1, 3 and 5years. A secondary meta-analysis was performed according to low (<32), or high (≥33) SYNTAX score.

RESULTS

Five studies comprising 4595 patients were included. There was no significant difference in all-cause death at all time points or when stratified with respect to SYNTAX score. The need for repeat revascularization was significantly higher with PCI at all time-points, and regardless of SYNTAX score. There was significant association between need for repeat revascularization with PCI and diabetics (p=0.04). At 5years, non-fatal MI was higher with PCI owing to increased non-procedural events (OR 3.00; CI 1.45-6.21; p=0.003). CABG showed higher rate of stroke at 1year (OR 0.21; CI 0.07-0.63; p=0.005). There was no difference in non-fatal MI or stroke at other time points, nor according to SYNTAX score.

CONCLUSIONS

PCI with DES or CABG are equivalent strategies for LMCAD up to 5years with respect to death, regardless of SYNTAX score. PCI increases the rate of non-procedural MI at 5years. CABG avoids the need for repeat revascularization, especially in diabetics, but this benefit is offset by higher rate of stroke in the first year of follow up.

Percutaneous coronary intervention using drug-eluting stents versus coronary artery bypass graft surgery in left main coronary artery disease an updated meta-analysis of randomized clinical trials

Objectives

To compare the safety and efficacy of percutaneous coronary intervention (PCI) using drug-eluting stent (DES) and coronary artery bypass graft (CABG) for the treatment of left main coronary artery (LMCA) disease.

Background

Several new randomized trials have recently examined the clinical outcomes of PCI and CABG in LMCA disease. However, the results of these studies were inconsistent.

Materials and Methods

We searched five online electronic databases to identify all the randomized clinical trials assessing the outcomes of PCI using DES and CABG in patients with LMCA. The clinical outcomes were the major adverse cardiac and cerebrovascular event (MACCE), all-cause death, myocardial infarction (MI), stroke, and repeat revascularization (RR).

Results

A total of 5 randomized clinical trials with 4595 LMCA patients were included in this meta-analysis. For one year follow-up, the results indicated that PCI were associated with a lower risk of stroke (RR = 0.21, 95% CI = 0.07–0.65, P = 0.007), a higher risk of RR (RR = 1.72, 95% CI = 1.28–2.33, P < 0.001) than CABG. Moreover, for long-term follow-up, there were significant higher risks of MACCE and RR with PCI versus CABG (MACCE: HR = 1.26, 95% CI = 1.11–1.44, P = 0.001; RR: HR = 1.70, 95% CI = 1.42–2.05, P < 0.001). However, there were no significant differences between the two groups in all-cause death and MI risks, regardless of follow-up duration.

Conclusions

PCI is noninferior to CABG in short term follow-up of patients with LMCA disease, but CABG is more safety and efficacy than PCI using DES in long-term follow-up.