Meta-Analysis of Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Narrowing

Clinical Outcomes of Patients with Coronary Artery Diseases and Moderate Left Ventricular Dysfunction: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery

Purpose

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are two revascularization strategies for patients with coronary artery disease (CAD) and left ventricular dysfunction. However, the comparisons of effectiveness between the two strategies are insufficient. This study is aimed to compare the effectiveness between PCI and CABG among patients with moderate left ventricular dysfunction.

Patients and Methods

A total of 1487 CAD patients with moderate reduced ejection fraction (36%≤EF≤40%), who underwent either PCI or CABG, were enrolled in a real-world cohort study (No. ChiCTR2100044378). Clinical outcomes included short- and long-term all-cause mortality, rates of heart failure (HF) hospitalization and repeat revascularization. Propensity score matching was used to balance the two cohorts.

Results

PCI was associated with lower 30-day mortality rate (hazard ratio [HR] [95% CI], 0.35 [0.15–0.83]; P=0.02). At a mean follow-up of 4.5 years, PCI and CABG had similar all-cause death (HR [95% CI], 0.82 [0.56–1.20]; P=0.30) and heart failure (HF) hospitalization (HR [95% CI], 0.93 [0.54–1.60]; P=0.79), but PCI had higher risk of repeat revascularization (HR [95% CI], 8.62 [3.67–20.23]; P<0.001). Improvement in EF measured at 3 months later after revascularization was also similar between PCI and CABG (P for interaction=0.87).

Conclusion

CAD patients with moderate reduced EF who had PCI had lower short-term mortality rate but higher risk of repeat revascularization during follow-up than patients who had CABG. PCI showed comparable long-term survival, HF hospitalization risk, and EF improvement.

A Case Summary of the Application of a Drug-Eluting Stent Combined with a Drug-Coated Balloon in Left Main Coronary Artery Disease

Objective: To evaluate the clinical efficacy of a drug-eluting stent (DES) combined with a drug-coated balloon (DCB)in the treatment of left main coronary artery bifurcation lesions.Methods: A retrospective analysis was conducted on the clinical data of eight patients with left main coronary arterybifurcation lesions treated with a DES combined with a DCB who were admitted to our hospital from July 2016 to July2017. These eight patients all underwent DES treatment for their left main coronary artery and left anterior descendingcoronary artery lesions, and DCB treatment at the ostium of the left circumflex artery; six of the patients underwentsurgical procedures under the guidance of intravascular ultrasonography. Immediate postoperative angiography wasused to evaluate the patency of the diseased vessels, and the restenosis rate at the 6-month follow-up after the operationand the incidence of serious clinical events within 6 months were assessed as well.Results: The use of a DES combined with a DCB in the treatment of left main coronary artery bifurcation lesions hada low restenosis rate (left main coronary artery (8.4 ± 5.3)%, left anterior descending coronary artery (18.2 ± 5.0)%,left circumflex artery (30.5 ± 16.5)%). No serious clinical events occurred in any patients.Conclusion: A DES combined with a DCB is a safe and effective interventional treatment for left main artery coronarybifurcation lesions.

Efficacy of Fractional Flow Reserve-Guided Percutaneous Cornary Intervention for Patients with Angina Pectoris

Evaluation of hemodynamic parameters, such as fractional flow reserve (FFR), is recommended before percutaneous coronary intervention (PCI) for patients with angina pectoris (AP). However, the advantage of FFR-guided PCI has not been fully established. This study was performed to confirm whether FFR-guided PCI improves the prognosis compared with other treatments. Multiple databases were searched for studies published from 2000 to 2018, and a network meta-analysis (NMA) was performed to compare outcomes of FFR-guided PCI, non-FFR-guided PCI, coronary artery bypass grafting (CABG), and medical treatment (MT) for AP based on estimated odds ratios (ORs). The study included 18,093 patients from 15 randomized controlled trials (RCTs). No evidence of inconsistency was observed among the studies. The NMA showed that the all-cause mortality of FFR-guided PCI was not significantly different from that of the other treatment groups (CABG: OR, 1.1; 95% confidence interval [CI], 0.67-1.7; non-FFR-guided PCI: OR, 0.85; 95% CI, 0.53-1.4; and MT: OR, 0.83; 95% CI, 0.52-1.3). The NMA for the composite of all-cause mortality and myocardial infarction, which included 15,454 patients from 12 RCTs, showed that FFR-guided PCI significantly reduced the composite outcome compared with non-FFR-guided PCI and MT (non-FFR-guided PCI: OR, 0.66; 95% CI, 0.46-0.95 and MT: OR, 0.66; 95% CI, 0.46-0.95). Although FFR-guided PCI for AP did not show significant prognostic improvement compared with non-FFR-guided PCI, CABG, and MT, FFR-guided PCI may significantly reduce the composite of all-cause mortality and myocardial infarction compared with non-FFR-guided PCI and MT.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis

PURPOSE OF REVIEW

This article reviews the latest data on unprotected left main (ULM) percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) surgery, with a focus on the NOBLE and EXCEL trials.

RECENT FINDINGS

In EXCEL trial, the primary endpoint at 3 years was 15.4% in the PCI group and 14.7% in the CABG group (p = 0.02 for non-inferiority of PCI versus CABG). In NOBLE, the primary endpoint at 5 years was 28% and 18% for PCI and CABG, respectively (HR 1.51, CI 1.13-2.0, which did not meet the criteria for non-inferiority of PCI to CABG; p for superiority of CABG was 0.0044). Higher repeat revascularization and non-procedural myocardial infarction were noted in PCI group but there was no difference in all-cause or cardiac mortality between the two groups. A heart team approach with appropriate patient selection, careful assessment of LM lesions, and meticulous procedural technique makes PCI a valid alternative to CABG for ULM stenosis.

The epidemiology of coronary artery bypass surgery in a community hospital: A comparison between 2 periods

During the last decades, the increased number of percutaneous interventions procedures causes a significant change in the profile of patients referred to coronary artery bypass grafting (CABG). We aimed to study changes in patients' characteristics and procedural outcomes of patients referred to CABG in a community hospital during the first 15 years of the millennium.A historical cohort study of all patients who underwent CABG in Cape Cod Hospital was performed. The period was divided into 2 sub-periods, 2000 to 2008 and 2009 to 2014. Patients' characteristics and procedure outcomes were compared. Data on age, sex, comorbidities, Society of Thoracic Surgery risk scores and surgical adverse outcomes (stroke, coma, and 30-days mortality) were collected.During the study period, 1108 patients underwent CABG; 612 were operated before 2009 and 496 after. Age and sex were similar in the 2 periods. The patients in the later period presented lower risk for mortality and stroke (P <.001). Diabetes (DM) was more common in the later period (P <.001) while peripheral vascular disease (PVD) (P <.001) and left main disease (LM) (P = .017) were more common in the earlier period. Mortality rates were similar between the 2 periods. Post-operative stroke (1.8%) and coma (0.8%) were presented only in the later period. In conclusion, a significant change in CABG patients' characteristics was observed.In conclusion, patients in the later period had lower risk score and were more likely to present with DM and less with PVD and LM. Despite the lower risk, the mortality rate was similar.

All-cause mortality and major cardiovascular outcomes comparing percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: a meta-analysis of short-term and long-term randomised trials

Objective

We compared percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of left main coronary artery (LMCA) disease by conducting a systematic review and meta-analysis of randomised controlled trials (RCTs).

Methods

RCTs of PCI versus CABG in patients with LMCA stenosis were identified from MEDLINE, the Cochrane Library and search of bibliographies to November 2016. Study-specific HRs with 95% CIs were aggregated for all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), and other cardiovascular events at time points of 30 days, 1 year and 3 years and beyond.

Results

Six RCTs comprising 4700 patients were included. There were no significant differences in risk of all-cause mortality in pooled analysis of relevant trials at 30 days (0.61, 95% CI 0.27 to 1.36), 1 year (0.66, 95% CI 0.42 to 1.04), and 3 years and beyond (1.04, 95% CI 0.81 to 1.33), comparing PCI with CABG. There was no significant difference in the risk of MACCE at 30 days (0.72, 95% CI 0.51 to 1.03) and 1 year (1.16, 95% CI 0.94 to 1.44); however, PCI was associated with a higher risk of MACCE compared with CABG during longer-term follow-up (1.27, 95% CI 1.12 to 1.44). Composite outcome of death, stroke or myocardial infarction was lower with PCI at 30 days (0.67, 95% CI 0.49 to 0.92). Repeat revascularisation was increased at 1 year and at 3 years and beyond for PCI.

Conclusions

All-cause mortality rates are not significantly different between PCI and CABG at short-term and long-term follow-up. However, PCI is associated with a reduction in the risk of major cardiovascular outcomes at short-term follow-up in patients with LMCA stenosis; but at long term, MACCE rate is increased for PCI.