Late Outcome After Stenting or Coronary Artery Bypass Surgery for the Treatment of Multivessel Disease: A Single-Center Matched-Propensity Controlled Cohort Study

Comparing 5-year Outcomes of Aorta-Coronary Bypass Surgery and Percutaneous Coronary Intervention Performed with New-Generation Drug-Eluting Stents in Non-Diabetic Patients with Multivessel Acute Coronary Syndrome Patients and Intermediate Syntax Score

Objective

Our main objective is to determine the difference between patients undergoing CABG and PCI with new-generation drug-eluting stents who were non-diabetic during the course of a multivessel acute coronary syndrome (ACS) and intermediate SYNTAX score.

Methods

Between 2012 and 2014, we retrospectively evaluated 1011 non-diabetic patients with ACS in a single center. The patients were followed up up to 5-years. All- cause mortality, cardiac death, myocardial infarction, stroke, revascularization and stent thrombosis were recorded accordingly.

Results

A total of 516 (51%) patients were included in the PCI group and 495 patients (49%) in the CABG group. Stroke occurrence (PCI group: 0.8%, and CABG group: 2.6%, p=0.022), requirement for recurrent revascularizations (PCI group: 13.6%, and CABG group: 8.1%, p=0.005) and the MACE percentage (PCI group: 20.3%, and CABG group: 14.5%, p=0.015) were statistically significant between two groups. However, there was no statistical significance difference between two groups in terms of primary endpoints including death, MI, and stroke (PCI group: 10.9%, and CABG group: 8.3%, p=0.165) and all-cause mortality PCI group 6.2%, and CABG group: 4.7%, p=0.298).

Conclusion

There was no difference in all-cause mortality and myocardial infarction between the PCI and the CABG groups during 5-year follow-up. The frequency of repeated revascularizations was lower in the CABG group than the PCI group. In contrast, the stroke rates were higher in the CABG group.

Long-term Outcome after Percutaneous Coronary Intervention Compared with Minimally Invasive Coronary Artery Bypass Surgery in the Elderly

Background:

Elderly patients with unstable coronary artery disease (CAD) have better outcomes with coronary revascularization than conservative treatment. With the improvement in percutaneous coronary intervention (PCI) techniques using drug eluting-stents, this became an attractive option in elderly. Minimally invasive coronary artery bypass grafting (MICS-CABG) is a safe and effective alternative to conventional CABG. We aimed to explore the long-term outcomes after PCI vs MICS-CABG in ≥75 year-old patients with severe CAD.

Methods:

A total of 1454 elderly patients (≥75 year-old patients) underwent coronary artery revascularization between January 2005 and December 2009. Patients were selected in the study if they have one of the Class-I indications for CABG. Groups were divided according to the type of procedure, PCI or MICS-CABG, and 5 year follow-up.

Results:

Among 175 elderly patients, 109 underwent PCI and 66 had MICS-CABG. There was no significant difference observed in both groups with long-term all-cause mortality (31 PCI vs 21% MICS-CABG, p=0.151) and the overall 5 year survival was similar on Kaplan-Meier curve (Log rank p=0.318). The average length of stay in hospital was significantly shorter in the PCI than in the MICS-CABG group (4.3 vs 7.8 days, p<0.001). Only 4.7% of the PCI group were discharged to rehabilitation facility compared with 43.9% of the MICS-CABG group (p<0.001). The rate of repeat revascularization was significantly higher in the PCI group than in the MICS-CABG group (15 vs 3%, p=0.014).

Conclusion:

Among elderly patients, long-term all-cause mortality is similar after PCI and MICS-CABG. However, there is a significantly higher rate of repeat revascularization after PCI.

Composite outcomes in coronary bypass surgery versus percutaneous intervention

BACKGROUND

Recent observational studies show that patients with multivessel coronary disease have a long-term survival advantage with coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI). Important nonfatal outcomes may also affect optimal treatment recommendation.

METHODS

CABG was compared with percutaneous catheter intervention by using a composite of death, myocardial infarction (MI), or stroke. Medicare patients undergoing revascularization for stable multivessel coronary disease from 2004 through 2008 were identified in national registries. Short-term clinical information from the registries was linked to Medicare data to obtain long-term follow-up out to 4 years from the time of the procedure. Propensity scoring with inverse probability weighting was used to adjust for baseline risk factors.

RESULTS

There were 86,244 CABG and 103,549 PCI patients. The mean age was 74 years, with a median 2.67 years of follow-up. At 4 years, the propensity-adjusted adjusted cumulative incidence of MI was 3.2% in CABG compared with 6.6% in PCI (risk ratio, 0.49; 95% confidence interval, 0.45 to 0.53). At 4 years, the cumulative incidence of stroke was 4.5% in CABG compared with 3.1% in PCI patients (risk ratio, 1.43; 95% confidence interval, 1.31 to 1.54). This difference was primarily due to the higher 30-day stroke rate for CABG (1.55% vs 0.37%). For the composite of death, MI, or stroke, the 4-year adjusted cumulative incidence was 21.6% for CABG and 26.7% for PCI (risk ratio, 0.81; 95% confidence interval, 0.78 to 0.83).

CONCLUSIONS

The 4-year composite event rate of death, MI, and stroke favored CABG, whereas the risk of stroke alone favored PCI.

Speckle-tracking imaging to monitor myocardial function after coronary artery bypass graft surgery

OBJECTIVES

The purpose of this study was to investigate the changes in myocardial function in patients after coronary artery bypass graft (CABG) surgery using longitudinal and circumferential strain on speckle-tracking imaging.

METHODS

A total of 145 patients who successfully underwent CABG surgery with a left ventricular ejection fraction (LVEF) of 50% or greater were enrolled in this study. Patients were classified into 4 groups based on age: group 1 (33-59 years), group 2 (60-64 years), group 3 (65-69 years), and group 4 (70-79 years). Routine echocardiography and longitudinal and circumferential strain measurements on speckle-tracking imaging were performed 1 week before and 1, 3, and 6 months after the CABG.

RESULTS

In all groups, longitudinal strain increased significantly at 3 and 6 months after CABG therapy compared to baseline (P < .05). A significant increase in circumferential strain was found 1 month after the CABG in groups 1, 2, and 3, and a continuous increase in the parameter was observed in all groups 3 months after therapy (P < .05). However, the LVEF, left ventricular end-diastolic dimension, and stroke volume measured by routine echocardiography were not significantly changed after successful CABG treatment in all groups during 6 months of follow-up.

CONCLUSIONS

Based on the results of our study in all age groups, speckle-tracking imaging parameters are more effective than the LVEF, left ventricular end-diastolic dimension, and stroke volume for monitoring improvement in myocardial function after CABG surgery.

Percutaneous versus surgical interventions for coronary artery disease in those with diabetes mellitus

Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies that causes long-term damage of various organs including the cardiovascular system. A consistent observation shows that DM amplifies the risk of cardiovascular events by 4- to 6-fold. Since coronary artery disease (CAD) in diabetic patients exhibits diffuse and accelerated lesions, invasive revascularization continues to be a challenge and has worse outcomes than patients without DM. Owing to the pathogenesis of DM and the presence of severe endothelial dysfunction, investigators have been trying to find new treatment modalities that could target the treatment of the disease rather than the treatment of the lesion. Until new treatment modalities are proven and gain acceptance, invasive revascularization remains to be the choice of treatment in such patients. The focus of this review is to compare the results of percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of stable CAD in patients with DM.

Comparative effectiveness of revascularization strategies

BACKGROUND

Questions persist concerning the comparative effectiveness of percutaneous coronary intervention (PCI) and coronary-artery bypass grafting (CABG). The American College of Cardiology Foundation (ACCF) and the Society of Thoracic Surgeons (STS) collaborated to compare the rates of long-term survival after PCI and CABG.

METHODS

We linked the ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008. Outcomes were compared with the use of propensity scores and inverse-probability-weighting adjustment to reduce treatment-selection bias.

RESULTS

Among patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, 86,244 underwent CABG and 103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year, there was no significant difference in adjusted mortality between the groups (6.24% in the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods. Residual confounding was assessed by means of a sensitivity analysis.

CONCLUSIONS

In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI. (Funded by the National Heart, Lung, and Blood Institute.).

Comparison of long-term outcome of off-pump coronary artery bypass grafting versus drug-eluting stents in triple-vessel coronary artery disease

After the introduction of drug-eluting stents (DESs), percutaneous coronary intervention with DESs has challenged coronary artery bypass grafting as the gold standard for the treatment of 3-vessel coronary artery disease. The purpose of this study was to compare the long-term clinical results between percutaneous coronary intervention with DESs and off-pump coronary artery bypass grafting (OPCAB) in 3-vessel coronary artery disease. Two hundred ninety propensity-score matched patients with 3-vessel coronary artery disease treated by DESs or OPCAB were included. Mean follow-up duration was 58.8 ± 11.5 months (2 to 73) and follow-up rate was 97.9%. Five-year survival rates were 94.8 ± 2.1% in the DES group and 96.5 ± 1.5% in the OPCAB group (p = 0.658). Five-year rates of freedom from major adverse cardiac and cerebrovascular event were 71.6 ± 4.1% in the DES group and 89.6 ± 2.5% in the OPCAB group (p < 0.001). Freedom from nonfatal myocardial infarction and target vessel revascularization rates were the determining factors between the 2 groups (p = 0.018 and p < 0.001, respectively). The OPCAB group showed better clinical outcomes compared to the DES group in 3-vessel coronary artery disease after 5-year follow-up. Freedom from major adverse cardiac and cerebrovascular event rate was significantly higher in the OPCAB group mainly because of the lower incidence of target vessel revascularization and nonfatal myocardial infarction. Longer follow-up with randomization will clarify our present conclusions.

Eight-year clinical outcome after radioactive stent implantation: a treatment failure without irreversible long-term clinical sequelae

AIMS

To assess the long-term outcome of patients who underwent radioactive stent (RS) implantation.

METHODS AND RESULTS

The RS study population consisted of 133 consecutive patients who underwent RS implantation between November 1997 and July 2000. They were matched using the propensity score method with 266 patients who underwent bare metal stenting (BMS) in the same span. Long-term survival status and information on MACE (death, non-fatal myocardial infarction or any re-intervention) was retrospectively obtained. Eight-year cumulative survival (90.2% vs. 87.4%, p = 0.57) was similar between the RS and BMS group respectively, while 8-year cumulative MACE-free survival was significantly lower in RS patients (42.1% vs. 64.3%, p < 0.001) due to the difference in events (mainly target lesion revascularisations [TLRs]) during the first year of follow-up (cumulative 1-year MACE-free survival: 59.4% vs. 86.7%, p < 0.001); there was no difference in the MACE rate after the first year (p = 0.71). The TLR rate at six months in the RS group was 29.3%, mainly due to edge restenosis and at one year 36.2% (control group: 9.5%, p < 0.001).

CONCLUSIONS

A high incidence of MACE and re-intervention was observed during the first year following RS implantation, mainly related to TLR for edge restenosis. After the first year, the clinical outcome of RS patients was similar to the control group indicating that there are no late adverse effects related to low dose-rate intracoronary radiation therapy.

Surgical Revascularization Is Associated With Improved Long-Term Outcomes Compared With Percutaneous Stenting in Most Subgroups of Patients With Multivessel Coronary Artery Disease: Results From the Intermountain Heart Registry

BACKGROUND

Coronary artery bypass surgery (CABG) and percutaneous coronary intervention with stenting (PCI-S) are both safe and effective approaches for revascularization in patients with multivessel coronary artery disease. However, conflicting information exists when comparing the efficacy of the two methods. In this study, we examined the outcomes of major adverse cardiovascular events and death for subgroups of typical "real-world" patients undergoing coronary revascularization in the modern era.

METHODS AND RESULTS

Patients were included if they were revascularized by CABG or PCI-S, had > or = 5 years of follow-up, and had > or = 2-vessel disease. Patients were followed for an average of 7.0+/-3.2 years for incidence of death and major adverse cardiovascular events (death, myocardial infarction, or repeat revascularization). Multivariate regression models were used to correct for standard cardiac risk factors including age, sex, hyperlipidemia, diabetes mellitus, family history of coronary artery disease, smoking, hypertension, heart failure, and renal failure. Subgroup analyses were also performed, stratified by age, sex, diabetes, ejection fraction, and history of PCI-S, CABG, or myocardial infarction. A total of 6369 patients (CABG 4581; PCI-S 1788) were included. Age averaged 66+/-10.9 years, 76% were male, and 26% were diabetic. Multivariate risk favored CABG over PCI-S for both death (hazard ratio 0.85; P=0.001) and major adverse cardiovascular events (hazard ratio 0.51; P<0.0001). A similar advantage with CABG was also found in most substrata, including diabetes.

CONCLUSIONS

In this large observational study of patients undergoing revascularization for multivessel coronary artery disease, a long-term benefit was found, in relationship to both death and major adverse cardiovascular events, for CABG over PCI-S regardless of diabetic status or other stratifications.

Myocardial revascularization: surgery or stenting?

There is current debate regarding the relative merits and roles of surgical revascularization and percutaneous revascularization for patients with obstructive coronary artery disease. This article reviews the current literature relating to this subject.

The life and hard times of a coronary surgeon

Coronary artery bypass is arguably the most extensively studied operation in surgical history. The technical advances and beneficial effects on symptoms and prognosis have been well documented over four decades. Percutaneous coronary interventions (PCIs) have also evolved through numerous modifications, and symptom relief has been substantiated; both modalities have been challenged by many randomized controlled trials. The rapid growth of PCIs has decreased coronary artery bypass volumes, and resulted in concerns about training, teaching, research, jobs and income. The most important concern, however, is the increasing 'off-label' application of PCIs with drug-eluting stents to a variety of untested coronary lesions. The randomized controlled trials studied a small fraction of those registered and excluded patients who are known to benefit from surgery and, thus, these studies were inherently biased. The results were then extrapolated to 'real-world' patients, who had been misinformed and misled about the performance and prognosis of coronary stents, as was later revealed in various registries. Hospitals should develop a collaborative revascularization strategy to provide patients and families with realistic alternatives.

Long-Term Survival of Patients After Coronary Artery Bypass Graft Surgery: Comparison of the Pre-Stent and Post-Stent Eras

BACKGROUND

Although coronary artery bypass graft surgery (CABG) has long been the "gold standard" for treatment of multivessel coronary artery disease, current percutaneous interventional technologies are challenging that claim. We sought to determine long-term survival after isolated CABG to establish a baseline for comparison with interventional patients.

METHODS

From 1968 through 2003, 20,835 patients underwent 22,378 isolated CABG procedures by a single surgical team. The intermittent fibrillation technique without use of cardioplegia was consistently utilized as a method of myocardial protection, using cardiopulmonary bypass. Patients were prospectively followed with direct contact at annual intervals. Age stratified survival was analyzed. Long-term survival was compared between pre-stent era patients and post-stent era patients.

RESULTS

Operative mortality was 2.5% (95% confidence interval: 2.2% to 2.7%) and remained approximately constant since 1974 despite increasing patient age and comorbidities. Follow-up was 84% complete with 172,773 patient-years. Overall 5-, 15-, 25-, and 35-year survival was 86% +/- 0.3%, 48% +/- 0.5%, 19% +/- 0.6%, and 7% +/- 1.2%. By Cox regression, older age, prior myocardial infarction, hypertension, diabetes mellitus, and history of CABG were risk factors for long-term survival. Surgery performed during the post-stent era was a protective factor for long-term survival.

CONCLUSIONS

This study presents the long-term survival of a large series of patients after CABG performed by a single surgical team with intermittent fibrillation technique. There was no difference in observed survival up to 8 years between the pre-stent and post-stent eras. This study establishes a baseline of long-term CABG survival that could be used for comparison with other methods of surgical, or nonsurgical coronary revascularization.

[Current evidence-based situation in coronary revascularization--CABG vs. PCI and diabetes?]

A variety of randomized, controlled trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) found similar results in mortality but significant differences in number of reinterventions in favor of CABG. This work gives an overview about the relevance and limitations of these studies in line with newly published large scale observational studies, which reveal significantly lower mortality-rates in CABG patients. Emphasis is placed on the special situation in the diabetic patient.