On-Pump Versus Off-Pump Surgical Revascularization for Left Main Stem Stenosis: Risk Adjusted Outcomes

Matched Analysis of Surgical versus Percutaneous Revascularization for Left Main Coronary Disease

BACKGROUND

Percutaneous coronary intervention (PCI) is being performed more frequently for left main coronary artery disease (LMCAD). This study evaluated a real-world propensity-matched analysis of surgical versus percutaneous revascularization for LMCAD.

METHODS

Adults (≥18 years) at a single academic institution undergoing coronary artery bypass grafting (CABG) or PCI for left main stenosis ≥50% between 2010-2018 were examined. Greedy propensity-matching techniques were used to generate well-matched cohorts, and Kaplan-Meier analysis was used to compare survival. Multivariable Cox models were created for 5-year mortality and major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

1091 with LMCAD were identified (898 CABG, 193 PCI). Patients undergoing PCI were significantly older (77 vs 68 years, p<0.001), more likely to have heart failure (26.94% vs 13.14%, p<0.001), and were less likely to have 3-vessel disease (42.49% vs 65.59%, p<0.001). Propensity-matching yielded 215 CABG and 134 PCI well-matched patients. In the matched analysis, 1-year (77.61% vs 88.37%) and 5-year (48.77% vs 75.62%) survival were lower with PCI. Rates of MACCE at 5-years were also higher with PCI (64.93% vs 32.56%, p<0.001). Rates of both myocardial infarction (19.40% vs 7.44%, p=0.001) and repeat revascularization (26.12% vs 7.91%, p<0.001) were higher with PCI. Following risk adjustment, CABG remained associated with reduced risk of mortality (HR 0.40, 95% CI 0.29-0.54; p<0.001) and MACCE (HR 0.37, 95% CI 0.28-0.48; p<0.001) at 5 years.

CONCLUSIONS

This real-world, propensity-matched analysis demonstrates substantial advantages in survival and MACCE with CABG for LMCAD, supporting surgical revascularization in this clinical setting in appropriate operative candidates.

Off-pump coronary artery bypass grafting in left main stem stenosis: outcomes, concerns and controversies

Left main stem (LMS) disease is known to be a poor prognostic factor in terms of morbidity or mortality. Traditionally, it has been treated with constitution of bypass to provide required haemodynamic stability. We searched the literature for evidence on off-pump (OFP) surgery for treating this high-risk group of patients focusing in our review on postoperative outcomes, concerns and controversies. The majority of the studies identified showed favourable or equal outcomes of OFP when compared to conventional approach. All of the studies, apart from two, which showed lower incidence of postoperative deaths, demonstrated equal mortality rates. Stroke rates were found less in three studies. Less blood transfusions, inotropic use and length of study has been also demonstrated. The main concerns of OFP surgery are: haemodynamic instability and less complete revascularization. Main controversies are: same or favourable outcomes despite lower number of grafts with OFP surgery and less stroke rates despite manipulation of aorta with side-clamping. Despite these concerns and controversies OFP surgery has been proven to be feasible and safe as demonstrated by results from numerous studies.

A propensity score analysis on the effect of on-pump versus off-pump coronary artery bypass grafting for patients with coronary artery disease

AIM

The aim of this retrospective observational study was to investigate the effect of on-pump versus off-pump coronary artery bypass grafting (CABG) for patients with coronary artery diseases (CAD).

METHODS

A retrospective observational study was performed using a propensity score analysis in 290 consecutive patients undergoing CABG between April 2009 and March 2014, of them, 54 patients undergoing off-pump CABG (OPCABG) were matched with 54 patients undergoing on-pump CABG (ONCABG) by propensity score. The perioperative complications and hospital mortality were documented.

RESULTS

Preoperative characteristics were comparable in both groups following propensity matching. Postoperative myocardial infarction (MI) incidence was lower in OPCABG group than in ONCABG group (3.7% vs. 14.8%, P=0.046); both hospital mortality and the major complications rates were similar in the two groups after propensity adjustment for preoperative characteristics.

CONCLUSIONS

The perioperative complications are similar in both off-pump and on pump CABG groups, the short-term effect of OPCABG is similar to that of ONCABG.

A propensity score analysis on the effect of on-pump versus off-pump coronary artery bypass grafting for patients with coronary artery disease

AIM

The aim of this retrospective observational study was to investigate the effect of on-pump versus off-pump coronary artery bypass grafting (CABG) for patients with coronary artery diseases (CAD).

METHODS

A retrospective observational study was performed using a propensity score analysis in 290 consecutive patients undergoing CABG between April 2009 and March 2014, of them, 54 patients undergoing off-pump CABG (OPCABG) were matched with 54 patients undergoing on-pump CABG (ONCABG) by propensity score. The perioperative complications and hospital mortality were documented.

RESULTS

Preoperative characteristics were comparable in both groups following propensity matching. Postoperative myocardial infarction (MI) incidence was lower in OPCABG group than in ONCABG group (3.7% vs. 14.8%, P=0.046); both hospital mortality and the major complications rates were similar in the two groups after propensity adjustment for preoperative characteristics.

CONCLUSIONS

The perioperative complications are similar in both off-pump and on pump CABG groups, the short-term effect of OPCABG is similar to that of ONCABG.

Evaluation of early and midterm results of offpump coronary artery bypass in patients with left main disease

PURPOSE

This study evaluated the early and midterm results of offpump coronary artery bypass (OPCAB) for left main coronary artery (LMCA) stenosis.

METHODS

Patients treated between November 2001 and December 2006, during which isolated coronary artery bypass grafting (CABG) was performed without cardiopulmonary bypass in principle, were included. Isolated CABG was performed in 206 patients, of whom 62 (30.1%) had LMCA stenosis >50%.

RESULTS

The in-hospital mortality rate (LMCA stenosis > 50%, 1.6%; LMCA stenosis <or=50%, 0.7%, p = 0.512), the incidence of postoperative complications, and the midterm survival rate (LMCA stenosis succeeds50%, 86.7 +/- 5.2%/5 years, LMCA stenosis<or=50%, 89.6 +/- 3.8%/5 years, p = 0.21) did not significantly differ between the two groups. Conversion was significantly frequent in patients with LMCA stenosis >75% and severe stenosis >90% in the right coronary artery (RCA) trunk.

CONCLUSIONS

Patients with LMCA stenosis can undergo OPCAB safely and the midterm results are good. As conversion was significantly frequent in patients with severe LMCA and RCA trunk stenosis, adequate preparation for pump application is necessary.

Off-pump coronary revascularization for left main coronary artery stenosis

Experience of on- and off-pump coronary artery bypass in 379 patients with significant left main coronary artery stenosis was retrospectively reviewed. Beating-heart operations were performed on 219 patients between January 2001 and October 2007. Their results were compared with 160 who underwent revascularization under cardiopulmonary bypass during the same period. All patients had multivessel grafting via a median sternotomy. Both groups were comparable demographically. Off-pump patients received significantly fewer grafts per patient (3.21 +/- 0.86 vs 3.74 +/- 0.82). The use of moderate or high doses of inotropics (> 5 microg kg(-1) min(-1)) was more frequent in the on-pump group (44% vs 26%). Postoperative blood transfusion requirement was lower in off-pump patients, and fewer of them experienced worsening of preexisting renal insufficiency. There were 2 operative deaths in the on-pump group and 1 in the off-pump group. The off-pump procedure is safe and effective in patients with left main coronary artery disease.

Favorable Long-Term Outcome After Drug-Eluting Stent Implantation in Nonbifurcation Lesions That Involve Unprotected Left Main Coronary Artery

Background— The presence of a lumen narrowing at the ostium and the body of an unprotected left main coronary artery but does not require bifurcation treatment is a class I indication of surgical revascularization.

Methods and Results— A total of 147 consecutive patients who had a stenosis in the ostium and/or the midshaft of an unprotected left main coronary artery (treatment of the bifurcation not required) and were electively treated with percutaneous coronary intervention and sirolimus-eluting stents (n=107) or paclitaxel-eluting stents (n=40) in 5 centres were included in this registry. In 72 patients (almost 50%), intravascular ultrasound guidance was performed. Procedural success was achieved in 99% of the patients; in 1 patient with stenosis in the left main coronary artery ostium, a >30% residual stenosis persisted at the end of the procedure, and the patient was referred for coronary artery bypass graft surgery. During hospitalization, no patients experienced a Q-wave myocardial infarction or died. One patient died 19 days after the procedure because of pulmonary infection. At long-term clinical follow-up (886±308 days), 5 patients had died; 7 patients had target vessel revascularization (5 repeat percutaneous coronary interventions and 2 coronary artery bypass graft surgeries), and of these only 1 patient had a target lesion revascularization. Angiographic follow-up was performed in 106 patients (72%) with a late loss of −0.01 mm. Restenosis in the left main trunk occurred only in 1 patient (0.9%).

Conclusions— Percutaneous coronary intervention with sirolimus-eluting stents or paclitaxel-eluting stents implantation in nonbifurcation left main coronary artery lesions appears safe with a long-term major adverse clinical event rate of 7.4% and a restenosis rate of 0.9%.

Percutaneous Treatment With Drug-Eluting Stent Implantation Versus Bypass Surgery for Unprotected Left Main Stenosis

Background— Improvements in results with percutaneous coronary intervention (PCI) with drug-eluting stents (DES) may extend their use in patients with left main coronary artery (LMCA) stenosis.

Methods and Results— Two hundred forty-nine patients with LMCA stenosis were treated with PCI and DES implantation (n=107) or coronary artery bypass grafting (CABG) (n=142), in a single center, between March 2002 and July 2004. A propensity analysis was performed to adjust for baseline differences between the two cohorts. At 1 year, there was no statistical difference in the occurrence of death in PCI versus CABG both for the unadjusted (OR=0.291; 95% CI=0.054 to 1.085; P =0.0710) and adjusted analyses (OR=0.331; 95% CI=0.055 to 1.404; P =0.1673). PCI was correlated to a lower occurrence of the composite end points of death and myocardial infarction (unadjusted OR=0.235; 95% CI=0.048 to 0.580; P =0.0002; adjusted OR=0.260; 95% CI=0.078 to 0.597; P =0.0005) and death, myocardial infarction, and cerebrovascular events (unadjusted OR=0.300; 95% CI=0.102 to 0.617; P =0.0004; adjusted OR=0.385; 95% CI=0.180 to 0.819; P =0.01). No difference was detected in the occurrence of major adverse cardiac and cerebrovascular event at the unadjusted (OR=0.675; 95% CI=0.371 to 1.189; P =0.1891) and adjusted analyses (OR=0.568; 95% CI=0.229 to 1.344; P =0.2266).

Conclusions— At 1 year, in this single-center, retrospective experience, there was no difference in the degree of protection against death, stroke, myocardial infarction, and revascularization between PCI with DES and CABG for LMCA disease. (Circulation. 2006;113:2542-2547.)