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Bianco V, Mulukutla S, Aranda-Michel E, Chu D, Kaczorowski D, Bonatti J, Yoon P, Kliner D, Toma C, Wang Y, Koscumb S, Thoma F, Navid F, Serna-Gallegos D, Sultan I. Coronary Artery Bypass With Multiarterial Grafting vs Percutaneous Coronary Intervention. Ann Thorac Surg 2023; 115:404-410. [PMID: 35835208 DOI: 10.1016/j.athoracsur.2022.06.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data comparing patients who undergo multiarterial grafting during coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) in patients with multivessel coronary disease are scarce. This study addresses the relevance of using multiple arterial conduits vs PCI for appropriate patients. METHODS This retrospective study included all patients with coronary artery disease who underwent CABG with multiple arterial conduits or PCI. Propensity score matching was performed for baseline characteristics. Kaplan-Meier estimates, cumulative incidence, and freedom from major adverse cardiac and cerebrovascular events (MACCE) curves were performed. RESULTS The total patient population consisted of 3648 patients from 2011 to 2018 divided into 902 CABG patients and 2746 PCI patients. Patients were propensity matched (PCI, n = 838; CABG, n = 838). In the CABG cohort the left internal mammary artery was used in 837 patients (99.9%), the right internal mammary artery in 770 patients (92%), and radial arteries in 108 patients (12.9%). Patients in the PCI cohort had significantly higher 30-day mortality (24 [2.9%] vs 7 [0.8%], P < .01). Survival over follow-up (median, 4.9 years; range, 3.3-6.8) was better for the CABG cohort (730 [87.1%] vs 625 [74.6%], P < .01). Patients in the CABG cohort had greater freedom from MACCE (607 [72.4%] vs 339 [40.5%], P < .01). Cox multivariable regression showed that patients who underwent CABG had a significantly reduced risk of mortality (hazard ratio, 0.49; 95% confidence interval, 0.39-0.61; P < .01) and of MACCE (hazard ratio, 0.33; 95% confidence interval, 0.28-0.38; P < .01). CONCLUSIONS Patients with coronary artery disease who undergo CABG with multiple arterial conduits have significantly fewer major adverse events, improved survival, and reduced hospital readmissions.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Suresh Mulukutla
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dustin Kliner
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steve Koscumb
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Arabi A, Naghshtabrizi B, Baradaran HR, Moradi Y, Asadi-Lari M, Mehrakizadeh A. Comparing clinical outcomes in patients with diabetes undergoing coronary artery bypass graft and percutaneous coronary intervention in real world practice in Iranian population. BMC Cardiovasc Disord 2022; 22:75. [PMID: 35240990 PMCID: PMC8895790 DOI: 10.1186/s12872-022-02521-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 02/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background Coronary artery bypass graft (CABG) is generally regarded as one the treatment options for coronary artery disease (CAD) in patients with diabetes. In recent years, with the advent of drug-eluting stents (DES), percutaneous coronary intervention (PCI) was introduced as a suitable alternative for CABG. The aim of this study was to compare the incidence of major adverse cardiac and cerebrovascular event (MACCE) during mid-term period in patients with diabetes treated with 2 revascularization strategies. Methods This historical cohort study was conducted on 750 consecutives patients with diabetes in a single cardiovascular center from July 2009 to March 2012 in Iran. We included previously known case of DM treated with antidiabetic medications (with or without end organ damage) and patient with preoperational evaluation FBS test > 126 (not on the day of the surgery) who were revascularized by 2 strategies. We excluded those patients whose follow-up was not possible. Results Finally, out of 697 eligible patients, 355 patients underwent a CABG and 342 underwent a PCI: 53 patients were lost to follow-up (27 in CABG and 26 in PCI groups). The mean follow-up time was 900.68 ± 462.03 days in the CABG and 782.60 ± 399.05 in PCI groups. There were 17 (9.13%) cardiac deaths in the CABG group and 8 (4.45%) in the PCI group; this difference was not significant (P = .11). There was 14 (7.58%) cerebrovascular accident in the CABG group and 4 (2.31%) in the PCI group; this difference was significant (P = .04). Moreover, the frequency of the target vessel revascularization in the CABG and PCI groups was 6 (3.32%) and 31 (17.11%) (P < .001), respectively. Myocardial infarction in the CABG group was 5 (2.77%) and 14 (7.86%) in the PCI group (P = .009). Finally, the frequency of MACCE in the CABG and PCI groups was 41(20.70%) and 47(24.16%) respectively; this difference was not statistically significant (P = .195). Conclusion Patients with CABG in this study experienced more CVA, while the frequency of TVR and non-fatal MI was higher in the PCI arm.
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Affiliation(s)
- Arezo Arabi
- Department of Cardiology, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Behshad Naghshtabrizi
- Department of Cardiology, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Hamid Reza Baradaran
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran.,Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Yousef Moradi
- Department of Epidemiology and Biostatistics, Faculty of Medicine, Kurdistan University of Medical Sciences, Kurdistan, Iran
| | - Mohsen Asadi-Lari
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran.
| | - Ali Mehrakizadeh
- Cardiology Department, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Gaudino M, Bakaeen FG, Benedetto U, Di Franco A, Fremes S, Glineur D, Girardi LN, Grau J, Puskas JD, Ruel M, Tam DY, Taggart DP, Antoniades C, Patrono C, Schwann TA, Tatoulis J, Tranbaugh RF. Arterial Grafts for Coronary Bypass. Circulation 2019; 140:1273-1284. [DOI: 10.1161/circulationaha.119.041096] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Observational and randomized evidence shows that arterial grafts have better patency rates than saphenous vein grafts (SVGs) in coronary artery bypass grafting. Observational studies suggest that the use of multiple arterial grafts is associated with longer postoperative survival, but this must be interpreted in the context of treatment allocation bias and hidden confounders intrinsic to the study designs. Recently, a pooled analysis of 6 randomized trials comparing the radial artery with the SVG as the second conduit and the largest randomized trial comparing the use of single and bilateral internal thoracic arteries have provided apparently divergent results about a clinical benefit with the use of >1 arterial conduit. However, both analyses have methodological limitations that may have influenced their results. At present, it is unclear whether the well-documented increased patency rate of arterial grafts translates into clinical benefits in the majority of patients undergoing coronary artery bypass grafting. A large randomized trial testing the arterial grafts hypothesis (ROMA [Randomized Comparison of the Clinical Outcome of Single Versus Multiple Arterial Grafts]) is underway and will report the results in a few years.
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Affiliation(s)
- Mario Gaudino
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York (M.G., A.D.F., L.N.G.)
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, OH (F.G.B.)
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, UK (U.B.)
| | - Antonino Di Franco
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York (M.G., A.D.F., L.N.G.)
| | - Stephen Fremes
- Schulich Heart Centre, Sunnybrook Health Science, University of Toronto, ON, Canada (S.F., D.Y.T.)
| | - David Glineur
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (D.G., J.G., M.R.)
| | - Leonard N. Girardi
- Department of Cardio-Thoracic Surgery, Weill Cornell Medicine, New York (M.G., A.D.F., L.N.G.)
| | - Juan Grau
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (D.G., J.G., M.R.)
| | - John D. Puskas
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York (J.D.P.)
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, ON, Canada (D.G., J.G., M.R.)
| | - Derrick Y. Tam
- Schulich Heart Centre, Sunnybrook Health Science, University of Toronto, ON, Canada (S.F., D.Y.T.)
| | - David P. Taggart
- Department of Cardiovascular Surgery, University of Oxford, UK (D.P.T.)
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Cui K, Lyu S, Song X, Liu H, Yuan F, Xu F, Zhang M, Wang W, Zhang M, Zhang D, Tian J. Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis. Angiology 2019; 70:765-773. [PMID: 30995117 DOI: 10.1177/0003319719839885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.
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Affiliation(s)
- Kongyong Cui
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Shuzheng Lyu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiantao Song
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Hong Liu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Fei Yuan
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Feng Xu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Min Zhang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Wei Wang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Mingduo Zhang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Dongfeng Zhang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jinfan Tian
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
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Tsuneyoshi H, Komiya T, Kadota K, Shimamoto T, Sakai J, Hiraoka T, Wada K, Kaneko H, Fujimoto Y, Furuichi Y, Hata R, Jinno T, Tominaga O. Coronary artery bypass surgery is superior to second generation drug-eluting stents in three-vessel coronary artery disease: a propensity score matched analysis†. Eur J Cardiothorac Surg 2017; 52:462-468. [DOI: 10.1093/ejcts/ezx031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 01/18/2017] [Indexed: 12/24/2022] Open
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Castelvecchio S, Menicanti L, Garatti A, Tramarin R, Volpe M, Parolari A. Myocardial Revascularization for Patients With Diabetes: Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention? Ann Thorac Surg 2016; 102:1012-1022. [PMID: 27217297 DOI: 10.1016/j.athoracsur.2016.02.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/17/2016] [Accepted: 02/22/2016] [Indexed: 11/25/2022]
Abstract
Patients affected by diabetes usually have extensive coronary artery disease. Coronary revascularization has a prominent role in the treatment of coronary artery disease in the expanding diabetic population. However, diabetic patients undergoing coronary artery bypass grafting or percutaneous coronary intervention experience worse outcomes than nondiabetic patients. Several studies comparing coronary artery bypass grafting vs percutaneous coronary intervention in subgroups of diabetic patients demonstrated a survival advantage and fewer repeat revascularization procedures with an initial surgical strategy. This review summarizes the current state of evidence comparing the effectiveness and safety of coronary artery bypass grafting and percutaneous coronary intervention in diabetic patients.
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Affiliation(s)
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Andrea Garatti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Roberto Tramarin
- Department of Cardiac Rehabilitation, IRCCS Policlinico San Donato, Milan, Italy
| | - Marianna Volpe
- Department of Cardiac Rehabilitation, IRCCS Policlinico San Donato, Milan, Italy
| | - Alessandro Parolari
- Unit of Cardiac Surgery and Translational Research, IRCCS Policlinico San Donato, Milan, Italy; Department of Biomedical Sciences for Health, Università Degli Studi di Milano, Milan, Italy.
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7
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Davierwala PM, Mohr FW. Bilateral internal mammary artery grafting: rationale and evidence. Int J Surg 2015; 16:133-9. [PMID: 25612853 DOI: 10.1016/j.ijsu.2015.01.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/13/2015] [Accepted: 01/15/2015] [Indexed: 11/19/2022]
Abstract
Coronary artery bypass graft (CABG) surgery remains the preferred mode of revascularization in patients with complex multi-vessel coronary artery disease. The left internal mammary artery (IMA) and saphenous vein are the most commonly utilized conduits in CABG surgery and are still considered to be the gold standard by most surgeons. However, there is emerging evidence that use of bilateral IMAs is associated with significantly better long-term outcomes and the benefit increases with time from surgery. In spite of this incremental beneficiary effect, most surgeons are reluctant to use both IMAs, because it is technically more demanding, time-consuming and is associated with marginally higher sternal wound infection rates. This review highlights the histological features, physiological characteristics and genomics of IMAs that provide the basis for the use of these vessels during CABG surgery. Additionally, the superiority of the bilateral IMAs with regard to patency and long-term outcomes is also discussed in detail. Furthermore, the safety of using bilateral IMAs with regard to early postoperative outcomes with special reference to deep sternal wound infections has been addressed. The present review provides enough evidence to convince more surgeons about the advantages of bilateral IMA grafting.
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Affiliation(s)
- Piroze M Davierwala
- Department of Cardiac Surgery, Heart Center, University Leipzig, Leipzig, Germany; Herzzentrum Leipzig, Universitätsklinik, Helios Kliniken, Struempellstraße 39, 04289 Leipzig, Germany.
| | - Friedrich W Mohr
- Department of Cardiac Surgery, Heart Center, University Leipzig, Leipzig, Germany; Herzzentrum Leipzig, Universitätsklinik, Helios Kliniken, Struempellstraße 39, 04289 Leipzig, Germany.
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8
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Nicolini F, Agostinelli A, Vezzani A, Benassi F, Gherli T. CABG versus PCI in the treatment of diabetic patients affected by coronary artery disease. Int Heart J 2014; 55:469-73. [PMID: 25297505 DOI: 10.1536/ihj.14-061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Surgical coronary revascularization and percutaneous coronary intervention were demonstrated to be effective treatments for coronary artery disease. However, the optimal revascularization strategy remains unclear in certain patient subsets. The recently published Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial is a randomized study evaluating the use of CABG versus PCI in diabetic patients with multivessel coronary disease. The purpose of this study was to review the available literature based on randomized trials and observational studies in order to allow clinicians to make evidence-based decisions when treating diabetic patients with multivessel coronary disease. The current evidence suggests that CABG should remain the standard of care for this patient population.
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Affiliation(s)
- Francesco Nicolini
- Cardiac Surgery Unit, Department of Clinical and Experimental Medicine, University of Parma
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9
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Gatti G, Soso P, Dell'Angela L, Maschietto L, Dreas L, Benussi B, Luzzati R, Sinagra G, Pappalardo A. Routine use of bilateral internal thoracic artery grafts for left-sided myocardial revascularization in insulin-dependent diabetic patients: early and long-term outcomes. Eur J Cardiothorac Surg 2014; 48:115-20. [DOI: 10.1093/ejcts/ezu360] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 08/07/2014] [Indexed: 11/14/2022] Open
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10
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Kieser TM. Bilateral internal mammary artery grafting in CABG surgery: an extra 20 minutes for an extra 20 years…. EUROINTERVENTION 2014; 9:899-901. [PMID: 24384286 DOI: 10.4244/eijv9i8a151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Teresa M Kieser
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
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11
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Lim JY, Deo SV, Kim WS, Altarabsheh SE, Erwin PJ, Park SJ. Drug-eluting stents versus coronary artery bypass grafting in diabetic patients with multi-vessel disease: a meta-analysis. Heart Lung Circ 2014; 23:717-25. [PMID: 24704466 DOI: 10.1016/j.hlc.2014.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 02/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Data comparing long-term results after percutaneous intervention with drug-eluting stents (DES/PCI) and coronary artery grafting (CABG) in diabetic patients (pts) with multi-vessel disease is conflicting. We have conducted a systematic review and meta-analysis to help answer this issue. METHODS MEDLINE, WoS, and Scopus were systematically analysed to yield observational studies (OBS) or randomised controlled trials (RCT) fulfilling search criteria. Odds ratio (OR) for studied end-points were obtained with inverse variance random effects analysis. Results are presented with 95% confidence intervals with significance at p<0.05. RESULTS A total of 14 studies (5 RCT; 9 OBS) including more than 5000 pts were selected for review. Early/30-day was lower in the DES/PCI cohort [OR 0.49(0.27, 0.88); p=0.02; I(2)=0%]. Post-procedural stroke was higher in the CABG (1.8%) cohort compared to DES/PCI (0.17%; p<0.01). A pooled analysis of RCT demonstrated that stroke rate was similar in both cohorts at the end of one year [OR 0.84(0.19, 3.74); p=0.82; I(2) =67%]. During a follow-up of three to five years, repeat intervention was much higher in the DES/PCI cohort [OR 3.02(2.13, 4.28; p<0.01]. The odds of suffering an adverse cardiovascular /cerebrovascular event were 1.71 (1.27, 2.3) times higher in the DES/PCI cohort compared to CABG. CONCLUSION In diabetic patients with multivessel disease, early mortality is lower in the DES/PCI cohort. While peri-procedural stroke rates are lower with PCI, they are, however, comparable at the end of one year. Use of drug-eluting stents leads to a higher rate of re-intervention and major cardiovascular/cerebrovascular events at three to five years.
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Affiliation(s)
- Ju Yong Lim
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester
| | - Salil V Deo
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester; Department of Cardiac Surgery, Adventist Wockhardt Heart Hospital, Surat Gujarat.
| | - Wook Sung Kim
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester; Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | | | - Soon J Park
- Division of Cardiovascular Surgery, Case Medical Center, Case Western Reserve University, Cleveland OH
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12
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De Luca G, Schaffer A, Verdoia M, Suryapranata H. Meta-analysis of 14 trials comparing bypass grafting vs drug-eluting stents in diabetic patients with multivessel coronary artery disease. Nutr Metab Cardiovasc Dis 2014; 24:344-354. [PMID: 24373711 DOI: 10.1016/j.numecd.2013.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/19/2013] [Accepted: 11/23/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM Clinical trials have reported lower mortality and repeated revascularization rate in diabetic patients treated with coronary artery bypass grafting (CABG) as compared to percutaneous revascularization. However, these studies were conducted in the era of bare-metal stents. Therefore, we performed a meta-analysis to compare CABG to PCI with drug-eluting stents (DES) in diabetic patients with multivessel and/or left main disease. METHODS AND RESULTS The literature was scanned by formal search of electronic databases (Medline, EMBASE, and Cochrane databases), and major international scientific session abstracts from 2000 to 2013. Primary endpoint was mortality. A total of 14 (4 randomized and 10 non-randomized) trials were finally included, with a total of 7072 patients. Up to 5 years follow-up, CABG was associated with a reduction in mortality (7.3% vs 10.4%, OR[95%CI] = 0.65[0.55-0.77], p < 0.0001; phet = 0.00001), with similar results in both RCTs (OR[95%CI] = 0.64[0.50-0.82], p = 0.0005) and NRCTs (OR[95%CI] = 0.75[0.6-0.94)], p = 0.01) (p int = 0.93). A significant relationship was observed between risk profile and benefits in mortality with CABG (p < 0.001). CABG reduced target vessel revascularization (TVR; 5.2% vs 15.7%, OR[95%CI] = 0.30[0.25-0.36], p < 0.00001, p het = 0.02), with a relationship between risk profile and the benefits from CABG as compared to DES (p < 0.0001). CABG was associated with a lower rate of MACCE (14.9% vs 22.9%, OR[95%CI] = 0.59[0.51-0.67], p < 0.00001, p het<0.00001) but higher risk of CVA (3.6% vs 1.4%, OR[95%CI] = 2.34[1.63-3.35], p < 0.00001, p het = 0.71). CONCLUSIONS The present meta-analysis demonstrates that among diabetic patients with multivessel disease and/or left main disease, CABG provides benefits in mortality and TVR, especially in high-risk patients but it is counterbalanced by a higher risk of stroke. Future trials are certainly needed in the era of new DES and improved antiplatelet therapies.
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Affiliation(s)
- G De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
| | - A Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - M Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - H Suryapranata
- Department of Cardiology, UMC St Radboud, Nijmegen, The Netherlands
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Lima EG, Hueb W, Garcia RMR, Pereira AC, Soares PR, Favarato D, Garzillo CL, D’Oliveira Vieira R, Rezende PC, Takiuti M, Girardi P, Hueb AC, Ramires JA, Kalil Filho R. Impact of diabetes on 10-year outcomes of patients with multivessel coronary artery disease in the Medicine, Angioplasty, or Surgery Study II (MASS II) trial. Am Heart J 2013; 166:250-7. [PMID: 23895807 DOI: 10.1016/j.ahj.2013.04.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/29/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Diabetes mellitus is a major cause of coronary artery disease (CAD). Despite improvement in the management of patients with stable CAD, diabetes remains a major cause of increased morbidity and mortality. There is no conclusive evidence that either modality is better than medical therapy alone for the treatment of stable multivessel CAD in patients with diabetes in a very long-term follow-up. Our aim was to compare 3 therapeutic strategies for stable multivessel CAD in a diabetic population and non-diabetic population. METHODS It was compared medical therapy (MT), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in 232 diabetic patients and 379 nondiabetic patients with multivessel CAD. Endpoints evaluated were overall and cardiac mortality. RESULTS Patients (n = 611) were randomized to CABG (n = 203), PCI (n = 205), or MT (n = 203). In a 10-year follow-up, more deaths occurred among patients with diabetes than among patients without diabetes (P = .001) for overall mortality. In this follow-up, 10-year mortality rates were 32.3% and 23.2% for diabetics and non-diabetics respectively (P = .024). Regarding cardiac mortality, 10-year cardiac mortality rates were 19.4% and 12.7% respectively (P = .031).Considering only diabetic patients and stratifying this population by treatment option, we found mortality rates of 31.3% for PCI, 27.5% for CABG and 37.5% for MT (P = .015 for CABG vs MT) and cardiac mortality rates of 18.8%, 12.5% and 26.1% respectively (P = .005 for CABG vs MT). CONCLUSIONS/INTERPRETATION Among patients with stable multivessel CAD and preserved left ventricular ejection fraction, the 3 therapeutic regimens had high rates of overall and cardiac-related deaths among diabetic compared with non-diabetic patients. Moreover, better outcomes were observed in diabetic patients undergoing CABG compared to MT in relation to overall and cardiac mortality in a 10-year follow-up.
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Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, Mack MJ, Holmes DR, Morel MA, Van Dyck N, Houle VM, Dawkins KD, Serruys PW. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381:629-38. [PMID: 23439102 DOI: 10.1016/s0140-6736(13)60141-5] [Citation(s) in RCA: 1158] [Impact Index Per Article: 105.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND We report the 5-year results of the SYNTAX trial, which compared coronary artery bypass graft surgery (CABG) with percutaneous coronary intervention (PCI) for the treatment of patients with left main coronary disease or three-vessel disease, to confirm findings at 1 and 3 years. METHODS The randomised, clinical SYNTAX trial with nested registries took place in 85 centres in the USA and Europe. A cardiac surgeon and interventional cardiologist at each centre assessed consecutive patients with de-novo three-vessel disease or left main coronary disease to determine suitability for study treatments. Eligible patients suitable for either treatment were randomly assigned (1:1) by an interactive voice response system to either PCI with a first-generation paclitaxel-eluting stent or to CABG. Patients suitable for only one treatment option were entered into either the PCI-only or CABG-only registries. We analysed a composite rate of major adverse cardiac and cerebrovascular events (MACCE) at 5-year follow-up by Kaplan-Meier analysis on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT00114972. FINDINGS 1800 patients were randomly assigned to CABG (n=897) or PCI (n=903). More patients who were assigned to CABG withdrew consent than did those assigned to PCI (50 vs 11). After 5 years' follow-up, Kaplan-Meier estimates of MACCE were 26·9% in the CABG group and 37·3% in the PCI group (p<0·0001). Estimates of myocardial infarction (3·8% in the CABG group vs 9·7% in the PCI group; p<0·0001) and repeat revascularisation (13·7%vs 25·9%; p<0·0001) were significantly increased with PCI versus CABG. All-cause death (11·4% in the CABG group vs 13·9% in the PCI group; p=0·10) and stroke (3·7%vs 2·4%; p=0·09) were not significantly different between groups. 28·6% of patients in the CABG group with low SYNTAX scores had MACCE versus 32·1% of patients in the PCI group (p=0·43) and 31·0% in the CABG group with left main coronary disease had MACCE versus 36·9% in the PCI group (p=0·12); however, in patients with intermediate or high SYNTAX scores, MACCE was significantly increased with PCI (intermediate score, 25·8% of the CABG group vs 36·0% of the PCI group; p=0·008; high score, 26·8%vs 44·0%; p<0·0001). INTERPRETATION CABG should remain the standard of care for patients with complex lesions (high or intermediate SYNTAX scores). For patients with less complex disease (low SYNTAX scores) or left main coronary disease (low or intermediate SYNTAX scores), PCI is an acceptable alternative. All patients with complex multivessel coronary artery disease should be reviewed and discussed by both a cardiac surgeon and interventional cardiologist to reach consensus on optimum treatment. FUNDING Boston Scientific.
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