PCI Versus CABG in Patients With Type 1 Diabetes and Multivessel Disease

Ten-year outcomes after percutaneous coronary intervention versus coronary artery bypass grafting for multivessel or left main coronary artery disease: a systematic review and meta-analysis

BACKGROUND

Short-term and long-term comparative outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for multivessel coronary artery (MVCA) or left main coronary artery (LMCA) disease are highly debated.

GOALS

We performed a meta-analysis to evaluate the difference between PCI and CABG for the treatment of patients with MVCA or LMCA in long-term follow-up.

METHODS

Literatures were searched in PubMed, EMBASE and The Cochrane Library from January 1, 2000 to January 1, 2021, including RCTs and observational studies (OSs). The primary outcome was all-cause mortality at 10 years follow-up, and the secondary outcomes included cardiac mortality, repeated revascularization, myocardial infarction, and stroke.

RESULTS

A total of 5 RCTs reporting data from 3013 participants and 4 OSs of 5608 participants were included for analysis. There was no significant difference between PCI and CABG in all-cause mortality (Odds Ratio (OR) 1.03 [95% confidence interval (CI) 0.89 to 1.19]), whereas PCI was associated with higher cardiac mortality (OR 0.76 [95% CI 0.65 to 0.90]) and repeated revascularization rate comparing to CABG (OR 1.77 [95% CI 1.08 to 2.89]; I² = 94.61%). The difference between PCI and CABG in repeated revascularization in either RCTs or OSs, in myocardial infarction in either RCTs or OSs were not significant. In OSs, stroke rate in PCI group was lower than those in CABG, but not in RCTs. There was a significant increase of stroke rate in CABG comparing to PCI (OR 0.65 [95% CI 0.53 to 0.80]; I² = 0.00%). No significant difference between PCI and CABG in myocardial infarction was not observed (OR 0.92 [95% CI 0.64 to 1.31]; I² = 57.84%).

CONCLUSION

Evidence from our study and prior studies suggested the superiority of CABG over PCI in improving 5- but not 10-year survival among patients with MVCA. In the contrast, there was no significant difference between CABG and PCI for treating patients with LMCA in either 5- or 10-year survival rate. More long-term trials are needed to better define differences of outcome between 2 techniques.

Case Fatality of Patients With Type 1 Diabetes After Myocardial Infarction

OBJECTIVE

Type 1 diabetes is a risk factor for myocardial infarction (MI). We aimed to evaluate the case fatality in patients with type 1 diabetes after MI.

RESEARCH DESIGN AND METHODS

Consecutive patients experiencing MI with type 1 diabetes (n = 1,935; 41% female; mean age 62.5 years) and without diabetes (n = 74,671) admitted to 20 hospitals in Finland from 2005 to 2018 were studied using national registries. The outcome of interest was death within 1 year after MI. Differences between groups were balanced by multivariable adjustments and propensity score matching.

RESULTS

Case fatality was higher in patients with type 1 diabetes than in propensity score-matched controls without diabetes at 30 days (12.8% vs. 8.5%) and at 1 year (24.3% vs. 16.8%) after MI (hazard ratio 1.55; 95% CI 1.32-1.81; P < 0.0001). Patients with type 1 diabetes had poorer prognosis in subgroups of men and women and of those with and without ST-elevation MI, with and without revascularization, with and without atrial fibrillation, and with and without heart failure. The relative fatality risk in type 1 diabetes was highest in younger patients. Older age, heart failure, peripheral vascular disease, renal failure, and no revascularization were associated with worse prognosis after MI. The case fatality among patients with type 1 diabetes decreased during the study period, but outcome differences compared with patients without diabetes remained similar.

CONCLUSIONS

Patients with type 1 diabetes are at higher risk of death after MI than patients without diabetes. Our findings call for attention to vigorous cardiovascular disease prevention in patients with type 1 diabetes.

Serum FGF21 Levels Predict the MACE in Patients With Myocardial Infarction After Coronary Artery Bypass Graft Surgery

Objectives

Prognosis evaluation in myocardial infarction (MI) patients with major adverse clinical events (MACE) who have undergone coronary artery bypass graft (CABG) is greatly important to identify high-risk patients. Elevated metabolic hormone fibroblast growth factor 21 (FGF21) is associated with the risk of MI. The aim of this study is to assess the relationship between FGF21 and the incidence of MACE in patients with MI after CABG surgery.

Methods

Patients with three-vessel disease who were scheduled for first-time isolated CABG were enrolled in this project and underwent to evaluate the incidence of MACE during 48 h after CABG surgery, as well as to collect serum samples for FGF21 levels in both preoperative- and postoperative-CABG (pre-CABG and post-CABG).

Results

A total of 265 patients with MI undergoing CABG were enrolled in this study, 21 patients experienced MACE during the 48 h after CAGB surgery. Serum FGF21 levels of patients with MACE at post-CABG were significantly higher than that in patients without MACE [553.7 (433.6) vs. 291.7 (334.4), p &lt; 0.001]. Furthermore, among 81 individuals of these 265 patients, a lower level of FGF21 in preoperative-CABG (pre-CABG) and a higher level of FGF21 at postoperative-CABG (post-CABG) were observed in MI patients with MACE as compared to those without MACE respectively [ (275.0 (260.4) vs. 410.3 (420.7), p = 0.049; 550.7 (519.9) vs. 370.6 (441.2), p = 0.031]. In addition, serum FGF21 levels of MI patients with MACE at post-CABG were significantly increased compared with the baseline levels in pre-CABG [550.7 (519.9) vs.275.0 (260.4) p &lt; 0.001]. However, these profiles were not observed in patients without MACE [410.3 (420.7) vs. 370.6 (441.2), p=0.2137]. Logistic regression analysis demonstrated that both serum FGF21 and CK-MB levels at post-CABG were independently associated with the incidence of MACE in patients with MI after CABG surgery. Finally, ROC analysis for FGF21 levels of 265 MI patients at post-CABG identified 455.4 pg/ml as an optimal cut-off value to predict MACE, with a sensitivity and specificity of 91.7 and 68.4% respectively.

Conclusion

Serum FGF21 levels at post-CABG are independently associated with the incidence of MACE in patients with MI who have undergone CABG. Measurement of FGF21 may help distinguish patients with MI at a high risk of MACE after CABG surgery.

Immunomodulation Strategies for the Successful Regeneration of a Tissue-Engineered Vascular Graft

Cardiovascular disease leads to the highest morbidity worldwide. There is an urgent need to solve the lack of a viable arterial graft for patients requiring coronary artery bypass surgery. The current gold standard is to use the patient's own blood vessel, such as a saphenous vein graft. However, some patients do not have appropriate vessels to use because of systemic disease or secondary surgery. On the other hand, there is no commercially available synthetic vascular graft available on the market for small diameter (<6 mm) blood vessels like coronary, carotid, and peripheral popliteal arteries. Tissue-engineered vascular grafts (TEVGs) are studied in recent decades as a promising alternative to synthetic arterial prostheses. Yet only a few studies have proceeded to a clinical trial. Recent studies have uncovered that the host immune response can be directed toward increasing the success of a TEVG by shedding light on ways to modulate the macrophage response and improve the tissue regeneration outcome. In this review, the basic concepts of vascular tissue engineering and immunoengineering are considered. The state-of-art of TEVGs is summarized and the role of macrophages in TEVG regeneration is analyzed. Current immunomodulatory strategies based on biomaterials are also discussed.

Coronary Revascularization for Patients with Diabetes Mellitus: A Contemporary Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis aims to review the contemporary literature comparing CABG and PCI in diabetic patients providing an up-to-date perspective on the differences between the interventions.

BACKGROUND

Diabetes is common and diabetic patients are at a 2-to-4-fold increased risk of developing coronary artery disease. Approximately 75% of diabetic patients die of cardiovascular disease. Previous literature has identified CABG as superior to PCI for revascularization in diabetic patients with complex coronary artery diseas.

METHODS

PubMed and Medline were systematically searched for articles published from January 1, 2015 to April 15, 2021. This systematic review included all retrospective, prospective, and randomized trial studies comparing CABG and PCI in diabetic patients. 1552 abstracts were reviewed and 25 studies were included in this review. The data was analyzed using the RevMan 5.4 software.

RESULTS

Diabetic patients undergoing CABG experienced significantly reduced rates of 5-year mortality, major adverse cardiovascular and cerebrovascular events, myocardial infarction, and required repeat revascularization. Patients who underwent PCI experienced improved rates of stroke that trended toward significance.

CONCLUSIONS

Previous literature regarding coronary revascularization in diabetic patients has consistently demonstrated superior outcomes for patients undergoing CABG over PCI. The development of 1st and 2nd generation DES have narrowed the gap between CABG and PCI, but CABG continues to be superior. Continued investigation with large randomized trials and retrospective studies including long term follow-up comparing CABG and 2nd generation DES is necessary to confirm the optimal intervention for diabetic patients.

Remote liver ischemic preconditioning attenuates myocardial ischemia/reperfusion injury in streptozotocin-induced diabetic rats

Diabetes mellitus (DM) exhibits a higher sensitivity to myocardial ischemia/reperfusion (I/R) injury and may compromise the effectiveness of cardioprotective interventions, including ischemic preconditioning. We previously found that liver ischemic preconditioning (RLIPC) could limit infarct size post I/R in non-diabetic rat hearts and further exerted anti-arrhythmic effects in diabetic or non-diabetic rats after myocardial I/R, however, little is known regarding the effect of RLIPC on infarct-sparing in diabetic hearts. In this study, we evaluated the protective effects of RLIPC on I/R injury in streptozotocin-induced type 1 diabetic rats. Type 1 diabetes mellitus was induced by one-time intraperitoneal injection of streptozotocin in Sprague-Dawley rats. Rats were exposed to 45 min of left anterior descend in (LAD) coronary artery occlusion, followed by 3 h of reperfusion. For liver ischemic preconditioning, four cycles of 5 min of liver I/R stimuli were performed before LAD occlusion. The cardioprotective effect of RLIPC was determined in diabetic rats. Compared to non-RLIPC treated DM rats, RLIPC treatment significantly reduced infarct size and cardiac tissue damage, inhibited apoptosis in diabetic hearts post I/R. RLIPC also improved cardiac functions including LVESP, LVEDP, dp/dtmax, and - dp/dtmax. In addition, RLIPC preserved cardiac morphology by reducing the pathological score post I/R in diabetic hearts. Finally, Westernblotting showed that RLIPC stimulated phosphorylation of ventricular GSK-3β and STAT-5, which are key components of RISK and SAFE signaling pathways. Our study showed that liver ischemic preconditioning retains strong cardioprotective properties in diabetic hearts against myocardial I/R injury via GSK-3β/STAT5 signaling pathway.

Long-term survival in patients who had CABG with or without prior coronary artery stenting

Objective

To conduct a large-scale, single-centre retrospective cohort study to understand the impact of prior percutaneous coronary intervention (PCI) on long-term survival of patients who then undergo coronary artery bypass graft (CABG).

Methods

Between 1999 and 2017, a total of 11 332 patients underwent CABG at a hospital in the UK. The patients were stratified into those who received PCI (n=1090) or no PCI (n=10 242) prior to CABG. A total of 1058 patients from each group were matched using propensity score matching. Kaplan-Meier estimates were used to assess risk-adjusted survival in patients with prior PCI. Cox proportional hazards (CoxPH) model was then used to assess the effect of prior PCI and other variables in patients undergoing CABG.

Results

The immediate postoperative outcome showed no difference in number of grafts per patients, blood transfusion, hospital stay or 30 days mortality between the groups. There was no significant difference in 5 years (90.8% vs 87.9), 10-year (76.5% vs 74.6%) and 15-year (64.4% vs 64.7%) survival between the non-PCI versus PCI groups. The Cox proportional hazards model further supports the null hypothesis as the PCI variable was found to be non-significant (CoxPH=1.03, p=0.75, CI=0.87–1.22) implying there was no difference in hazard of death for CABG patients with or without previous PCI. However, the model did yield information on the covariates that do affect the hazard of death.

Conclusion

There is no difference in 5-year, 10-year and 15-year survival between patients undergoing CABG with or without prior PCI. However, certain patient, preoperative and intraoperative risk factors were identified with high hazard of death which needs to be investigated further.

Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention in Patients With Diabetes

As percutaneous coronary intervention (PCI) continues to evolve, comparative outcomes for PCI vs coronary artery bypass grafting (CABG) remain relevant in diabetic patients. All revascularization procedures in patients with coronary artery disease and diabetes mellitus from 2010 to 2018 were included. Propensity matching was used to identify equivalent cohorts to compare revascularization strategies. Primary outcomes included 30-day, 1-year, and 5-year mortality. Multivariable analysis was used to define factors associated with major adverse cardiovascular and cerebrovascular events (MACCE). A total of 2869 patients with diabetes were divided into PCI (n = 653) and CABG (n = 2216) cohorts. Propensity matching yielded a 1:1 match consisting of 552 patients in each cohort (CABG vs PCI). Total median follow-up was 3.28 years (range: 1.83-5.00). Following propensity matching in patients with no prior PCI (1:1; n = 279), mortality remained significantly higher in the PCI cohort at 1 year (13.98% vs 7.53%; P = 0.014) and 5 years (26.88% vs 16.85%; P < 0.004). Hospital readmissions were higher for PCI patients at 1 year (16.49% vs 9.32%; P < 0.0122) and 5 years (19.71% vs 11.83%; P = 0.011). MACCE occurred more frequently in the PCI cohort (32.97% vs 21.51%; P = 0.002). Need for subsequent revascularization (6.45% vs 2.51%; P = 0.024) were significantly higher in the PCI cohort, and time interval to revascularization was significantly longer in the CABG cohort (3.48 [2.11-5.17] vs 2.62 [1.33-4.25] years; P < 0.001). The current study reports improved survival, fewer long-term hospital readmissions, and reduced MACCE and need for repeat revascularization in the CABG cohort. Given these data, patients with diabetes mellitus and coronary artery disease may fare better with surgical revascularization, compared to PCI.

Type 1 diabetes mellitus and coronary revascularization

Over the last three decades, trials of coronary revascularization have taken into account whether populations did or did not have diabetes. What has not been considered is whether or not patients with diabetes in these studies have type 1 or type 2 diabetes. 'Diabetes' appears to be largely used as a synonym for type 2 diabetes. The number of patients with type 1 diabetes has not been reported in most trials. Many questions remain unanswered. Do patients with type 1 diabetes have the same response to various modes of revascularization as those with type 2 diabetes? We know type 2 diabetes affects coronary endothelial function and the coronary artery wall but to what extent does type 1 diabetes affect these? Any response to revascularization does not just depend on the coronary artery but also on the myocardium. How does type 1 diabetes affect the myocardium? To what extent do patients with type 1 diabetes have viable or ischaemic myocardium or scar? What does 'diabetic cardiomyopathy' refer to in the context of type 1 diabetes? This manuscript reviews the evidence for revascularization in type 1 diabetes. We conclude that there has been a near absence of investigation of the pros and cons of revascularization in this population. Investigations to establish both the nature and extent of coronary and myocardial disease in these populations are necessary. Clinical trials of the pros and cons of revascularization in type 1 diabetes are necessary; many will declare that these will be too challenging to perform.

Cardiac surgery 2017 reviewed

For the year 2017, more than 21,000 published references can be found in PubMed when entering the search term "cardiac surgery". This review focusses on conventional cardiac surgery, considering the new interventional techniques only if they were directly compared to classic techniques but also entails aspects of perioperative intensive care management. The publications last year provided a plethora of new and interesting information that helped to quantify classic surgical treatment effects and provided new guidelines for the management of structural heart disease, which made comparisons to interventional techniques easier. The field of coronary bypass surgery was primarily filled with confirmatory evidence for the beneficial role of coronary artery bypass grafting for complex coronary disease and equal outcomes for percutaneous coronary intervention for less complex disease including main stem lesions. For aortic valve treatment, the new guidelines provide an equal recommendation for surgical and transcatheter aortic valve replacement for high and intermediate risk giving specific check lists to individualize decision-making by the heart team. For low-risk aortic stenosis, surgical valve replacement remains the primary indication. For the mitral valve, the importance of surgical experience of the individual surgeon on short- and long-term outcome was presented and the prognostic impact of mitral repair for primary mitral regurgitation was emphasized. In addition, there were many relevant and interesting other contributions from the purely operative arena in the fields of tricuspid disease as well as terminal heart failure (i.e., transplantation and ventricular assist devices). While this article attempts to summarize the most pertinent publications, it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

The Potential Effects of New Stent Platforms for Coronary Revascularization in Patients With Diabetes

Coronary artery disease in patients with diabetes mellitus (DM) is characterized by extensive atherosclerosis, longer lesions, and diffuse distal disease. Consequently, these patients have worse outcomes after coronary revascularization, regardless of the modality used. Traditionally, coronary artery bypass grafting (CABG) has been regarded as more effective than percutaneous coronary intervention (PCI) in patients with DM, likely because of more complete revascularization and protection against disease progression in the bypass segment. Revascularization with balloon angioplasty, bare-metal stents, and first-generation drug-eluting stents have all been shown to be inferior to CABG in patients with DM. Current professional society guidelines reflect these findings, strongly recommending CABG over PCI in this setting. Newer stent platforms, however, have challenged this notion. The use of thinner struts, biocompatible polymer coating, and newer antiproliferative agents have improved the rates of cardiovascular events in patients with DM revascularized percutaneously. Since the publication of current guidelines, new studies suggested acceptable outcomes in patients with DM revascularized with second-generation drug-eluting stents, even though these conclusions are drawn from small subgroup analyses or nonrandomized studies. Robust registry data suggest similar mortality with lower rates of stroke after PCI compared with surgery, at the expense of increased rates of repeat revascularization. If complete revascularization can be achieved, similar rates of myocardial infarction are also observed. Therefore, contemporary revascularization in patients with DM with multivessel coronary artery disease should involve a multidisciplinary approach, in which interventional cardiologists and cardiac surgeons involve their patients to individualize treatment choices, and balance the risks and effectiveness of each modality.

Bilateral Versus Single Internal Thoracic Artery Grafts

Purpose of Review

Several advances have been made in recent years to improve outcome for patients with coronary artery disease. One of the most debated topics regarding surgical treatment with coronary artery bypass grafting (CABG) is graft selection. This review aims to present the current status and scientific evidence for bilateral internal thoracic artery (BITA) grafting.

Recent Findings

Observational studies and pooled analyses suggest that BITA grafting is associated with improved survival. Early results from a large randomized controlled trial report safety and efficacy of the method. The improved survival might be amplified in select groups, but with an increase in sternal wound-related complications. The benefit of BITA grafts seems to remain to an approximate age of 69 years at surgery.

Summary

CABG with BITA grafts is likely associated with improved long-term survival at a cost of an increase in sternal wound infections. Ten-year results from the Arterial Revascularization Trial are expected in 2018, providing the best evidence regarding the method yet. Early results show it is a safe method in most patient categories considerable for CABG.