Contemporary Outcomes Following Coronary Artery Bypass Graft Surgery for Left Main Disease

Multiple arterial coronary bypass grafting is associated with better survival compared with second-generation drug-eluting stents in patients with stable multivessel coronary artery disease

OBJECTIVE

We sought to compare the long-term outcomes of multiarterial graft (MAG) coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) to treat stable multivessel coronary artery disease.

METHODS

This study was a multicenter population-based retrospective analysis of all residents of Ontario, Canada, from January 1, 2011, to December 31, 2019. We identified 3600 cases of elective primary isolated CABG with MAG and 2187 cases of PCI with second-generation DES.

RESULTS

After the application of propensity score-weighting using overlap weights, MAG was associated with better survival over 5 years compared with DES (96.8% vs 94.5%; hazard ratio [HR], 0.56; 95% CI, 0.37-0.85). MAG was also associated with better secondary outcomes including a composite of death, myocardial infarction, and stroke (94.3% vs 88.5%; HR, 0.49; 95% CI, 0.36-0.65). The rate of death, stroke, myocardial infarction, and repeat revascularization (91.2% vs 70.7%; HR, 0.24; 95% CI, 0.20-0.30), and the individual end points of myocardial infarction (1.4% vs 6.9%; HR, 0.22; 95% CI, 0.13-0.35), and repeat revascularization (4.1% vs 24.2%; HR, 0.14; 95% CI, 0.10-0.18) were lower with MAG. PCI with second-generation DES was associated with a lower rate of stroke up to 5 years (0.6% vs 1.8%; HR, 3.97; 95% CI, 1.45-10.88).

CONCLUSIONS

CABG with MAG was associated with better survival and fewer major cardiac adverse events compared with second-generation DES and might be considered the treatment of choice for patients with stable multivessel coronary artery disease. Further randomized controlled trials are needed to confirm this hypothesis.

Early and mid-term outcomes of off-pump versus on-pump coronary artery bypass surgery in patients with triple-vessel coronary artery disease: a randomized controlled trial

BACKGROUND AND AIM OF THE STUDY

Several studies have compared early and late outcomes of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However, there is still an ongoing debate on this matter, especially in patients with triple-vessel coronary artery disease (3VD).

METHODS

We randomly assigned 274 consecutive patients with 3VD to two equal groups to undergo on-pump CABG or off-pump CABG. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization. The secondary outcomes were postoperative infection, ventilation time, ICU admission duration, hospital stay length, and renal failure after surgery.

RESULTS

The median follow-up duration was 31.2 months (range 24.6-35.2 months). The mean age of patients was 61.4 ± 9.3 years (range: 38-86), and 207 (78.7%) were men. There were 15 (11.2%) and 9 (7.0%) MACCE occurrences in on-pump and off-pump groups, respectively (P value = 0.23). MACCE components including all-cause death, non-fatal MI, CVA, and revascularization did not significantly differ between on-pump and off-pump groups. We observed no difference in the occurrence of MACCE between off-pump and on-pump groups in multivariable regression analysis (HR = 0.57; 95% CI 0.24-1.32; P value = 0.192). There were no statistical differences in postoperative outcomes between the off-pump and on-pump CABG groups.

CONCLUSIONS

Off-pump CABG is an equal option to on-pump CABG for 3VD patients with similar rates of MACCE and postoperative complications incidence when surgery is performed in the same setting by an expert surgeon in both methods. (IRCT20190120042428N1).

Preoperative frailty assessment could be a predictive factor for the prognosis of elderly patients undergoing coronary artery bypass grafting: a retrospective case-control study

BACKGROUND

Frailty has been considered to be associated with major mortality and increased length of stay after cardiac surgery. This study aimed to explore the predictive potential of frailty assessment in the prognosis of elderly patients undergoing bypass surgery.

METHODS

This study assessed the preoperative frailty according to the Fried's frailty phenotype, and included 150 frail and 150 non-frail elderly patients (≥ 65 y) who underwent bypass surgery. The present study evaluated the prognosis of elderly patients based on sequential organ failure assessment (SOFA) score, and collected clinical indicators to construct logistic regression models with the prognosis as the dependent variable, to explore the potential predictive ability of preoperative frailty. Moreover, this study focused on the complications and analyzed the relationship between preoperative frailty and postoperative complications.

RESULTS

In the present study, 244 patients were divided into the favorable prognosis group and 56 patients were divided into the unfavorable prognosis group. Logistic regression analysis showed that increased myoglobin and high cardiac function classification were independent risk factors for unfavorable prognosis in elderly patients undergoing bypass surgery. The discrimination of the clinical prediction model was determined by the receiver operating characteristic (ROC) curve, and the area under curve (AUC) was 0.928. After adding preoperative frailty assessment, the AUC was improved to 0.939. This study found a significant correlation between preoperative frailty and postoperative complications, mainly in the circulatory system.

CONCLUSION

Preoperative frailty assessment could be a predictive factor for the prognosis of elderly patients undergoing coronary artery bypass grafting. According to our study, frailty assessment and appropriate intervention before bypass surgery may be beneficial to the enhanced recovery after cardiac surgery.

TRIAL REGISTRATION

The clinical study was approved by the Medical Ethics Committee of The First Affiliated Hospital of Nanjing Medical University (2021-SR-393). All patients signed an informed consent form.

Clinical event rate in patients with and without left main disease undergoing isolated CABG: results from the European DuraGraft registry

OBJECTIVES

Left main coronary artery disease (LMCAD) is considered an independent risk factor for clinical events after coronary artery bypass grafting (CABG). We have conducted a subgroup analysis of the multicentre European DuraGraft registry to investigate clinical event-rates at 1-year in patients with and without LMCAD undergoing isolated CABG in contemporary practice.

METHODS

Patients undergoing isolated CABG were selected. The primary end-point was the incidence of a major adverse cardiac event (MACE) defined as the composite of death, myocardial infarction (MI) or repeat revascularization (RR) at 1-year. The secondary end-point was major adverse cardiac and cerebrovascular events (MACCE) defined as MACE plus stroke. Propensity score matching (PSM) was performed to balance for differences in baseline characteristics.

RESULTS

LMCAD was present in 1,033 (41.2%) and absent in 1,477 (58.8%) patients. At 1-year, the MACE rate was higher for LMCAD patients (8.2% vs 5.1%, p = 0.002) driven by higher rates of death (5.4% vs 3.4%, p = 0.016), MI (3.0% vs 1.3%, p = 0.002) and numerically higher rates of RR (2.8% vs 1.8%, p = 0.13). The incidence of MACCE was 8.8% vs 6.6%, p = 0.043 with a stroke rate of 1.0% and 2.4%, p = 0.011, for LMCAD and non-LMCAD group, respectively. After PSM, the MACE rate was 8.0% vs 5.2%, p = 0.015. The incidence of death was 5.1% vs 3.7%, p = 0.10, MI 3.0% vs 1.4%, p = 0.020, and RR was 2.7% vs 1.6%, p = 0.090, for the LMCAD and non-LMCAD group, respectively. Less strokes occurred in LMCAD patients (1.0% vs 2.4%, p = 0.017). The MACCE rate was not different: 8.5% vs 6.7%, p = 0.12.

CONCLUSIONS

In this large registry, LMCAD was demonstrated to be an independent risk factor for MACE after isolated CABG. Conversely, the risk of stroke was lower in LMCAD patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02922088.

Meta-analysis comparing percutaneous coronary intervention with coronary artery bypass grafting for non-ST elevation acute coronary syndrome in patients with multivessel or left main disease

OBJECTIVES

Outcomes of patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary disease (MVD) and/or unprotected left main coronary artery disease (CAD) revascularized with percutaneous coronary intervention(PCI) or coronary artery bypass grafting(CABG) is not well defined.

DESIGN

MEDLINE/PubMed and EMBASE/Ovid were queried for studies that investigated PCI vs. CABG in this disease subset. The primary outcome was major cardiac adverse events (MACE) at 30 days and long-term follow-up (3 to 5 years).

RESULTS

The final analysis included 9 studies with a total of 9299 patients. No significant difference was observed between PCI and CABGin30 days MACE (risk ratio [RR] 0.96; 95% confidence interval [CI] 0.38-2.39, all-cause mortality, myocardial infarction, and stroke. A meta-regression analysis revealed patients with a history of PCI had higher risk of MACE with PCI as compared with CABG. At long-term follow-up, PCI compared with CABG was associated with higher risk of MACE (RR 1.52; 95% CI 1.28-1.81), myocardial infarction, and repeat revascularization, while no difference was observed in the risk of stroke and all-cause mortality.

CONCLUSION

In patients with NSTE-ACS and MVD and/or unprotected left main CAD, no differences were observed in the clinical outcomes between PCI and CABG at 30 days follow-up. With long-term follow-up, PCI was associated with a higher risk of MACE.

Sex differences in outcomes following coronary artery bypass grafting: a meta-analysis

OBJECTIVES

Previous reports have found females are a higher risk of morbidity and mortality following isolated coronary artery bypass grafting (CABG). Here, we describe the differences in outcomes following isolated CABG between males and females.

METHODS

Following a systematic literature search, studies reporting sex-related outcomes following isolated CABG were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was operative mortality. Secondary outcomes included rates of stroke, repeat revascularization, myocardial infarction, major adverse cardiac events, and late mortality. Subgroup analyses were performed for studies published before and after the year 2000 and for the type of risk adjustment.

RESULTS

Eighty-four studies were included with a total of 903 346 patients. Females were at higher risk for operative mortality (odds ratio: 1.77, 95% confidence interval [CI]: 1.64-1.92, P < 0.001). At subgroup analysis, there was no difference in operative or late mortality between studies published prior and after 2000 or between studies using risk adjustment. Females were at a higher risk of late mortality (incidence rate ratio [IRR]: 1.16, 95% CI: 1.06-1.26, P < 0.001), major adverse cardiac events (IRR: 1.40, 95% CI: 1.19-1.66, P < 0.001), myocardial infarction (IRR: 1.28, 95% CI: 1.13-1.45, P < 0.001) and stroke (IRR: 1.31, 95% CI: 1.15-1.51, P > 0.001) but not repeat revascularization (IRR: 0.99, 95% CI: 0.76-1.29, P = 0.95). The use of the off-pump technique or multiple arterial grafts was not associated with the primary outcome.

CONCLUSIONS

Females undergoing CABG are at higher risk for operative and late mortality as well as postoperative events including major adverse cardiac events, myocardial infarction and stroke.

PROSPERO REGISTRATION

CRD42020187556.

Effect of continuous positive airway pressure associated to exercise on the breathing pattern and heart rate variability of patients undergoing coronary artery bypass grafting surgery: a randomized controlled trial

Continuous positive airway pressure (CPAP) has been used to improve gas exchange and diaphragmatic function, among others benefits. Moreover, it can be used to increase exercise tolerance and positively influence ventilatory function and breathing pattern (BP) during exercise. However, there is no information about the long-term effects of CPAP, as an adjunct to an inpatient cardiac rehabilitation (CR) program, on BP and heart rate variability (HRV) of patients after coronary artery bypass grafting surgery (CABG). Twenty patients were allocated to receive, after randomization, standard inpatient CR without CPAP (control group - CG) or CR with CPAP between 10 to 12 cmH₂O (CPAP group - CPG) associated with the exercises. Participants were assessed preoperatively and on the discharge day, in the sitting rest position. Outcome measurements included BP variables, collected by respiratory inductive plethysmography, and HRV, collected by polar precision performance. The CPG presented lower values of percent rib cage inspiratory and expiratory contributions to tidal volume (%RCi and %RCe) at discharge time, compared to CG. No statistical differences between groups were observed for HRV variables and both groups presented lower values of these indices, compared to preoperative ones. In this context, the patients who received CPAP throughout the whole rehabilitation program were discharged with a better BP, which could indicate more synchronized breathing. CPAP did not influence cardiac autonomic modulation in the long term.

Percutaneous Coronary Revascularization: JACC Historical Breakthroughs in Perspective

Over the last 4 decades, percutaneous coronary intervention has evolved dramatically and is now an acceptable treatment option for patients with advanced coronary artery disease. However, trialists have struggled to establish the respective roles for percutaneous coronary intervention and coronary artery bypass graft surgery, especially in patients with multivessel disease and unprotected left-main stem coronary artery disease. Several pivotal trials and meta-analyses comparing these 2 revascularization strategies have enabled the relative merits of each technique to be established with regard to the type of ischemic syndrome, the coronary anatomy, and the patient's overall comorbidity. Precision medicine with individualized prognosis is emerging as an important method of selecting treatment. However, the never-ending advancement of technology, in conjunction with the emergence of novel pharmacological agents, will in the future continue to force us to reconsider the evolving question: "Which treatment strategy is better and for which patient?"

Intraoperative transit-time flow measurement and high-frequency ultrasound in coronary artery bypass grafting: impact in off versus on-pump, arterial versus venous grafting and cardiac territory grafted

OBJECTIVES

Despite society guideline recommendations, intraoperative high-frequency ultrasound (HFUS) and transit-time flow measurement (TTFM) use in coronary artery bypass grafting (CABG) has not been widely adopted worldwide. This retrospective review of the REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study assesses the impact of protocolled high-frequency ultrasound/TTFM use in specific technical circumstances of CABG.

METHODS

Three REQUEST study sub-analyses were examined: (i) For off-pump (OPCAB) versus on-pump (ONCAB) procedures: strategy changes from preoperative plans for the aorta, conduits, coronary targets and graft revisions; and for all REQUEST patients, revision rates in: (ii) arterial versus venous grafts; and (iii) grafts to different cardiac territories.

RESULTS

Four hundred and two (39.6%) of 1016 patients undergoing elective isolated CABG for multivessel disease underwent OPCAB procedures. Compared to ONCAB, OPCAB patients experienced more strategy changes regarding the aorta [14.7% vs 3.4%; odds ratios (OR) = 4.03; confidence interval (CI) = 2.32-7.20], less regarding conduits (0.2% vs 2.8%; OR = 0.09; CI = 0.01-0.56), with no differences in coronary target changes or graft revisions (4.1% vs 3.5%; OR = 1.19; CI = 0.78-1.81). In all REQUEST patients, revisions were more common for arterial versus venous grafts (4.7% vs 2.4%; OR = 2.05; CI = 1.29-3.37), and inferior versus anterior (5.1% vs 2.9%; OR = 1.77; CI = 1.08-2.89) and lateral (5.1% vs 2.8%; OR = 1.83; CI = 1.04-3.27) territory grafts.

CONCLUSIONS

High-frequency ultrasound/TTFM use differentially impacts strategy changes and graft revision rates in different technical circumstances of CABG. Notably, patients undergoing OPCAB experienced 4 times more changes related to the ascending aorta than ONCAB patients. These findings may indicate where intraoperative assessment is most usefully applied.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02385344.

The Better Option of Revascularization in Complex Coronary Artery Disease Patients Complicate With Chronic Kidney Disease: A Review and Meta-Analysis

The treatment of complex coronary artery disease (CAD) combined with chronic kidney disease (CKD) faces great challenges. We thus did a systematic review and meta-analysis to assess the effect of percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). We systematically searched PubMed, Embase, Cochrane Library and other relevant articles refer to reference. Our main endpoints were main adverse cardiovascular and cerebrovascular events (MACCE), all cause death, myocardial infarction (MI), repeat revascularization and stoke. 24 studies were included in our analysis. Compared with PCI, CABG improved outcomes such as MACCE (Odds Ratio [OR] 1.75; 95%CI 1.26-2.42), all cause death (OR 1.13; 95%CI 1.00-1.28), repeat revascularization (OR 4.24; 95%CI 3.29-5.47) and MI (OR 2.16; 95%CI 1.59-2.91), but stoke (OR 0.84, 95%CI 0.61-1.17). CABG shows absolute advantage in complex CAD complicated with CKD and ESRD patients than stent implantation in the long-term following-up.

Impact of stent length and diameter on 10-year mortality in the SYNTAXES trial

OBJECTIVES

We investigated the impact of total stent length (TSL) and average nominal stent diameter (ASD) on 10-year mortality after percutaneous coronary intervention (PCI) in the SYNTAXES trial.

BACKGROUND

TSL and ASD in patients treated with PCI are associated with major adverse cardiovascular events. However, the treatment effect of PCI with extensive and/or small stenting as compared with coronary artery bypass grafting (CABG) for complex coronary artery disease has not been fully evaluated.

METHODS

Impacts on mortality of extensive stenting defined as TSL >100 mm and small stenting as ASD <3 mm were analyzed in 893 PCI patients and were compared to 865 CABG patients.

RESULTS

TSL as a continuous variable was significantly associated with 10-year mortality (adjusted hazard ratio [HR], 1.05 [1.01-1.09] per 10 mm increase). PCI patients with extensive stenting had a higher 10 year mortality than CABG patients (adjusted HR, 1.97 [1.41-2.74]) or not- extensive stenting PCI (adjusted HR, 1.94 [1.36-2.77]). Although ASD did not have a significant association with 10 year mortality (adjusted HR, 0.97 [0.85-1.11] per 0.25 mm increase), PCI with small stents was associated with a higher 10 year mortality, compared to CABG (adjusted HR, 1.66 [1.23-2.26]) and PCI performed with large stents (adjusted HR, 1.74 [1.19-2.53]). Patients treated with not-extensive and large stents had similar mortality rates (24.0 versus 23.8%) as those treated with CABG.

CONCLUSIONS

Extensive and small stenting were associated with higher 10 year mortality, compared with CABG. When patients have to be treated with extensive or small stenting, revascularization with CABG should be preferred.

Incidence, Characteristics, and Outcomes of Emergent Isolated Coronary Artery Bypass Grafting

Data on emergency coronary artery bypass surgery (CABG) are limited. We studied patients who underwent isolated CABG at Mayo Clinic between 1993 and 2019. Baseline characteristics and in-hospital outcomes of emergent CABG were described in consecutive eras (1993 to 2000, 2001 to 2010, and 2011 to 2019). Cumulative survival was estimated by the Kaplan Meier method for the overall group, and stratified by the indication of surgery. In the 14,455 isolated CABG included, 427 (2.95%) were emergent. The number of emergent CABG decreased from 222 to 150 and 55 in the consecutive study eras. There was a temporal increase in the prevalence of heart failure, but no change in mean age, and prevalence of hypertension, diabetes, renal failure, or atrial fibrillation. The proportion of patients with failed/complicated percutaneous coronary intervention decreased from 38.2% in 1993 to 2000 to 22.7% in 2001 to 2010 and 25.5% in 2011 to 2019 (p = 0.003). In 2011 to 2019, 100% of patient received an internal mammary graft compared with 75.6% in 1993 to 2000 (p < 0.001). Operative mortality was 8.7% overall (8.6% in 1993 to 2000, 10.0% in 2001 to 2010, and 5.5% in 2011 to 2019, p = 0.56). There were no differences in postoperative complications except for the incidence of renal failure and new dialysis which increased over time. Predicted 10-year survival was 57.0% and was not different according to CABG indication (p = 0.12). In conclusion, we documented a temporal decrease in the incidence of emergent CABG between 1993 and 2019, especially those performed due to complications of coronary interventions. Despite the higher prevalence of left ventricular dysfunction and the more complete revascularization in more recent years, in-hospital mortality did not increase.

Advances in the Protective Mechanism of NO, H2S, and H2 in Myocardial Ischemic Injury

Myocardial ischemic injury is among the top 10 leading causes of death from cardiovascular diseases worldwide. Myocardial ischemia is caused mainly by coronary artery occlusion or obstruction. It usually occurs when the heart is insufficiently perfused, oxygen supply to the myocardium is reduced, and energy metabolism in the myocardium is abnormal. Pathologically, myocardial ischemic injury generates a large number of inflammatory cells, thus inducing a state of oxidative stress. This sharp reduction in the number of normal cells as a result of apoptosis leads to organ and tissue damage, which can be life-threatening. Therefore, effective methods for the treatment of myocardial ischemic injury and clarification of the underlying mechanisms are urgently required. Gaseous signaling molecules, such as NO, H₂S, H₂, and combined gas donors, have gradually become a focus of research. Gaseous signaling molecules have shown anti-apoptotic, anti-oxidative and anti-inflammatory effects as potential therapeutic agents for myocardial ischemic injury in a large number of studies. In this review, we summarize and discuss the mechanism underlying the protective effect of gaseous signaling molecules on myocardial ischemic injury.

Redevelopment and validation of the SYNTAX score II to individualise decision making between percutaneous and surgical revascularisation in patients with complex coronary artery disease: secondary analysis of the multicentre randomised controlled SYNTAXES trial with external cohort validation

BACKGROUND

Randomised controlled trials are considered the gold standard for testing the efficacy of novel therapeutic interventions, and typically report the average treatment effect as a summary result. As the result of treatment can vary between patients, basing treatment decisions for individual patients on the overall average treatment effect could be suboptimal. We aimed to develop an individualised decision making tool to select an optimal revascularisation strategy in patients with complex coronary artery disease.

METHODS

The SYNTAX Extended Survival (SYNTAXES) study is an investigator-driven extension follow-up of a multicentre, randomised controlled trial done in 85 hospitals across 18 North American and European countries between March, 2005, and April, 2007. Patients with de-novo three-vessel and left main coronary artery disease were randomly assigned (1:1) to either the percutaneous coronary intervention (PCI) group or coronary artery bypass grafting (CABG) group. The SYNTAXES study ascertained 10-year all-cause deaths. We used Cox regression to develop a clinical prognostic index for predicting death over a 10-year period, which was combined, in a second stage, with assigned treatment (PCI or CABG) and two prespecified effect-modifiers, which were selected on the basis of previous evidence: disease type (three-vessel disease or left main coronary artery disease) and anatomical SYNTAX score. We used similar techniques to develop a model to predict the 5-year risk of major adverse cardiovascular events (defined as a composite of all-cause death, non-fatal stroke, or non-fatal myocardial infarction) in patients receiving PCI or CABG. We then assessed the ability of these models to predict the risk of death or a major adverse cardiovascular event, and their differences (ie, the estimated benefit of CABG versus PCI by calculating the absolute risk difference between the two strategies) by cross-validation with the SYNTAX trial (n=1800 participants) and external validation in the pooled population (n=3380 participants) of the FREEDOM, BEST, and PRECOMBAT trials. The concordance (C)-index was used to measure discriminative ability, and calibration plots were used to assess the degree of agreement between predictions and observations.

FINDINGS

At cross-validation, the newly developed SYNTAX score II, termed SYNTAX score II 2020, showed a helpful discriminative ability in both treatment groups for predicting 10-year all-cause deaths (C-index=0·73 [95% CI 0·69-0·76] for PCI and 0·73 [0·69-0·76] for CABG) and 5-year major adverse cardiovascular events (C-index=0·65 [0·61-0·69] for PCI and C-index=0·71 [0·67-0·75] for CABG). At external validation, the SYNTAX score II 2020 showed helpful discrimination (C-index=0·67 [0·63-0·70] for PCI and C-index=0·62 [0·58-0·66] for CABG) and good calibration for predicting 5-year major adverse cardiovascular events. The estimated treatment benefit of CABG over PCI varied substantially among patients in the trial population, and the benefit predictions were well calibrated.

INTERPRETATION

The SYNTAX score II 2020 for predicting 10-year deaths and 5-year major adverse cardiovascular events can help to identify individuals who will benefit from either CABG or PCI, thereby supporting heart teams, patients, and their families to select optimal revascularisation strategies.

FUNDING

The German Heart Research Foundation and the Patient-Centered Outcomes Research Institute.

Mapping decision making for bypass surgery in the era of interventional medicine: towards an integrative model of patient-centeredness

This article reviews the context and evidence of recent myocardial revascularization trials on PCI versus CABG with particular emphasis on patient selection and treatment of surgical patients. Moreover, one of our intended purposes is to identify the values underpinning the integrated care model, which incorporates decision to proceed with surgical myocardial revascularization in conjunction with established pillars of the use of optimal surgical techniques, and aggressive risk-factor modification through guideline-directed pharmacological therapies and lifestyle modifications.

Second Generation Drug-Eluting Stent Implantation versus Coronary Artery Bypass Grafting in the Treatment of Young Patients with Left Main and/or Multivessel Coronary Disease

Background

Many studies have compared the outcomes of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) for complex coronary artery disease (CAD). However, no trials have focused on young patients (<45 years) with complex CAD. We conducted a retrospective evaluation to compare the outcomes of a second-generation drug-eluting stent (DES) and CABG in young patients with LM or three-vessel disease.

Methods

In young patients with complex CAD who underwent PCI or CABG, a Kaplan-Meier analysis and Cox regression before and after propensity score matching were used to compare major adverse cardiac and cerebrovascular events (MACCE), including myocardial infarction (MI), stroke, death, and repeat revascularization.

Results

During follow-up, MACCE occurred in 20.5% of patients in the PCI group and 8.6% of patients in the CABG group (hazard ratio (HR): 3.263, 95% confidence interval (CI): 1.379 to 7.722, p=0.007). Repeat revascularization occurred more frequently in the PCI group (18.9% vs. 3.7%, respectively, HR: 6.968, 95% CI: 2.036 to 23.842, p=0.002). There were no significant differences in the other endpoints. After propensity score matching, no conclusions were modified.

Conclusions

In young patients with LM or three-vessel disease, PCI showed a higher incidence of MACCE, which was mainly driven by repeat revascularization. However, this did not translate into hard endpoint differences. Therefore, PCI is an alternative treatment to CABG in young patients with complex CAD.

Impact of non-respect of SYNTAX score II recommendation for surgery in patients with left main coronary artery disease treated by percutaneous coronary intervention: an EXCEL substudy

OBJECTIVES

The SYNTAX score II (SSII) was developed from the SYNTAX trial to predict the 4-year all-cause mortality after left main or multivessel disease revascularization and to facilitate the decision-making process. The SSII provides the following treatment recommendations: (i) coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (equipoise risk), (ii) CABG preferred (excessive risk for PCI) or (iii) PCI preferred (excessive risk for CABG). We sought to externally validate SSII and to investigate the impact of not abiding by the SSII recommendations in the randomized EXCEL trial of PCI versus CABG for left main disease.

METHODS

The calibration plot of predicted versus observed 4-year mortality was constructed from individual values of SSII in EXCEL. To assess overestimation versus underestimation of predicted mortality risk, an optimal fit regression line with slope and intercept was determined. Prospective treatment recommendations based on SSII were compared with actual treatments and all-cause mortality at 4 years.

RESULTS

SSII variables were available from EXCEL trial in 1807/1905 (95%) patients. For the entire cohort, discrimination was possibly helpful (C statistic = 0.670). SSII-predicted all-cause mortality at 4 years overestimated the observed mortality, particularly in the highest-risk percentiles, as confirmed by the fit regression line [intercept 2.37 (1.51-3.24), P = 0.003; slope 0.67 (0.61-0.74), P < 0.001]. When the SSII-recommended treatment was CABG, randomized EXCEL patients treated with PCI had a trend towards higher mortality compared with those treated with CABG (14.1% vs 5.3%, P = 0.07) in the as-treat population. In the intention-to-treat population, patients randomized to PCI had higher mortality compared with those randomized to CABG (15.1% vs 4.1%, P = 0.02), when SSII recommended CABG.

CONCLUSIONS

In the EXCEL trial of patients with left main disease, the SSII-predicted 4-year mortality overestimated the 4-year observed mortality with a possibly helpful discrimination. Non-compliance with SSII CABG treatment recommendations (i.e. randomized to PCI) was associated with higher 4-year all-cause mortality.

Mortality After Repeat Revascularization Following PCI or CABG for Left Main Disease: The EXCEL Trial

OBJECTIVES

The aim of this study was to investigate the incidence and impact on mortality of repeat revascularization after index percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD).

BACKGROUND

The impact on mortality of the need of repeat revascularization following PCI or CABG in patients with unprotected LMCAD is unknown.

METHODS

All patients with LMCAD and site-assessed low or intermediate SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores randomized to PCI (n = 948) or CABG (n = 957) in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial were included. Repeat revascularization events were adjudicated by an independent clinical events committee. The effect of repeat revascularization on mortality through 3-year follow-up was examined in time-varying Cox regression models.

RESULTS

During 3-year follow-up, there were 346 repeat revascularization procedures among 185 patients. PCI was associated with higher rates of any repeat revascularization (12.9% vs. 7.6%; hazard ratio: 1.73; 95% confidence interval: 1.28 to 2.33; p = 0.0003). Need for repeat revascularization was independently associated with increased risk for 3-year all-cause mortality (adjusted hazard ratio: 2.05; 95% confidence interval: 1.13 to 3.70; p = 0.02) and cardiovascular mortality (adjusted hazard ratio: 4.22; 95% confidence interval: 2.10 to 8.48; p < 0.0001) consistently after both PCI and CABG (p_int = 0.85 for both endpoints). Although target vessel revascularization and target lesion revascularization were both associated with an increased risk for mortality, target vessel non-target lesion revascularization and non-target vessel revascularization were not.

CONCLUSIONS

In the EXCEL trial, repeat revascularization during follow-up was performed less frequently after CABG than PCI and was associated with increased mortality after both procedures. Reducing the need for repeat revascularization may further improve long-term survival after percutaneous or surgical treatment of LMCAD. (EXCEL Clinical Trial; NCT01205776).

Epiaortic Ultrasound for Assessment of Intraluminal Atheroma; Insights from the REGROUP Trial

OBJECTIVES

To assess the use of epiaortic ultrasound in contemporary cardiac surgery, as well as its impact on surgical cannulation strategy and cerebrovascular events.

DESIGN

Epiaortic ultrasound data was prospectively collected in the Randomized Endovein Graft Prospective (REGROUP) trial (VA Cooperative Studies Program #588, ClinicalTrials.gov, NCT01850082), which randomized 1,150 coronary artery bypass graft patients between 2014 and 2017 to endoscopic or open-vein graft harvest.

SETTING

Sixteen cardiac surgery programs within the Veterans Affairs Healthcare System with expertise at performing endoscopic vein-graft harvesting.

PARTICIPANTS

Veterans Affairs patients, greater than 18 years of age, undergoing elective or urgent coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest with at least one planned saphenous vein graft were eligible for enrollment.

INTERVENTIONS

Epiaortic ultrasound was performed by the surgeon using a high frequency (>7 MHz) ultrasound transducer. Two-dimensional images of the ascending aorta in multiple planes were acquired before aortic cannulation and cross-clamping.

MEASUREMENTS AND MAIN RESULTS

Epiaortic ultrasound was performed in 34.1% (269 of 790) of patients in REGROUP. Among these patients, simple intraluminal atheroma was observed in 21.9% (59 269), and complex intraluminal atheroma comprised 2.2% (6 of 269). The aortic cannulation or cross-clamp strategy was modified based on these findings in 7.1% of cases (19 of 269). There was no difference in stroke between patients who underwent epiaortic ultrasound and those who did not (1.9% v 1.2% p = 0.523).

CONCLUSIONS

Despite current guidelines recommending routine use of epiaortic ultrasound (IIa/B) to reduce the risk of stroke in cardiac surgery, in this contemporary trial, use remains infrequent, with significant site-to-site variability.