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

Comparative Analysis of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting in Left Main Disease Stratification by Angiographic SYNTAX Score

Using the SYNTAX score (SS) for decision-making between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for left main coronary artery (LMCA) revascularization is under scrutiny. This study investigated the clinical outcomes of LMCA revascularization stratified by SS. This multicenter study included 2138 patients recruited between 2015 and 2020 who underwent LMCA disease revascularization using PCI or CABG and were categorized based on their SS into three groups: low (≤22), intermediate (23-32), and high (≥33). Patients with a high SS compared with those with an intermediate SS experienced increased hospital mortality (Odds ratio: 1.99; P = .026) and Major Adverse Cardiac and Cerebrovascular Event (MACCE; OR: 2.17; P = .006). With an average follow-up of 24.7 months, no substantial differences emerged in MACCE (Hazard ratio: 1.23; P = .52) or mortality (HR: 3.26; P = .073] between patients with high and intermediate SSs. A significant interaction between the SS category (low vs intermediate) and LMCA revascularization modality was observed for hospital MACCEs, favoring PCI over CABG (OR: 0.32; P = .033). However, no noteworthy interactions between SS categories and revascularization modalities were noted concerning hospital or follow-up mortality or follow-up MACCEs. These findings raise doubts about the utility of SS alone in selecting left-main revascularization modalities for LMCA disease.

Severe left main coronary artery disease and STEMI in a 19-year-old without traditional risk factors: A rare case of premature coronary artery disease

Premature coronary artery disease (CAD) is defined by the early onset of significant atherosclerotic narrowing of the coronary arteries, generally occurring before age 55 in men and 60 in women. This condition is an increasing concern in cardiovascular medicine due to its impact on younger populations, resulting in greater morbidity, diminished quality of life, and a substantial economic burden. Common risk factors include dyslipidemia, hypertension, diabetes, smoking, obesity, and genetic predispositions such as familial hyperlipidemia. This case report describes a 19-year-old male with no known cardiovascular risk factors who presented with an ST-segment elevation myocardial infarction and ventricular tachycardia caused by left main coronary artery disease including the left anterior descending artery and the left circumflex artery. Despite lacking common risk factors, he underwent successful coronary artery bypass grafting with two grafts.

Outcomes of Left Main Chronic Total Occlusion Percutaneous Coronary Interventions

BACKGROUND

Percutaneous coronary intervention (PCI) of left main (LM) chronic total occlusions (CTO) has received limited study.

METHODS

We compared the clinical and procedural characteristics and outcomes of patients who underwent LM versus non-LM CTO PCI at 41 US and non-US centers between 2012 and 2024.

RESULTS

During the study period 85 of 15,254 CTO PCIs (0.6%) performed in 14,969 patients were LM CTO PCIs. LM CTO PCI patients were older, had higher rates of dyslipidemia and heart failure and most (88.8%) had prior coronary artery bypass graft surgery (CABG). They were more likely to have moderately or severely calcified lesions (80.7% vs. 45.7%, p < 0.001) and had higher J-CTO (2.76 ± 1.17 vs. 2.37 ± 1.26, p = 0.008), PROGRESS-CTO MACE (3.56 vs. 2.57, p < 0.001), Mortality (2.45 vs. 1.68, p < 0.001), Pericardiocentesis (2.74 vs. 1.87, p < 0.001), Acute MI (1.72 vs. 0.89, p < 0.001) and Perforation (3.21 vs. 2.19, p < 0.001) scores. There was no difference in technical success (80.5% vs. 87.2%, p = 0.086) or major cardiovascular adverse events (MACE) (2.4% vs. 2.0%, p = 0.700). LM CTO PCI patients with and without prior CABG surgery had similar technical success and MACE. The retrograde approach in prior CABG patients was more likely to be performed through saphenous vein grafts.

CONCLUSIONS

LM CTO PCI is infrequently performed, is associated with high comorbidity burden and angiographic complexity but can be performed with high success and acceptable complication rates.

Chest Pain at Rest With Unremarkable ECG and Cardiac Enzymes: Case Study Emphasising the Importance of Clinical Suspicion in the Diagnosis of Coronary Artery Disease

BACKGROUND

Coronary artery disease (CAD), primarily caused by atherosclerosis, is a leading cause of death, presenting as angina or myocardial infarction. Advances in cardiac imaging, angiography, and procedures like percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery have improved early detection and management of this condition. This report presents the case of a man who experienced worsening exertional chest pain and discomfort while at rest.

CASE REPORT

A 66-year-old man with a history of neurogenic syncope and asthma presented at the same-day emergency care (SDEC) unit with worsening exertional chest pain and discomfort whilst at rest. Despite normal ECG and cardiac enzyme results, further cardiac computed tomography angiography (CTCA) revealed significant CAD with moderate stenosis in the right coronary artery (RCA) and severe stenosis at the left anterior descending artery (LAD) bifurcation, leading to CABG surgery. Echocardiography showed a left ventricular ejection fraction of 50-54% with mid-inferior and basal to mid-inferoseptal hypokinesia. The cardiology-cardiothoracic multidisciplinary team concluded that CABG surgery would provide the most durable long-term outcome.

CONCLUSION

This case demonstrates the high importance of clinical suspicion of CAD despite normal initial investigations in the early identification and timely investigation as well as the role multidisciplinary teams and CABG can play in the timely management of complex CAD, ultimately leading to improved patient outcomes.

A Systematic Review and Meta-Analysis of 35,409 Patients Undergoing PCI versus CABG for Unprotected Left Main Coronary Artery Diseases

Background

Patients with unprotected left main (UPLM) disease who underwent percutaneous coronary intervention (PCI) were found to have inconsistent results compared to those treated with coronary artery bypass grafting (CABG).

Methods

We identified and enrolled randomized controlled trials (RCTs) and observational studies (OSs) comparing PCI versus CABG for UPLM disease. A meta-analysis was performed using Stata 17.0. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCEs). Additionally, all-cause death, cardiac death, myocardial infarction (MI), stroke, target vessel revascularization (TVR), and stent thrombosis (ST) were included as secondary endpoints. The odds ratios and 95% confidence intervals (CIs) were calculated. Sensitivity analyses were implemented if I 2 > 50% or p < 0.01. Publication bias analysis was conducted if more than 10 studies were included.

Results

A total of 5 RCTs and 18 OSs involving 35,409 patients were included. The CABG strategy had a significantly lower incidence of MACCEs, primarily due to TVR. A significantly lower stroke rate was observed with the PCI strategy, as well as a significantly lower all-cause death, cardiac death, MI, and ST rate compared with the CABG strategy.

Conclusions

MACCE rates were significantly lower in patients who underwent CABG, primarily due to TVR, but stroke rates were higher. RCTs with different study types need further investigation to confirm the most effective strategy.

Comparative Efficacy of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in the Treatment of Ischemic Heart Disease: A Systematic Review and Meta-Analysis of Recent Randomized Controlled Trials

Background

Ischemic heart disease (IHD) is a major global health issue and a leading cause of death. This study compares the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the management of IHD, focusing on their impact on revascularization, myocardial infarction (MI), and post-procedural stroke. This study aimed to evaluate and compare the effectiveness of PCI and CABG in treating IHD based on an exhaustive literature review of the past 5 years, emphasizing recent advancements and outcomes in IHD management.

Methods

A comprehensive literature review analyzed 32 randomized controlled trials (RCTs) retrieved from databases such as PubMed, Cochrane Library, and Google Scholar. The study specifically assessed the incidences of revascularization, stroke, and MI in patients treated with either PCI or CABG. The comparison between CABG and PCI exclusively focused on lesions with a SYNTAX score exceeding 32.

Results

Our findings highlight CABG's significant efficacy over PCI in reducing revascularization and MI. The aggregated Mantel-Haenszel (M-H) value for revascularization was 1.85 (95% confidence interval (CI): 1.65 - 2.07), signifying CABG's advantage. Additionally, CABG demonstrated superior performance in diminishing MI occurrences (M-H = 2.71, 95% CI: 1.13 - 6.53). In contrast, PCI was more effective in reducing stroke (M-H = 0.80, 95% CI: 0.60 - 1.10).

Conclusion

The study confirms CABG's superiority in reducing revascularization and MI in IHD patients, highlighting PCI's effectiveness in reducing stroke risk. These findings underscore the importance of personalized treatment strategies in IHD management and emphasize the need for ongoing research and evidence-based guidelines to aid in treatment selection for IHD patients.

2023 ACC/AHA Chronic Coronary Disease Guideline - An opportunity to reestablish coronary artery bypass recommendations

Coronary artery bypass (CABG) has evolved over the decades, supported by scientific evidence from robust studies. The downgrade of the recommendation for CABG in patients with multivessel coronary artery disease proposed by the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization and the 2023 ACC/AHA Chronic Coronary Disease Guidelines has brought this discussion to the fore, with prestigious cardiothoracic surgery societies such as AATS and STS not supporting these recommendations. The purpose of this article is to broaden this discussion in light of published studies.

Five-year outcomes in patients with multivessel coronary artery disease undergoing surgery or percutaneous intervention

The outcomes from real-life clinical studies regarding the optimal revascularization strategy in patients with multivessel coronary artery disease (MVD) are still poorly investigated. In this retrospective study we assessed 5-year outcomes: primary, secondary endpoints and quality of life of 1035 individuals with severe coronary artery disease (CAD) treated either with coronary artery bypass grafting (CABG)-356 patients or percutaneous coronary intervention (PCI)-679 patients according to the recommendation of a local Heart Team (HT). At 5 years no significant difference in overall mortality and rates of myocardial infarctions (MI) were observed between CABG and PCI cohorts (11.0% vs. 13.4% for PCI, P = 0.27 and 9.6% vs. 12.8% for PCI, P = 0.12, respectively). The incidence of major adverse cardiac and cerebrovascular events (MACCE), mainly driven by increased rates of repeat revascularization (RR) were higher in PCI-cohort than in CABG-group (56.1% vs. 40.4%, P < 0.01 and 26.8% vs. 12.6%, P < 0.01, respectively), while CABG-patients experienced stroke more often (7.3% vs. 3.1% for PCI, P < 0.01). In real-life practice with long-term follow-up, none of the two revascularization modalities implemented following HT decisions showed overwhelming superiority: occurrence of death and MI were similar, rates of RR favoured CABG, while incidence of strokes advocated PCI.