Percutaneous treatment with drug-eluting stent vs bypass surgery in patients suffering from chronic stable angina with multivessel disease involving significant proximal stenosis in left anterior descending artery

MicroRNA Mediated Regulation of Schwann Cell Migration and Proliferation in Peripheral Nerve Injury

Schwann cells (SCs) contribute to nerve repair following injury; however, the underlying molecular mechanism is poorly understood. MicroRNAs (miRNAs), which are short noncoding RNAs, have been shown to play a role in neuronal disease. In this work, we show that miRNAs regulate the peripheral nerve system by modulating the migration and proliferation of SCs. Thus, miRNAs expressed in peripheral nerves may provide a potential therapeutic target for peripheral nerve injury or repair.

Outcomes of DES in Diabetic and Nondiabetic Patients with Complex Coronary Artery Disease after Risk Stratification by the SYNTAX Score

Diabetes mellitus (DM) increases the risk of adverse outcomes after coronary revascularization. Controversy persists regarding the optimal revascularization strategy for diabetic patients with multivessel coronary artery disease (MVD).

Cost-effectiveness modelling of percutaneous coronary interventions in stable coronary artery disease

The objective of this study is to develop a cost-effectiveness model comparing drug eluting stents (DES) vs bare metal stent (BMS) in patients suffering of stable coronary artery disease. Using a 2-years time horizon, two simulation models have been developed: BMS first line strategy and DES first line strategy. Direct medical costs were estimated considering ambulatory and hospital costs. The effectiveness endpoint was defined as treatment success, which is the absence of major adverse cardiac events. Probabilistic sensitivity analyses were carried out using 10000 Monte-Carlo simulations. DES appeared slightly more efficacious over 2 years (60% of success) when compared to BMS (58% of success). Total costs over 2 years were estimated at 9303 € for the DES and at 8926 € for bare metal stent. Hence, corresponding mean cost-effectiveness ratios showed slightly lower costs (P < 0.05) per success for the BMS strategy (15520 €/success), as compared to the DES strategy (15588 €/success). Incremental cost-effectiveness ratio is 18850 € for one additional percent of success. The sequential strategy including BMS as the first option appears to be slightly less efficacious but more cost-effective compared to the strategy including DES as first option. Future modelling approaches should confirm these results as further comparative data in stable coronary artery disease and long-term evidence become available.

A review with meta-analysis of observational studies for survival following off-pump coronary artery bypass versus drug-eluting stent implantation

To determine whether off-pump coronary artery bypass (OPCAB) improves survival over drug-eluting stent (DES) implantation, we performed a review with meta-analysis of exclusive OPCAB versus DES. Databases including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched through October 2013 using Web-based search engines (PubMed and OVID). Studies that met the following criteria were considered for inclusion: the design was a randomized controlled trial or observational comparative study; the study population was patients with any coronary artery disease; patients were assigned to OPCAB versus DES and outcomes included all-cause mortality at ≥1 years. Our exhaustive search identified no randomized trial and 10 observational studies of OPCAB versus DES. A pooled analysis demonstrated no statistically significant difference in all-cause mortality between OPCAB and DES (hazard ratio, 0.94; 95% confidence interval, 0.76-1.15; P = 0.55). In general, exclusion of any single study from the analysis did not substantially alter the overall result of our analysis. There was no evidence of significant publication bias. In conclusion, OPCAB may not improve survival over DES despite greater number of treated vessels in OPCAB than in DES or greater number of distal anastomosis in OPCAB than that of implanted stents in DES.

Percutaneous versus surgical interventions for coronary artery disease in those with diabetes mellitus

Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies that causes long-term damage of various organs including the cardiovascular system. A consistent observation shows that DM amplifies the risk of cardiovascular events by 4- to 6-fold. Since coronary artery disease (CAD) in diabetic patients exhibits diffuse and accelerated lesions, invasive revascularization continues to be a challenge and has worse outcomes than patients without DM. Owing to the pathogenesis of DM and the presence of severe endothelial dysfunction, investigators have been trying to find new treatment modalities that could target the treatment of the disease rather than the treatment of the lesion. Until new treatment modalities are proven and gain acceptance, invasive revascularization remains to be the choice of treatment in such patients. The focus of this review is to compare the results of percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of stable CAD in patients with DM.

Long-Term Mortality of 306,868 Patients with Multi-Vessel Coronary Artery Disease: CABG versus PCI

Background

Several randomized controlled trials (RCT) have reported no difference in long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The purpose of this pooled observational analysis was to compare recent retrospective studies examining long-term survival of patients with multi-vessel coronary artery disease undergoing CABG and PCI.

Methodology

We searched Medline for observational studies comparing long-term (>1 year) survival between CABG and PCI for the treatment of multi-vessel coronary artery disease over the past 10 years.

Results

Eight studies met inclusion criteria. A total of 306,868 patients (155,502 CABG; 151,366 PCI) were identified. Follow-up ranged from 1 to 8 years. Mantel-Haenszel combined hazard ratios (HR) for mortality demonstrated a protective benefit of CABG compared with PCI (HR=0.77, 95%CI=0.75–0.79).

Conclusion

These findings suggest a long-term survival advantage for CABG compared with PCI in patients with multi-vessel coronary artery disease.

Off-pump coronary artery bypass vs percutaneous coronary intervention. Therapeutic strategies for 3-vessel coronary artery disease: OPCAB vs PCI(PCI-Side)

Coronary artery bypass graft (CABG) surgery is still the best therapy for patients with multivessel and left main coronary artery disease. Recently, the introduction of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in these patients has improved the restenosis rate compared with bare metal stents. Furthermore, according to the results of the SYNTAX trial, no differences were found in the frequencies of mortality or myocardial infarction between CABG and PCI patients. PCI with DES is being increasingly performed for the treatment of patients with either left main trunk, diffuse, or multivessel lesions. In Japan, to avoid any side effects from cardiopulmonary bypass, off-pump coronary artery bypass (OPCAB) was performed in 66% of the total isolated CABG procedures in 2009, and is markedly different from the procedures performed in North America and Europe. However, the comparative effectiveness of PCI and OPCAB remains uncertain. In the present study, the current evidence from randomized trials, a meta-analysis and several observation studies are reviewed.

Is angioplasty able to become the gold standard of treatment beyond bypass surgery for patients with multivessel coronary artery disease? Therapeutic strategies for 3-vessel coronary artery disease: OPCAB vs PCI(PCI-Side)

This article reviews the treatment of patients with multivessel coronary artery disease (CAD). Percutaneous coronary intervention (PCI) has been challenging coronary artery bypass grafting (CABG) as the gold standard of care for patients with multivessel disease; however, the application of PCI to these patients has been mainly limited by restenosis. Up to the beginning of the 2000s, many large-scale, randomized trials addressed this issue by comparing CABG to PCI with balloon angioplasty or bare metal stents in not only Western countries but also in Asian countries. These studies demonstrated similar rates of all-cause death and myocardial infarction in both groups, although the need for revascularization remained significantly lower in the CABG group. PCI with drug-eluting stents (DES) is safe and may represent a viable alternative to CABG for selected patients with diabetes and multivessel CAD. Moreover, DES implantation under intravascular ultrasound guidance and with fractional flow reserve might have the potential to influence treatment strategy and reduce both DES thrombosis and repeat revascularization. The evolution of DES and advanced vascular imaging would mean that PCI continues to challenge CABG as treatment of choice for patients who need revascularization for a better prognosis.

Correlation of akinesia with graft patency and cardiac enzyme after off-pump coronary artery bypass graft surgery

BACKGROUND

The aim of the present study was to identify the clinical implications of newly developed akinesia in echocardiography after off-pump coronary artery bypass graft (CABG) surgery and its relationship with graft patency.

METHODS AND RESULTS

A total of 512 patients underwent off-pump CABG from January 2007 to November 2008. Two hundred and thirty-nine patients, whose echocardiography and multi-slice computed tomography data were available, were included in the study. Wall motion was subdivided into 16 segments and analyzed. Patients were separated into group A with newly developed akinesia (n=20), and group B without newly developed akinesia (n=219). Morbidity and early mortality, cardiac enzyme level, and graft patency were compared. The incidence of newly developed akinesia according to the anatomical territory was as follows: anterior, 5; lateral, 3; posterior, 7; and multiple territories, 5. Significant differences in preoperative ejection fraction were observed between the 2 groups (group A, 45.0+/-7%; group B, 58.0+/-12.2%, P<0.001). There was no statistical difference in the mean number of bypassed grafts and the complete revascularization rate. Complication and early mortality rates were insignificant between the 2 groups. There was little association between graft patency, cardiac enzyme level, and newly developed akinesia (P>0.05). Multivariate analysis showed that the preoperative ejection fraction was a risk factor for newly developed akinesia.

CONCLUSIONS

The mechanism of development of akinesia after off-pump CABG might be attributable to intraoperative coronary malperfusion, which is probably due to cardiac manipulation rather than graft occlusion.

Late progression after sirolimus-eluting stent implantation for de novo lesions--comparison with bare metal stent implantation

BACKGROUND

In previous studies, the minimal luminal diameter (MLD) of lesions treated with a bare metal stent (BMS) was shown to improve from 6 months to 3 years. However, the long-term response to a sirolimus-eluting stent (SES) implantation remains unclear.

METHODS AND RESULTS

To evaluate 6-month, 12-month and 3-year outcomes, clinical and angiographic follow-up data were analyzed for 367 consecutive patients (506 de novo lesions) who underwent successful SES implantation compared to follow-up data for 617 consecutive patients (802 de novo lesions) who underwent BMS implantation. Clinical follow-up information was obtained for 363 SES-treated patients (98.9%) and 581 BMS-treated patients (94.2%) at 1 year, and 334 SES-treated patients (91.0%) and 566 BMS-treated patients (91.7%) at 3 years. At 3 years, there were no significant differences in the cumulative cardiac death and myocardial infarction. Target lesion revascularization (TLR) rates were significantly higher in BMS-treated patients than in SES-treated patients. In BMS-treated patients, most TLR was performed within 450 days, however, after 450 days, the TLR rate was significantly lower than that for the SES-treated patients. In quantitative coronary angiographic data, among lesions that required no revascularization at the initial 12-month follow up, MLD increased significantly from the 12-month to the 3-year follow-up angiography in BMS-treated lesions. However, MLD decreased significantly in SES-treated lesions.

CONCLUSIONS

From a 12-month follow-up to a 3-year follow-up, stenosis in BMS-treated lesions regressed, but stenosis in SES-treated lesions progressed. And late TLR was more frequently required in the SES-treated patients.