Reply from authors: Left main disease and multivessel coronary artery disease should not be thought as two separate manifestations of ischemic heart disease

Abstract

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. We thank Dr Sakata and colleagues1Sakata T. Miyamoto Y. Kuno T. Combining left main and multivessel coronary artery disease as a revascularization target.J Thorac Cardiovasc Surg. 2023; ([Epub ahead of print])Google Scholar for their interest in our recently published meta-analysis.2Urso S. Sadaba R. González Martín J.M. Dayan V. Nogales E. Tena M.Á. et al.Coronary surgery provides better survival than drug eluting stent: a pooled meta-analysis of Kaplan–Meier-derived individual patient data.J Thorac Cardiovasc Surg. 2023; (XXX:XXX. https://doi.org/10.1016/j.jtcvs.2023.03.020)Google Scholar Their main concern lies with our choice to pool together patients with left main disease (LMD) and multivessel coronary artery disease (CAD) in the same analysis. Our main reason to do so was that, as shown in Table 2 of our publication,2Urso S. Sadaba R. González Martín J.M. Dayan V. Nogales E. Tena M.Á. et al.Coronary surgery provides better survival than drug eluting stent: a pooled meta-analysis of Kaplan–Meier-derived individual patient data.J Thorac Cardiovasc Surg. 2023; (XXX:XXX. https://doi.org/10.1016/j.jtcvs.2023.03.020)Google Scholar in different LMD trials, a significant proportion of patients with LMD suffers as well from multivessel CAD. In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease)3Park D.W. Ahn J.M. Park H. Yun S.C. Kang D.Y. Lee P.H. et al.PRECOMBAT InvestigatorsTen-year outcomes after drug-eluting stents versus coronary artery bypass grafting for left main coronary disease: extended follow-up of the PRECOMBAT trial.Circulation. 2020; 141: 1437-1446Google Scholar and EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization)4Stone G.W. Kappetein A.P. Sabik J.F. Pocock S.J. Morice M.C. Puskas J. et al.EXCEL Trial InvestigatorsFive-year outcomes after PCI or CABG for left main coronary disease.N Engl J Med. 2019; 381: 1820-1830Google Scholar trials, for example, isolated LMD accounts for approximately 10% and 17% of the respective populations. In the same trials, LMD plus multivessel CAD is present in more than 70% and 50% of the sample populations, respectively. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) trial,5Thuijs D.J.F.M. Kappetein A.P. Serruys P.W. Mohr F.W. Morice M.C. Mack M.J. et al.SYNTAX Extended Survival InvestigatorsPercutaneous coronary intervention versus coronary artery bypass grafting in patients with three- vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Google Scholar patients with isolated LMD were 5% and those with LMD plus multivessel CAD were 26% of the sample population. Considering, within the comparison of the surgical versus the percutaneous treatment, the lack of interaction or effect modification of LMD/multivessel CAD on survival, it is likely that both conditions share a common relative outcome after revascularization.6Freemantle N. Ruel M. Gaudino M.F.L. Pagano D. On the pooling and subgrouping of data from percutaneous coronary intervention versus coronary artery bypass grafting trials: a 411 call to circumspection.Eur J Cardiothorac Surg. 2018; 53: 915-918Google Scholar This aspect reinforces the need to consider LMD and multivessel CAD not as 2 separate manifestations of ischemic heart disease but as a common entity. Finally, we appreciate the suggestion by Sakata and colleagues to use time-to-benefit analysis, which we may include in further studies. Combining left main and multivessel coronary artery disease as a revascularization targetThe Journal of Thoracic and Cardiovascular SurgeryPreviewWe read with great interest the article by Urso and colleagues1 with regard to the meta-analysis comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel or left main coronary artery disease (CAD). They have underscored the better long-term survival in the surgical arm using the generic inverse variance method and individual patient data derived from the Kaplan–Meier method. However, we would like to raise a potential concern about its heterogeneous population and a suggestion of time-to-benefit analysis. Full-Text PDF