Advantages Of Coronary Artery Bypass Grafting Research Articles

What is better for a patient with stable coronary artery disease — bypass surgery or percutaneous coronary intervention?

Background: The main methods of treating patients with stable coronary artery disease (CAD) are myocardial revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI). These are two fundamentally different in technique and volume of surgical interventions; PCI is associated with rapid rehabilitation of the patient, and only CABG demonstrated effective in survival benefit.
 Aims: Comparison of the long-term results of myocardial revascularization with CABG and PCI in patients with stable CAD.
 Methods: The results of a prospective one-center cohort study of 369 patients with stable CAD are presented, the average age is 60.1 5.4 years. Patients were randomized into 2 groups by the Heart Team: CABG (n = 196) and PCI (n = 173). In each group, subgroups were identified depending on the severity of the coronary lesion, and the CABG group was also separately studied in according to CABG technique ― beating-heart (off-pump) and with cardiopulmonary bypass (on-pump). The average follow-up was 54.3 7 months. The main outcomes of the study were major adverse cardiac and cerebral events (MACCE): death from all causes, cardiac mortality, nonfatal myocardial infarction (MI), nonfatal stroke and repeated coronary revascularization.
 Results: Over the 5-year follow-up period, no differences were found between the CABG and PCI groups with a low complexity of coronary artery lesions (SYNTAX Score 14.2 4.8) in terms of survival, cardiac mortality, nonfatal MI and stroke, and the need for repeated myocardial revascularization. Patients with stenosis of the left main coronary artery (LMCA) and/or multivascular CA disease (SYNTAX Score 25.8 5.0) in the long-term follow-up after CABG and PCI did not differ in MACCE, but the CABG group demonstrated a significant advantage in repeated myocardial revascularization. No significant differences were found in any study endpoint in patients after CABG on-pump versus off-pump.
 Conclusions: Our study demonstrates the advantage of CABG in patients with stable CAD with stenosis of the LMCA and/or multivascular CA disease, and which CABG technique should depends on the comorbidity of the patient, the experience of the surgeon and the surgical center.

Outcomes of different revascularization strategies among patients presenting with acute coronary syndromes without ST elevation

ObjectiveTo compare short- and long-term outcomes of patients hospitalized with non–ST-segment myocardial infarction (NSTEMI) or unstable angina (UA) who were referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-world national cohort. MethodsThis observational study included 5112 patients, who underwent either CABG or PCI, admitted for NSTEMI or UA and were enrolled in the Acute Coronary Syndrome Israeli Survey between 2000 and 2016. Propensity score-matching analysis compared early outcomes and all-cause mortality in patients who underwent revascularization by PCI with revascularization by CABG. ResultsOf the 5112 patients, 4327 (85%) underwent PCI and 785 (15%) CABG. Following propensity score analysis, 447 pairs were chosen (1:1). Independent predictors for CABG referral included 3-vessel CAD (odds ratio [OR], 5.5; 95% confidence interval [CI], 4.5-6.7, P < .001), absence of on-site cardiac surgery (OR, 1.3; 95% CI, 1.1-1.6, P = .004), no previous PCI (OR, 1.5; 95% CI, 1.2-1.9, P = .002) and no previous myocardial infarction (OR, 1.3; 95% CI, 1-1.7, P = .022). The 10-year mortality risk was significantly lower among those who underwent CABG compared with PCI (20.4% vs 28.4%, P = .006). Consistent with these findings, multivariable analysis showed that referral to CABG was independently associated with a significant 65% reduction in the risk of 10-year mortality (P < .001). This long-term advantage was seen among male patients (P < .001) and not female patients (P = .910). ConclusionsIn a real-life setting, revascularization by CABG provides excellent long-term outcomes in patients with NSTEMI or UA. The advantage of CABG over PCI was seen only in male patients.

The DELTA 2 Registry: A Multicenter Registry Evaluating Percutaneous Coronary Intervention With New-Generation Drug-Eluting Stents in Patients With Obstructive Left Main Coronary Artery Disease

ObjectivesThe aim of this study was to evaluate clinical outcomes of unprotected left main coronary artery percutaneous coronary intervention (PCI) with new-generation drug-eluting stents in a “real world” population. BackgroundPCI of the unprotected left main coronary artery is currently recommended as an alternative to coronary artery bypass grafting (CABG) in selected patients. MethodsAll consecutive patients with unprotected left main coronary artery stenosis treated by PCI with second-generation drug-eluting stents were analyzed in this international, all-comers, multicenter registry. The results were compared with those from the historical DELTA 1 (Drug Eluting Stent for Left Main Coronary Artery) CABG cohort using propensity score stratification. The primary endpoint was the composite of death, myocardial infarction (MI), or stroke at the median time of follow-up. ResultsA total of 3,986 patients were included. The mean age was 69.6 ± 10.9 years, diabetes was present in 30.8%, and 21% of the patients presented with acute MI. The distal left main coronary artery was involved in 84.6% of the lesions. At a median of 501 days (≈17 months) of follow-up, the occurrence of the primary endpoint of death, MI, or cerebrovascular accident was lower in the PCI DELTA 2 group compared with the historical DELTA 1 CABG cohort (10.3% vs. 11.6%; adjusted hazard ratio: 0.73; 95% confidence interval: 0.55 to 0.98; p = 0.03). Of note, an advantage of PCI was observed with respect to cerebrovascular accident (0.8% vs. 2.0%; adjusted hazard ratio: 0.37; 95% confidence interval: 0.16 to 0.86; p = 0.02), while an advantage of CABG was observed with respect to target vessel revascularization (14.2% vs. 2.9%; adjusted hazard ratio: 3.32; 95% confidence interval: 2.12 to 5.18; p < 0.0001). ConclusionsAfter a median follow-up period of 17 months, PCI with new-generation drug-eluting stents was associated with an overall low rate of the composite endpoint of death, MI, or cerebrovascular accident.

Coronary Artery Bypass Surgery VersusDrug-Eluting Stent Implantation forLeftMain or Multivessel Coronary ArteryDisease: A Meta-Analysis of Individual Patient Data.

The authors undertook a patient-level meta-analysis to compare long-term outcomes after coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in 3,280patients with left main or multivessel coronary artery disease (CAD). The relative efficacy and safety of CABG versus PCI with DES for left main or multivessel CAD remain controversial. Data were pooled from the BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease), PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery vs. Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trials. The primary outcome was a composite of all-cause death, myocardial infarction, or stroke. The median follow-up was 60 months, and follow-up was completed for 96.2% of patients. The rate of primary outcome was significantly lower with CABG than with PCI (13.0% vs. 16.0%; hazard ratio [HR]: 0.83; 95% confidence interval [CI]: 0.69 to 1.00; p= 0.046). The difference was mainly driven by reduction in myocardial infarction (HR: 0.46; 95% CI: 0.33 to 0.64; p< 0.001). There was significant interaction between treatment effect and types of CAD, showing CABG to be superior compared with PCI with DES in patients with multivessel CAD (p= 0.001), but no between-group difference in those with left main CAD (p= 0.427). The rates for all-cause death and stroke were similar between the 2 groups. By contrast, the need for repeat revascularization was significantly lower in the CABG group compared with the PCI group. CABG, as compared with PCI with DES, reduced long-term rates of the composite of all-cause death,myocardial infarction, or stroke in patients with left main or multivessel CAD. The advantage of CABG over PCIwith DESwas particularly pronounced in those with multivessel CAD.

Impact of Multivessel Coronary Artery Disease With Versus Without Left Main Coronary Artery Disease on Long-Term Mortality After Coronary Bypass Grafting Versus Drug-Eluting Stent Implantation

Limited data are available on the impact of concomitant left main coronary artery disease (CAD) on mortality after revascularization of multivessel coronary artery disease (MVD) alone or multivessel plus left main coronary artery disease (MVLMD). This study compared long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents in 2,887 patients with MVD or MVLMD. Data were pooled from the BEST, PRECOMBAT, and SYNTAX trials. The primary outcome was death due to any cause. Of the 2,887 patients, 1,975 (68.4%) were classified as having MVD and 912 (31.6%) as having MVLMD. The median follow-up duration was 60.2months. In the patients with MVD, primary outcome rate after CABG was significantly lower than after PCI (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.49 to 0.89; p= 0.007). In the patients with MVLMD, however, CABG and PCI showed similar primary outcome rates (HR 0.98; 95% CI 0.67 to 1.43; p= 0.896). Among those who underwent CABG, primary outcome rate was lower in the patients with MVD than in those with MVLMD (HR 0.66; 95% CI 0.46 to 0.95; p= 0.024). Kaplan-Meier analysis showed a clear separation between the patients with MVD and those with MVLMD 2.5years after the index surgery. The risk of death due to any cause was significantly lower after CABG than after PCI with drug-eluting stents in patients with MVD but not in those with MVLMD. The advantage of CABG over PCI for multivessel CAD was significantly attenuated if concomitant left main CAD was present.

Comparison of Percutaneous Coronary Intervention (With Drug-Eluting Stents) Versus Coronary Artery Bypass Grafting in Women With Severe Narrowing of the Left Main Coronary Artery (from the Women–Drug-Eluting stent for LefT main coronary Artery disease Registry)

Women typically present with coronary artery disease later than men with more unfavorable clinical and anatomic characteristics. It is unknown whether differences exist in women undergoing treatment for unprotected left main coronary artery (ULMCA) disease. Our aim was to evaluate long-term clinical outcomes in women treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). All consecutive women from the Drug-Eluting stent for LefT main coronary Artery disease registry with ULMCA disease were analyzed. A propensity matching was performed to adjust for baseline differences. In total, 817 women were included: 489 (59.8%) underwent treatment with PCI with drug-eluting stents versus 328 (40.2%) with CABG. Propensity score matching identified 175 matched pairs, and at long-term follow-up there were no differences in all-cause (odds ratio [OR] 0.722, 95% confidence interval [CI] 0.357 to 1.461, p=0.365) or cardiovascular (OR 1.100, 95% CI 0.455 to 2.660, p=0.832) mortality, myocardial infarction (MI; OR 0.362, 95% CI 0.094 to 1.388, p=0.138), or cerebrovascular accident (CVA; OR 1.200, 95% CI 0.359 to 4.007, p=0.767) resulting in no difference in the primary study objective of death, MI, or CVA (OR 0.711, 95% CI 0.387 to 1.308, p=0.273). However, there was an advantage of CABG in major adverse cardiovascular and cerebrovascular events (OR 0.429, 95% CI 0.254 to 0.723, p=0.001), driven exclusively by target vessel revascularization (OR 0.185, 95% CI 0.079 to 0.432, p<0.001). In women with significant ULMCA disease, no difference was observed after PCI or CABG in death, MI, and CVA at long-term follow-up.

058 THE ROLE OF FEMALE SEX IN THE CONTEMPORARY TREATMENT OF THE LEFT MAIN CORONARY ARTERY INSIGHTS FROM THE W-DELTA (WOMEN-DRUG ELUTING STENT FOR LEFT MAIN CORONARY ARTERY DISEASE) REGISTRY

Background The optimal revascularization strategy of women with unprotected left main coronary artery (ULMCA) disease is unknown. Therefore, the aim of this study was to evaluate long-term clinical outcomes in this cohort treated with percutaneous coronary intervention (PCI) utilising drug-eluting stents (DES) versus coronary artery bypass grafting (CABG). Methods All consecutive women from the Drug Eluting stent for LefT main coronary Artery disease (DELTA) Registry with ULMCA disease treated by PCI with DES or CABG were analysed. A propensity matching was performed to adjust for baseline differences between the 2 treatment groups. Results In total, 818 women were included: 489 (59.8%) underwent treatment with PCI with DES versus 329 (40.2%) with CABG. Propensity score matching identified 176 matched pairs of patients, with no differences in the primary study objective of death, myocardial infarction (MI) or cerebrovascular accident (CVA) HR 0.711; 95% CI 0.387 to 1.308; p=0.273), all-cause (HR 0.722; 95% CI 0.357 to 1.461; p=0.365) or cardiovascular mortality (HR 1.100; 95% CI 0.455 to 2.660; p=0.832), MI (HR 0.362; 95% CI 0.094 to 1.388) or CVA (HR 1.200; 95% CI 0.359 to 4.007; p=0.767). However, there was an advantage of CABG over PCI in major adverse cardiovascular and cerebrovascular events (MACCE) (HR 0.429; 95% CI 0.254 to 0.723; p=0.001), driven exclusively by target vessel revascularization (TVR) (HR 0.185; 95% CI 0.079 to 0.432; p Conclusions In women with significant ULMCA disease, no difference was observed in death, MI and stroke at long term follow-up. However, repeat revascularization remained higher in the PCI cohort.

Drug-Eluting Stent for Left Main Coronary Artery Disease: The DELTA Registry: A Multicenter Registry Evaluating Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Treatment

The aim of this study was to compare, in a large all-comers registry, major adverse cardiac and cerebrovascular events (MACCE) after percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) in unprotected left main coronary artery (ULMCA) stenosis. Percutaneous coronary intervention with DES implantation in ULMCA has been shown to be a feasible and safe approach at midterm clinical follow-up. All consecutive patients with ULMCA stenosis treated by PCI with DES versus CABG were analyzed in this multinational registry. A propensity score analysis was performed to adjust for baseline differences in the overall cohort. In total 2,775 patients were included: 1,874 were treated with PCI versus 901 with CABG. At 1,295 (interquartile range: 928 to 1,713) days, there were no differences, at the adjusted analysis, in the primary composite endpoint of death, cerebrovascular accidents, and myocardial infarction (MI) (adjusted hazard ratio [HR]: 1.11; 95% confidence interval [CI]: 0.85 to 1.42; p = 0.47), mortality (adjusted HR: 1.16; 95% CI: 0.87 to 1.55; p = 0.32), or composite endpoint of death and MI (adjusted HR: 1.25; 95% CI: 0.95 to 1.64; p = 0.11). An advantage of CABG over PCI was observed in the composite secondary endpoint of MACCE (adjusted HR: 1.64; 95% CI: 1.33 to 2.03; p < 0.0001), driven exclusively by the higher incidence of target vessel revascularization with PCI. In our multinational all-comers registry, no difference was observed in the occurrence of death, cerebrovascular accidents, and MI between PCI and CABG. An advantage of CABG over PCI was observed in the incidence of MACCE, driven by the higher incidence of target vessel revascularization with PCI.

Ischemic heart disease in the elderly: the role of coronary angioplasty and coronary artery bypass grafting.

Management of ischemic heart disease in the elderly is complex. Invasive therapies such as percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) are associated with significant morbidity and mortality. The short-term advantage of PTCA is that its associated noncardiac morbidity and mortality are less than that of CABG, particularly in the incidence of stroke. Unfortunately, PTCA revascularization is less complete and less durable than CABG revascularization. The advantages of CABG are that cardiac revascularization is more complete, the result is more durable, and long-term results are improved over those of PTCA. Conversely, the initial morbidity and mortality are higher for CABG and are adversely affected by factors such as recent myocardial infarction, lung disease, and renal failure. We provide an overview of the results and outcomes of PTCA and CABG in the elderly, as well as suggestions for management.