Benefits Of Coronary Artery Bypass Grafting Research Articles

Phenomapping the Response of Patients With Ischemic Cardiomyopathy With Reduced Ejection Fraction to Surgical Revascularization.

Coronary artery bypass grafting (CABG) has demonstrated long-term mortality benefits in patients with HFREF and obstructive coronary artery disease (CAD), but whether phenotypic heterogeneity influences the benefits of CABG is unknown. We applied clustering analysis to STICHES (Surgical Treatment for Ischemic Heart Failure Extension Study) to identify phenogroups with different long-term risk profiles and investigate differences in CABG benefits between phenogroups. STICHES was a randomized controlled trial evaluating the effect of CABG in addition to medical therapy versus medical therapy alone. We split the STICHES participants into derivation (n = 753) and validation (n = 459) cohorts. We phenomapped the derivation cohort using penalized model-based clustering. We fit multivariable Cox models to investigate long-term differences in all-cause mortality, cardiovascular (CV) mortality, and a composite of all-cause mortality/CV hospitalization between phenogroups and whether phenogroup assignment modified the effects of CABG on these outcomes. Findings were internally validated on the validation cohort. Four phenogroups were identified in the derivation cohort. The highest-risk group was at a twofold greater risk of death (HR: 2.0, 95% CI: 1.4-2.9, p < 0.001) and CV death (HR: 2.0, 95% CI: 1.3-3.1, p = 0.002), and a 1.5-fold greater risk for death/CV hospitalization (HR: 1.5, 95% CI: 1.1-2.1, p = 0.016). Phenogroup assignment did not modify the effects of CABG on the outcomes (p > 0.05 for all). Similar results were obtained in the validation cohort. The beneficial effects of CABG on all-cause mortality, CV mortality, and a composite of all-cause mortality and CV hospitalization persist despite phenotypic heterogeneity in HFREF and CAD.

Safety and therapeutic potential of allogeneic adipose-derived stem cell spray transplantation in ischemic cardiomyopathy: a phase I clinical trial

BackgroundIschemic cardiomyopathy, characterized by coronary artery atherosclerosis, impairs the myocardial tissue. Coronary artery bypass grafting (CABG) is commonly used to revascularize affected areas and improve patient survival rates; however, it can fail to enhance cardiac function. Impaired capillary blood flow may obstruct functional recovery, prompting interest in treatments, such as angiogenic factor administration. Adipose-derived stem cells (ADSCs), which are known for immune evasion, have shown the potential to construct capillary networks and improve myocardial function. This clinical trial aimed to evaluate the safety and efficacy of ADSC spray therapy combined with CABG.MethodsThis single-center, randomized, double-blind study involved patients with ischemic cardiomyopathy who were scheduled for CABG and who had a left ventricular ejection fraction ≤ 40%. The participants were randomized to receive CABG as well as ADSC spray therapy or placebo. The primary endpoints were safety, changes in late gadolinium-enhanced (LGE) magnetic resonance imaging (MRI) volumes, and feasibility. The secondary endpoints included left ventricular function, exercise tolerance, and heart failure symptoms.ResultsSeven patients were enrolled; of them, six were randomized to receive ADSC therapy (n = 3) or placebo (n = 3). The procedure was successfully completed with minimal adverse events. One patient in the ADSC group developed pleural effusion that was resolved with drainage. The LGE-MRI volumes decreased in the ADSC group but remained unchanged in the placebo group. Improvements in left ventricular function and exercise tolerance were noted in the ADSC group, with heart failure symptoms improving to New York Heart Association class I. In contrast, the placebo group showed no significant changes, with one patient experiencing worsening symptoms.ConclusionsADSC spray therapy combined with CABG demonstrated safety and efficacy at enhancing cardiac function. ADSC likely contributes to capillary network reconstruction, thereby augmenting the benefits of CABG. Future phase II and III trials are warranted to confirm its therapeutic efficacy and long-term outcomes. This novel approach represents a significant advancement in the treatment of ischemic cardiomyopathy and offers a viable strategy for improving myocardial function and patient prognosis.Trial registration This study was registered with the Japan Registry of Clinical Trials (jRCT2053190103) and ClinicalTrials.gov (NCT04695522)Graphical

Frailty, age, and treatment effect of surgical coronary revascularization in ischemic cardiomyopathy: a post hoc analysis of the STICHES trial.

Frailty is common among older patients with heart failure (HF). The efficacy of coronary artery bypass grafting (CABG) on the risk of mortality amongfrailpatients with ischemic cardiomyopathy and HF is uncertain, and whether frailty burden modifies the treatment benefits of CABG among these patients is unknown. We performed a post hoc analysis of the STICHES trial, a randomized trial of CABG with medical therapy vs medical therapy alone among participants with ischemic cardiomyopathy with ejection fraction ≤ 35%. Baseline frailty was assessed through a Rockwood Frailty Index (FI), and based on FI cut-offs from prior HF studies, participants with FI ≥ 0.311 were classified as more frail, and those with FI < 0.311 were classified as less frail. A multivariable Cox proportional hazard model with multiplicative interaction terms was constructed to evaluate whether frailty status modified the treatment effect of CABG on mortalityin the overall trial cohort and among those < 60 vs ≥ 60 years of age. Of 1187 participants (12.4% female, 2.6% Black, median FI = 0.33 [IQR 0.27-0.39]), 678 were characterized as more frail. Frailty burden did not modify the efficacy of CABG on the risk of all-cause death in the overall cohort (Pint CABG × frailty = 0.2). In age stratified analysis,Baseline frailty status did not modify the treatment effect of CABG on the risk of all-cause mortality among younger (< 60years, Pint CABG × frailty = 0.2) as well as older participants (≥60years, Pint CABG × frailty = 0.6). In this post hoc analysis of the STICHES trial, baseline frailty status did not modify the efficacy of CABG in the overall cohort as well asamong younger or older participants. Frailty alone should not be used as a criterion to determine the utilization of CABG among patients with ischemic cardiomyopathy.

Percutaneous coronary intervention with drug-eluting stents versus coronary bypass surgery for coronary artery disease: A Bayesian perspective

ObjectivesCoronary revascularization is frequently performed for coronary artery disease (CAD). This study aims to assess the totality of randomized evidence comparing percutaneous coronary intervention with drug-eluting stents (DES-PCI) with coronary artery bypass grafting (CABG) for CAD. MethodsA systematic search was applied to 3 electronic databases, including randomized trials comparing DES-PCI with CABG for CAD with 5-year follow-up. A Bayesian hierarchical meta-analytic model was applied. The primary outcome was all-cause mortality at 5 years; secondary outcomes were stroke, myocardial infarction, and repeat revascularization. End points were reported in median relative risks (RRs) and absolute risk differences, with 95% credible intervals (CrIs). Kaplan-Meier curves were used to reconstruct individual patient data. ResultsSix studies comprising 8269 patients (DES-PCI, n = 4134; CABG, n = 4135) were included. All-cause mortality at 5 years was increased with DES-PCI (median RR, 1.23; 95% CrI, 1.01-1.45), with a median absolute risk difference of +2.3% (95% CrI, 0.1%-4.5%). For stroke, myocardial infarction, and repeat revascularization, the median RRs were 0.79 (95% CrI, 0.54-1.25), 1.84 (95% CrI, 1.23-2.75), and 1.80 (95% CrI, 1.51-2.16) for DES-PCI, respectively. In a sample of 1000 patients undergoing DES-PCI instead of CABG for CAD, a median of 23 additional deaths, 46 myocardial infarctions, and 85 repeat revascularizations occurred at 5 years, whereas 10 strokes were prevented. ConclusionsThe current data suggest a clinically relevant benefit of CABG over DES-PCI at 5 years in terms of mortality, myocardial infarction, and repeat revascularization, despite an increased risk of stroke. These findings may guide the heart-team and the shared decision-making process.

Impact of Diabetes in Patients With Acute Myocardial Infarction Undergoing Coronary Artery Bypass Surgery Within 48 Hours

Diabetic patients with coronary artery disease may benefit from elective coronary artery bypass graft (CABG) surgery. It is unknown whether this merit is transferable to patients with acute myocardial infarction (AMI) undergoing surgery. A total of 1,427 patients underwent CABG within 48 hours of being diagnosed with AMI at the current institution between 2001 and 2019. Of these patients, 206 (14.4%) had insulin-dependent diabetes mellitus (IDDM) and 148 (10.4%) had non-insulin dependent diabetes mellitus (NIDDM). Retrospective data analysis was performed. Patients with NIDDM showed the highest perioperative risk profile, with a EuroScore II of 11.6 (±10.3) compared with 7.8 (±8.0) in non-diabetic patients and 8.4 (±7.8) in patients with IDDM (p<0.001). Sub-analysis demonstrated a higher proportion of non-ST-elevation myocardial infarction patients in the NIDDM cohort compared with the IDDM cohort (70.9% vs 56.8%; p=0.005). Postoperatively, NIDDM patients had more sepsis (p<0.01) and longer ventilation times (p<0.001) compared with non-DM and IDDM patients (p<0.01). Wound healing complications were rare, but almost twice as high in NIDDM patients compared with non-DM and IDDM patients (4.7% vs 0.9% vs 2.4%, respectively). The 30-day mortality was highest in the NIDDM cohort (18.3% vs 11.3% vs 7.8%; p=0.012). Analysis of survival for up to 15 years revealed a significantly reduced survival of diabetic patients compared with non-diabetic patients, with lowest survival rates in NIDDM patients (p<0.001). Non-insulin dependent diabetes mellitus patients undergoing CABG within 48 hours of being diagnosed with AMI are at increased risk of short-term and long-term complications. Therefore, this particular group should undergo a careful evaluation concerning the expected risks and benefits of CABG in this setting.

Coronary Revascularisation in Heart Failure with Reduced Ejection Fraction

The role of myocardial revascularisation in patients suffering from ischaemic cardiomyopathy with extensive coronary artery disease and heart failure with reduced ejection fraction (HFrEF) remains controversial. Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are considered revascularisation procedures. Evidence prior to the latest medical treatment advances only suggests a long-term benefit of CABG over pharmacological therapy in this population. When angina-related symptoms dominate patients’ lives despite optimal medical treatment, PCI can be considered if the patient is ineligible for CABG after carefully weighing up the perioperative risk. Viability and/or ischaemia detection to guide revascularisation have been unable to accurately predict treatment effects of CABG or PCI. Optimal heart failure treatment should be initiated in all patients presenting with ischaemic cardiomyopathy and HFrEF as the first and most important measure to improve long-term prognosis.

ASSESSMENT OF LEFT VENTRICULAR FUNCTION AFTER CORONARY ARTERY BYPASS GRAFTING

Coronary artery bypass grafting (CABG) is a commonly performed surgical intervention for coronary artery disease (CAD), aiming to restore blood flow to the myocardium and improve cardiac function. Left ventricular (LV) systolic function is a crucial determinant of postoperative outcomes in CABG patients, yet the predictors of adverse outcomes remain incompletely understood. Objective: This study aimed to evaluate left ventricular function outcomes following CABG and identify predictors of mortality among CABG patients. Methods: A prospective cohort study was conducted at, Ch. Pervaiz Elahi Institute Of Cardiology (CPEIC), Multan, Pakistan, from December 2022 to December 2023. The study included 96 patients undergoing CABG surgery. Preoperative data collection encompassed demographic information, medical history, and baseline clinical characteristics. Left ventricular function was assessed using echocardiography preoperatively and postoperatively. Statistical analysis involved descriptive statistics, univariate analysis, and univariate regression. Results: The study cohort comprised 96 participants, with a mean age of 56.1 years (±12.2) and a male predominance (67.7%). Prevalent comorbidities included diabetes mellitus (78.1%) and hypertension (79.2%). LV systolic dysfunction (30.2%) and old ischemic heart disease (72.9%) were common preexisting conditions. Intraoperative variables included perioperative inotropes (5.2%) and emergent surgeries (3.1%). Postoperative complications included reoperation for bleeding (5.2%) and deterioration of LV ejection fraction (34.4%). The mortality rate was 5.2%. Postoperatively, the mean LVEF increased significantly from 32.00% (±5.219) to 37.00% (±9.801) in isolated CABG patients. Conclusion: This study confirms the significant improvement in LV systolic function following CABG and underscores the high benefit of CABG in patients with reduced EF. However, diabetes mellitus, advanced diastolic dysfunction, and the insertion of IABP were identified as significant predictors of adverse outcomes. Identifying patients with these risk predictors could provide complementary prognostic information and help optimise care, monitoring, and follow-up to improve their expected poor outcomes.

Left main coronary artery disease: percutaneous coronary intervention or coronary artery bypass grafting? A critical review of current knowledge and contemporary debates.

Significant unprotected left main (ULM) disease is the highest-risk coronary artery lesion, carries high morbidity and mortality related to a large amount of myocardium supplied, and should undergo prompt revascularization. Among recent randomized controlled trials (RCTs), NOBLE failed to demonstrate non-inferiority of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). However, all the other RCTs have shown comparable outcomes. While CABG is associated with higher stroke rates at 30 days and 1 year, PCI is associated with increased spontaneous myocardial infarction (MI) events and the need for repeat revascularization. Furthermore, the benefit of CABG is more evident with the increased complexity of coronary artery disease. In current European and American guidelines, CABG is the standard of care for ULM disease. PCI is considered a reasonable alternative in selected patients (2a B-NR). There is still a great need for carefully designed RCTs with longer follow-up times to validate the role of recent technological and pharmacological regimens.

Can machine learning improve risk prediction and individualise decision making between percutaneous and surgical revascularisation?

Abstract Background/Introduction In patients with three-vessel coronary artery disease (CAD) and/or left main (LM) CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Purpose The aim of this study was to assess whether these individualised revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors. Methods The present study consisted of patients enrolled in the SYNTAX study, which is a randomized trial comparing PCI and CABG in patients with complex coronary artery disease. ML algorithms were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG), and pre-specified effect-modifiers: disease type (3-vessel or LMCAD) and anatomical SYNTAX score. The model’s discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n=1800 patients) and externally validated in the CREDO-KYOTO registry (n=7362), and then compared to the original SYNTAX score II 2020 (SS2020). Results The gradient boosting ML model identified the top 10 prognostic factors at the time of decision making as: age, creatinine clearance, left ventricular ejection fraction, peripheral vascular disease, C-reactive protein, hemoglobin, HbA1c, glucose, systolic and diastolic pressure. The ML model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95% CI 0.75-0.81) in cross-validation and 0.77 (95% CI 0.76-0.79) in external validation. The ML model discriminated 5-year mortality better than the SS2020 in the external validation cohort (vs C-index 0.72 for SS2020, p &amp;lt;0.001) and identified heterogeneity in the treatment benefit of CABG versus PCI (Figure). Conclusions An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems—trained to collect large numbers of parameters—may harmonize decision making.Figure

Can Machine Learning Aid the Selectionof Percutaneous vs SurgicalRevascularization?

In patients with 3-vessel coronary artery disease (CAD) and/or left main CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The aim of this study was to assess whether these individualized revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study, ML algorithms (Lasso regression, gradient boosting) were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG) and prespecified effect-modifiers: disease type (3-vessel or left main CAD) and anatomical SYNTAX score. The model's discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n=1,800) and externally validated in the CREDO-Kyoto (Coronary REvascularization Demonstrating Outcome Study in Kyoto) registry (n=7,362), and then compared with the original SYNTAX score II 2020 (SSII-2020). The hybrid gradient boosting model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95%CI: 0.75-0.81) in cross-validation and 0.77 (95%CI: 0.76-0.79) in external validation. The ML models discriminated 5-year mortality better than the SSII-2020 in the external validation cohort and identified heterogeneity in the treatment benefit of CABG vs PCI. An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems-trained to collect large numbers of parameters-may harmonize decision making globally. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries; NCT00114972).

The ISCHEMIA trial revisited: setting the record straight on the benefits of coronary bypass surgery and the misinterpretation of a landmark trial.

The ISCHEMIA trial is a landmark study that has been the subject of heated debate within the cardiovascular community. In this analysis of the ISCHEMIA trial, we aim to set the record straight on the benefits of coronary artery bypass grafting (CABG) and the misinterpretation of this landmark trial. We sought to clarify and reorient this misinterpretation. We herein analyse the ISCHEMIA trial in detail and describe how its misinterpretation has led to an erroneous guideline recommendation downgrading for prognosis-altering surgical therapy in these at-risk patients. The interim ISCHEMIA trial findings align with previous evidence where CABG reduces the long-term risks of myocardial infarction and mortality in advanced coronary artery disease. The trial outcomes of a significantly lower rate of cardiovascular mortality and a higher rate of non-cardiovascular mortality with the invasive strategy are explained according to landmark evidence. The ISCHEMIA trial findings are aligned with previous evidence and should not be used to downgrade recommendations in recent guidelines for the indisputable benefits of CABG.

Triple Vessel Coronary Artery Disease Needs a Consistent Definition for Management Guidelines

For over forty years, coronary artery bypass grafting (CABG) has been recommended to patients with triple vessel disease (TVD) with the aim of providing a survival benefit compared to medical therapy. Generally, the survival benefit of CABG is determined by (a) the volume of myocardium at risk of infarction according to the extent of coronary artery disease (CAD), (b) the impairment of coronary flow reserve according to severity of coronary stenoses, severity of symptoms, or objective evidence of regional ischemia, and (c) the impairment of myocardial reserve according to left ventricular function and viability. The most frequently used index of survival benefit is the extent of CAD as described by the terms of the left main coronary stenosis and TVD. However, TVD has been inconsistently defined in randomised controlled trials. Furthermore, international guidelines do not provide a specific definition of TVD. This impacts a substantially sized and high-risk population. Here, we argue that the definition of TVD should include diseases in the major artery in each of the three coronary territories in order to estimate the survival benefit provided by CABG.

What is the role of coronary revascularization to recover the contractility of the dysfunctional heart?

Coronary artery disease is the predominant aetiology of heart failure and left ventricular dysfunction in industrialized countries. The pathophysiological substrate of hibernating myocardium constitutes the conceptual target of coronary revascularization by coronary artery bypass graft (CABG) or coronary angioplasty or percutaneous coronary intervention (PCI). Studies, mainly observational, conducted in the past have demonstrated a prognostic benefit of CABG on survival. These findings were confirmed by the long-term follow-up of the STICH study in which, however, documentation of inducible ischaemia or myocardial viability was not predictive of a prognostic benefit of CABG. Revascularization via PCI in the recent REVIVED-BCIS2 study did not demonstrate a significant benefit in terms of death or heart failure hospitalization compared with optimal medical therapy. Pending the long-term follow-up of the REVIVED-BCIS2 study, optimized medical therapy, cardiac resynchronization therapy, and the implantable cardioverter defibrillator, where indicated, are the mainstay of treatment in patients with dilated ischaemic cardiomyopathy. The decision for coronary revascularization is made in the individual patient, possibly with a higher bias in patients with angina, three-vessel coronary artery disease, severe left ventricular dysfunction, and cardiac remodelling.

Ten years survival benefit of CABG or PCI based on individual prediction

Abstract Background To compare the observed and individual predicted mortalities according to the SYNTAX score II 2020 (SSII-2020) in the all-comers SYNTAX population, and retrospectively assess the appropriateness of revascularization with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three vessel disease (3VD) and/or left main disease (LMCAD). Methods Internal and external validation of the SSII-2020 to predict 10-year all-cause death was performed in the respective randomized and registry SYNTAX populations. Differences in individual predicted mortalities following CABG or PCI were ranked and displayed with the observed mortalities. The proportions of screened patients deriving a survival benefit from CABG or PCI were determined retrospectively. Results A total of 2602 participants (as-treated population) were included in the randomized and registry cohorts. In the randomized cohort, all-cause mortality at 10 years, as an average treatment effect, was 23.8% (199/865) with CABG and 28.6% (249/901) with PCI, with a differential survival benefit of 4.6% (95% CI: 0.58% to 8.7%, log-rank p value=0.023). In the CABG and PCI registries, mortalities were 27.8% (167/644) and 55.4% (99/192), respectively. Calibration and discrimination of the SSII-2020 was helpful in CABG and PCI patients in the randomized and registry cohorts. In the PCI registry, the SSII-2020 underestimated mortality since specific comorbidities that entail high mortality are not included in the formula (C-index: 0.72, intercept: 0.38, slope: 0.66), whilst in the CABG registry, it predicted mortality with a helpful calibration and discrimination (C-index: 0.70, intercept: 0.00, slope: 0.76). The proportions of patients with a predicted survival benefit following CABG and PCI were respectively 78.3% (1383/1766) and 21.7% (383/1766) in the randomized cohort, and 82.4% (2143/2602) and 17.7% (459/2602) in the whole SYNTAX trial population. Conclusion In the randomized and registry cohort of this all-comers population with 3VD and/or LMCAD, there was reasonable agreement between the individual predicted and observed mortalities after CABG or PCI, such that the predicted 10-year survival benefit might be helpful in determining the appropriateness of each modality of revascularization. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The SYNTAX Extended Survival study was supported by the German Foundation of Heart Research (Frankfurt am Main, Germany). The SYNTAX trial, during 0-5 years follow-up, was funded by Boston Scientific Corporation (Marlborough, MA, USA). Both sponsors had no role in the study design, data collection, data analyses, and interpretation of the study data, nor were involved in the decision to publish the final manuscript. The principal investigators and authors had complete scientific freedom.

External Validation of the FREEDOM Score for Individualized Decision Making Between CABG and PCI

BackgroundAlthough randomized trials have established that coronary artery bypass grafting (CABG) is, on average, the most effective revascularization strategy compared with percutaneous coronary intervention (PCI) in patients with diabetes and multivessel disease (MVD), individual patients differ in many characteristics that can affect the benefits and harms of treatment. The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus) score was developed to predict different outcomes with CABG vs PCI on the basis of 8 patient characteristics and the smoking-treatment interaction. ObjectivesThis study aimed to assess the ability of the 5-year major adverse cardiovascular event (MACE) model to predict treatment benefit of CABG vs PCI in the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) and BEST (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) trials. MethodsThis study identified 702 patients with diabetes and MVD to mirror the FREEDOM participants. Discrimination was assessed by C-index, and calibration was assessed by calibration plots in the PCI and CABG arms, respectively. The ability of the FREEDOM score to predict treatment benefit of CABG vs PCI was assessed. ResultsOverall, CABG was associated with a lower rate of 5-year MACE compared with PCI (12.4% vs 20.3%; log-rank P = 0.021) irrespective of a history of smoking (Pinteraction = 0.975). Both discrimination and calibration were helpful in the PCI arm (C-index: 0.69; slope: 0.96, intercept: −0.24), but moderate in the CABG arm (C-index: 0.61; slope: 0.61; intercept: −0.53). The FREEDOM score showed some heterogeneity of treatment benefit. ConclusionsThe FREEDOM score could identify some heterogeneity of treatment benefit of CABG vs PCI for 5-year MACE. Until further prospective validations are performed, these results should be taken into consideration when using the FREEDOM score in patients with diabetes and MVD. (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery [SYNTAX]; NCT00114972) (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease [BEST]; NCT00997828) (Future Revascularization Evaluation in Patients with Diabetes Mellitus [FREEDOM]; NCT00086450)

Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Medicine in Ischemic Cardiomyopathy: The STICH Randomized Clinical Trial.

The STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure) demonstrated that coronary artery bypass grafting (CABG) reduced all-cause mortality rates out to 10 years compared with medical therapy alone (MED) in patients with ischemic cardiomyopathy and reduced left ventricular function (ejection fraction ≤35%). We examined the economic implications of these results. We used a decision-analytic patient-level simulation model to estimate the lifetime costs and benefits of CABG and MED using patient-level resource use and clinical data collected in the STICH trial. Patient-level costs were calculated by applying externally derived US cost weights to resource use counts during trial follow-up. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. For the CABG arm, we estimated 6.53 quality-adjusted life-years (95% CI, 5.70-7.53) and a lifetime cost of $140 059 (95% CI, $106 401 to $180 992). For the MED arm, the corresponding estimates were 5.52 (95% CI, 5.06-6.09) quality-adjusted life-years and $74 894 lifetime cost (95% CI, $58 372 to $93 541). The incremental cost-effectiveness ratio for CABG compared with MED was $63 989 per quality-adjusted life-year gained. At a societal willingness-to-pay threshold of $100 000 per quality-adjusted life-year gained, CABG was found to be economically favorable compared with MED in 87% of microsimulations. In the STICH trial, in patients with ischemic cardiomyopathy and reduced left ventricular function, CABG was economically attractive relative to MED at current benchmarks for value in the United States. URL: https://www. gov; Unique identifier: NCT00023595.

CABG outcomes in patients with postinfarctional ventricular septal rupture

Aim: Postinfarctional ventricular septal rupture (Post MI VSR) is the most fatal complication of the myocardial infarction. The mortality rate in modern and in-time surgical management is varying between 10 and 40%; the survival rate is 88% in the first year. The issue of CABG (coronary artery by-pass grafting) is still the subject of great discussion. In order to clarify this issue, we decided to analyze the short- and long-term outcomes of CABG in our patients with Post MI VSR. Material and Methods: In our research we analyzed 90 patients with IHD (ischemic heart disease), complicated with Post-MI IVS rupture (Post -MI IVSR). Most of the patients with Post MI VSR were over 60 years old. The Post MI VSR within first days after acute myocardial infarction (AMI) was detected in 10 patients; up to 3 days – in 6 patients; up to 7 days – in 3 patients; from 7 to 29 days – in 4 patients. The time of IVS rupture after AMI was varying from 1 to 29 days (5.5±7.6 дней). All patients were distributed into groups depending on the hospitalization time after AMI. Out of 83 patients underwent reconstruction after Post MI VSR, 79 (95.2%) required CABG. Two- or three-vessel lesions were detected in 67 (80.7%) patients. Cumulative mortality in CABG group was 19.7%, whereas in the group without accompanied CABG – 20%. The long-term outcomes were followed from 1- to 8 years, averagely in 18 patients (28.6%). Results: The decompensation of heart failure and relapse of coronary symptoms during follow-up up to 3 years was observed in 6 (33.3%) patients, during follow-up from 3 to 8 years – in 3 (25%) out of 12 patients. The repeated revascularization was conducted in 5 patients. Conclusion: Our results are showing the benefits of CABG in patients with Post MI VSR, which requires mandatory coronary angiography in pre-op period.

Comparison of invasive treatment strategies in patients with non–ST elevation acute coronary syndrome: A systematic review and meta-analysis

ObjectiveTo compare the mortality associated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with non–ST elevation acute coronary syndrome (NSTE-ACS). MethodsWe searched publications from PubMed, Embase, Web of Science, and the Cochrane Library from inception until December 23, 2020. All randomized clinical trials (RCTs) and observational studies comparing all-cause mortality after treatment with CABG versus PCI for patients with NSTE-ACS with minimum follow-up of 6 months were included. Restricted mean survival time (RMST) differences from RCTs and adjusted RMST differences from observational studies were computed by reconstructing time-to-event data from published Kaplan–Meier curves. Extracted hazard ratios (HRs) were also assessed as a secondary analysis. ResultsOur systematic review included an individual participant data analysis of 3 RCTs and 8 observational studies. A meta-regression showed a significant association between log-transformed HRs and duration of follow-up (−0.009 [95% confidence interval (CI), −0.002 to −0.016] log-HR per 1-year longer follow-up; P = .037), suggesting a violation of the proportional hazard assumption. Analysis of 6 studies with available RMST data showed a significant inverse association between adjusted RMST differences and cutoff years (slope, −0.028 [95% CI, −0.042 to −0.013] year difference per 1-year longer cutoff; P < .005), suggesting a longer survival benefit in the CABG arm compared with the PCI arm with longer follow-up. ConclusionsThere was a trend toward a benefit of CABG compared with PCI in the longer follow-up in patients with NSTE-ACS. A large, well-designed RCT with longer follow-up is needed to obtain definitive evidence on this topic.

Percutaneous coronary intervention versus coronary artery surgery for left main disease according to lesion site: A meta-analysis

BackgroundComparative data after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) disease according to lesion site (ostial/shaft vs distal) are scant. The aim of this meta-analysis was to investigate outcomes after PCI or CABG for ULMCA disease according to lesion site. MethodsRandomized controlled trials (RCTs) and adjusted observational studies that compared PCI versus CABG in patients with ULMCA disease and reported outcomes according to lesion site were systematically identified. Major adverse cardiovascular events (MACE; a composite of all-cause death, myocardial infarction, stroke, and repeat revascularization) and all-cause death were the co-primary end points. Individual components of MACE were secondary end points. Sensitivity analysis including RCTs only were performed for each outcome. ResultsNine studies (3 RCTs, 6 adjusted observational), encompassing 6296 patients (2274 and 4022 treated for ostial/shaft or distal ULMCA, respectively) were included. At the 5-year follow-up, there were no significant differences between CABG and PCI for MACE, death, or any other secondary outcome for ostial/shaft ULMCA lesions (MACE: hazard ratio [HR], 1.0 [95% confidence interval (CI), 0.79-1.27]; death: HR, 1.10 [95% CI, 0.84-1.46]). For distal ULMCA, PCI was associated with an increased risk of MACE (HR, 1.32; 95% CI, 1.10-1.58), death (HR, 1.56; 95% CI, 1.19-2.04), and revascularization (HR, 2.07; 95% CI, 1.5-2.84). The benefit of CABG for MACE and revascularization was confirmed in the analysis limited to RCTs, whereas the benefit for mortality was not. ConclusionsAmong patients with distal ULMCA disease, CABG is associated with lower incidence of MACE and revascularization compared with PCI, whereas no differences in outcomes were observed for ostial/shaft ULMCA disease.

СЛУЧАЙ АОРТОКОРОНОРНОГО ШУНТИРОВАНИЯ У БОЛЬНОГО С ИНФАРКТОМ МИОКАРДА С ПОДЪЕМОМ СЕГМЕНТА ST, МНОГОСОСУДИСТЫМ ПОРАЖЕНИЕМ КОРОНАРНОГО РУСЛА И НИЗКОЙ ФРАКЦИЕЙ ВЫБРОСА

For decades, coronary artery bypass grafting (CABG) has been the main method of myocardial revascularization in patients with coronary artery disease, including those with acute coronary syndrome (ACS). Over the past decades, with the development of endovascular interventions and the development of drug-eluting stents, percutaneous coronary intervention (PCI) has become the main method of revascularization after ACS. [1,6]. Acute coronary syndrome (ACS) includes clinical manifestations such as unstable angina pectoris (NS), acute non-ST-segment elevation myocardial infarction (STEMI), and ST-segment elevation myocardial infarction (STEMI). Approximately 40% of all patients diagnosed with ACS have multivessel coronary artery disease, for which coronary artery bypass grafting (CABG) is better than PCI. [2]. The majority of studies comparing PCI and CABG have mainly included patients with stable coronary artery disease who underwent planned myocardial revascularization, rather than those requiring emergency or urgent myocardial revascularization. Thus, the results of these studies have limited applicability to patients with ACS. However, the long-term results of these studies, in particular the low need for re-revascularization, a lower rate of re-myocardial infarction, and the survival benefits of CABG, still need to be considered when determining the best course of treatment for ACS. The current recommendations for treatment in most patients with ACS give preference to early revascularization using PCI or CABG [3, 4]. Thus, our main goal here is to provide the current indications and options for surgical revascularization of the coronary arteries, including current guidelines and the latest published literature. In STEMI patients, early PCI of the main lesion remains the gold standard because it provides the fastest revascularization of the ischemic myocardium and is generally better tolerated than emergency CABG [5]. Since up to 50% of STEMI patients have multivessel coronary artery disease, early arterial revascularization without myocardial infarction has been recommended to provide optimal opportunities for myocardial rescue, reduction of ischemic watershed and improvement of left ventricular function [6,7]. A clinical case of successful beating coronary artery bypass grafting in a patient with ST-segment elevation myocardial infarction, multivessel coronary artery disease and low ejection fraction. The patient was discharged on the 11th day after surgery without complications.