Higher Risk Of Repeat Revascularization Research Articles

Clinical Outcomes of Patients with Coronary Artery Diseases and Moderate Left Ventricular Dysfunction: Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Surgery.

PurposePercutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are two revascularization strategies for patients with coronary artery disease (CAD) and left ventricular dysfunction. However, the comparisons of effectiveness between the two strategies are insufficient. This study is aimed to compare the effectiveness between PCI and CABG among patients with moderate left ventricular dysfunction.Patients and MethodsA total of 1487 CAD patients with moderate reduced ejection fraction (36%≤EF≤40%), who underwent either PCI or CABG, were enrolled in a real-world cohort study (No. ChiCTR2100044378). Clinical outcomes included short- and long-term all-cause mortality, rates of heart failure (HF) hospitalization and repeat revascularization. Propensity score matching was used to balance the two cohorts.ResultsPCI was associated with lower 30-day mortality rate (hazard ratio [HR] [95% CI], 0.35 [0.15–0.83]; P=0.02). At a mean follow-up of 4.5 years, PCI and CABG had similar all-cause death (HR [95% CI], 0.82 [0.56–1.20]; P=0.30) and heart failure (HF) hospitalization (HR [95% CI], 0.93 [0.54–1.60]; P=0.79), but PCI had higher risk of repeat revascularization (HR [95% CI], 8.62 [3.67–20.23]; P<0.001). Improvement in EF measured at 3 months later after revascularization was also similar between PCI and CABG (P for interaction=0.87).ConclusionCAD patients with moderate reduced EF who had PCI had lower short-term mortality rate but higher risk of repeat revascularization during follow-up than patients who had CABG. PCI showed comparable long-term survival, HF hospitalization risk, and EF improvement.

Medical therapy vs early revascularization in diabetics with chronic total occlusions: A meta-analysis and systematic review.

BACKGROUNDManagement of chronic total occlusions (CTO) in diabetics is challenging, with a recent trend towards early revascularization [ER: Percutaneous coronary intervention (PCI) and bypass grafting] instead of optimal medical therapy (OMT). We hypothesize that ER improves morbidity and mortality outcomes in diabetic patients with CTOs as compared to OMT. AIMTo determine the long term clinical outcomes and to compare morbidity and mortality between OMT and ER in diabetic patients with CTOs.METHODSPotentially relevant published clinical trials were identified in Medline, Embase, chemical abstracts and Biosis (from start of the databases till date) and pooled hazard ratios (HR) computed using a random effects model, with significant P value < 0.05. Primary outcome of interest was all-cause death. Secondary outcomes included cardiac death, prompt revascularization (ER) or repeat myocardial infarction (MI). Due to scarcity of data, both Randomized control trials and observational studies were included. 4 eligible articles, containing 2248 patients were identified (1252 in OMT and 1196 in ER). Mean follow-up was 45-60 mo.RESULTSOMT was associated with a higher all-cause mortality [HR: 1.70, 95% confidence interval (CI): 0.80-3.26, P = 0.11] and cardiac mortality (HR: 1.68, 95%CI: 0.96-2.96, P = 0.07). Results were close to significance. The risk of repeat MI was almost the same in both groups (HR: 0.97, 95%CI: 0.61-1.54, P = 0.90). Similarly, patients assigned to OMT had a higher risk of repeat revascularization (HR: 1.62, 95%CI: 1.36-1.94, P < 0.00001). Sub-group analysis of OMT vs PCI demonstrated higher all-cause (HR: 1.98, 95%CI: 1.36-2.87, P = 0.0003) and cardiac mortality (HR: 1.87, 95%CI: 0.96-3.62, P = 0.06) in the OMT group. The risk of repeat MI was low in the OMT group vs PCI (HR: 0.53, 95%CI: 0.31-0.91, P = 0.02). Data on repeat revascularization revealed no difference between the two (HR: 1.00, 95%CI: 0.52-1.93, P = 1.00).CONCLUSIONIn diabetic patients with CTO, there was a trend for improved outcomes with ER regarding all-cause and cardiac death as compared to OMT. These findings were reinforced with statistical significance on subgroup analysis of OMT vs PCI.

Clinical outcomes of complete versus incomplete revascularization in patients treated with coronary artery bypass grafting: insights from the TiCAB trial.

In this post hoc analysis of the Ticagrelor in coronary artery bypass grafting (CABG) trial, we aimed to analyse patients treated with CABG receiving either complete revascularization (CR) or incomplete revascularization (ICR) independent from random allocation to either ticagrelor or aspirin. Of 1859 patients enrolled in the Ticagrelor in CABG trial, 1550 patients (83.4%) received CR and 309 patients (16.6%) ICR. Outcomes were evaluated regarding all-cause mortality, cardiovascular death, myocardial infarction (MI), repeat revascularization, stroke and bleeding within 12 months after CABG. Baseline parameters revealed significant differences regarding clinical presentation (stable angina pectoris: CR 68.9% vs ICR 71.2%, instable angina pectoris: 14.1% vs 7.8%, non-ST elevation MI: 17.0% vs 21.0%, P ˂ 0.01), lesion characteristics (chronic total occlusion: CR 91.3% vs ICR 96.8%, P ˂ 0.01), operative technique [off-pump coronary artery bypass surgery (OPCAB): CR 3.0% vs ICR 6.1%, P ˂ 0.01] and number of utilized grafts (total number of grafts: 2.69/patient vs 2.49/patient, P ˂ 0.001). ICR patients displayed a significantly increased risk of repeat revascularization [hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.16-3.16; P < 0.01] and percutaneous coronary intervention (HR 1.95, 95% CI 1.13-3.35; P < 0.05) within 12 months after CABG. Higher risk for repeat revascularization in ICR patients was independent from random allocation to either ticagrelor or aspirin and persisted after adjustment for baseline imbalances. Patients with ICR presented more stable at the time of admission, but received less grafts, highly likely due to a higher rate of chronic total occlusion lesions and performed OPCAB. Although mortality presented no difference between groups, our results suggest that patients benefit from CR with regard to prevention of repeat revascularization.

Long-term follow-up of percutaneous coronary intervention versus coronary artery bypass grafting in left main coronary artery disease: A systematic review and meta-analysis.

We conducted a systematic review and meta-analysis to evaluate the long-term outcomes of PCI compared to CABG in patients with LMCAD. Recent data from randomized controlled trials (RCTs) has raised concerns regarding the long-term efficacy and safety of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). We searched MEDLINE and EMBASE databases for published RCTs comparing PCI using stenting with CABG in patients with LMCAD. Preferred reporting items for systematic review and meta-analysis guidelines were used for the present study. End-points of interest were all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), stroke, and repeat revascularization at longest available follow-up. Relevant data were collected and pooled odds ratio (OR) with 95% confidence intervals (CI) was calculated using random-effects model. Five RCTs including a total of 4,499 patients were included in the final analysis. Mean duration of follow-up was 96 months. The risks of all-cause mortality [OR 1.09 (95% CI 0.88-1.34)] and cardiovascular mortality [1.14 (0.88-1.47)] were comparable between PCI and CABG. There were no statistically significant differences between PCI and CABG for MI [1.52 (0.98-2.37)] and stroke [0.84 (0.48-1.45)]. Conversely, repeat revascularization was significantly higher with PCI as compared with CABG [1.82 (1.49-2.22)]. At long-term follow-up, PCI is associated with similar risks of mortality but a higher risk of repeat revascularization compared with CABG in LMCAD. Long-term risk of MI with PCI compared to CABG needs to be further explored in future studies.

Patient perspectives on left main stem revascularization strategies, the OPINION-2 study

BackgroundTreatment preferences in patients with left main (LM) stem disease and no prior revascularization are unknown. The objectives of this study were to determine (i) patient-reported importance ratings of particular features related to percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery, (ii) how these features determine treatment preference, and (iii) how educational and psychosocial background influence this preference. MethodsIn this prospective, multicenter study a total of 500 patients without previous revascularization who underwent diagnostic angiography for suspected coronary disease were asked to complete a case-vignette on a (hypothetical) LM stenosis qualifying for both PCI and CABG, in addition to 6 validated questionnaires to assess the influence of psychosocial factors on treatment preference. ResultsOverall, 90% favored PCI over CABG because of the lower bleeding and stroke risk despite a higher likelihood for repeat revascularization. By multivariable regression, the only independent determinant of treatment preference for CABG was lower educational level (14% in low vs. 8% in higher educated patients, OR: 3.22, CI: 1.16–8.95, p=0.025) while psychosocial variables were not associated. Compared to higher educated patients, those with lower educational level suffered more from depression, anxiety, loneliness, and uncertainty. ConclusionsOverall, patients who are informed about risk and benefits of each treatment modality clearly favor PCI over CABG and particularly value lower short-term morbidity while being aware of higher risk of repeat revascularization. Lower educational level was associated with a higher prevalence of psychosomatic phenotypes and a 14% preference for CABG. Educational and psychosocial background matter in the revascularization strategy decision-making process.

Long-Term Outcomes of Left Main Coronary Artery Disease Treated With Drug-Eluting Stents vs Coronary Artery Bypass Grafting: A Meta-Analysis and Systematic Review

BackgroundCurrently, DES is a reasonable treatment option for LMCA disease but CABG continues to be first-line treatment. Multiple randomized clinical trials (RCTs) have compared outcomes between these two treatment modalities. Recently, these trials published their long-term results with conflicting findings. MethodsWe conducted a systematic review and meta-analysis of RCTs that compared DES vs CABG in patients with LMCA disease. We only included trials with follow up duration of at least 5 years. The primary outcome was all-cause mortality. Secondary outcomes included risk of cardiac death, myocardial infarction (MI), stroke and repeat revascularization. ResultsWe included a total of 4 RCTs. The median-weighted follow up period was 6.5 years. There was no significant difference between DES and CABG in all-cause mortality (Risk ratio (RR) 1.10; 95% confidence interval (CI) 0.92 to 1.31; p = 0.28), risk of cardiac death (RR of 1.08, 95% CI 0.84 to 1.38; p = 0.56), total MI (RR of 1.22, 95% CI 0.96 to 1.56; p = 0.11), and stroke (RR of 0.85, 95% CI 0.46 to 1.57; p = 0.60). The risk of repeat revascularization (RR of 1.75, 95% CI 1.50 to 2.03; p < 0.00001), and non-periprocedural MI (RR of 2.13, 95% CI 1.53 to 2.97; p < 0.00001) were significantly higher in the DES arm. ConclusionsDES has similar long-term outcomes compared to CABG in terms of all-cause mortality, cardiac death, total MI and stroke; but was associated with a higher risk of repeat revascularization, and non-periprocedural MI.

Five-year outcomes comparing percutaneous coronary intervention with drug-eluting stents versus coronary artery bypass grafting in patients with left main coronary artery disease: A systematic review and meta-analysis

Background and aimsIn patients with left main coronary artery disease (LMCAD), long-term outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) compared with coronary artery bypass grafting (CABG) remain controversial. We conducted a meta-analysis to compare the efficacy and safety of PCI with DES and CABG in LMCAD patients. MethodsWe comprehensively searched in Web of Science, EMBASE, PubMed, and Cochrane databases for eligible randomised controlled trials (RCTs) comparing the 5-year clinical outcomes between PCI with DES and CABG in LMCAD patients. Random-effect models were applied to analyse risk ratios (RRs) and hazard ratios (HRs) across studies, and I2 to assess heterogeneity. ResultsWe screened 4 RCTs including 4394 patients distributed randomly into PCI (n = 2197) and CABG (n = 2197) groups. In comparison to CABG, PCI showed non-inferiority concerning a composite of death, myocardial infarction, and stroke (HR 1.22, 95% confident interval [CI] 0.84–1.75), death (HR 1.06, 95% CI 0.81–1.40) and stroke (HR 0.80, 95% CI 0.42–1.53). Regarding major adverse cardiac or cerebrovascular events (MACCE) rate, both strategies show clinical equipoise in patients with a low-to-intermediate Synergy Between PCI with TAXUS and Cardiac Surgery (SYNTAX) score (HR 1.20, 95% CI 0.85–1.70), while CABG had an advantage over PCI in those with a high SYNTAX score (HR 1.64, 95% CI 1.20–2.24). ConclusionsCABG showed advantage over PCI with DES for LMCAD patients in MACCE. PCI and CABG showed equivalent 5-year clinical risk of a composite of all-cause mortality, myocardial infarction, and stroke, but the former had higher risk of repeat revascularization.

Incidence and Outcomes of Acute Coronary Syndrome After Transcatheter Aortic Valve Replacement

ObjectivesThis study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries. BackgroundEvidence about incidence and outcomes of ACS after TAVR is scarce. MethodsWe identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non–ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis. ResultsOut of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non–ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001). ConclusionsAfter TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.

A case-vignette based assessment of patient's perspective on coronary revascularization strategies, the OPINION study

Background and aimsSignificant left main (LM) stem disease is potentially life-threatening and mandates revascularization. This study aimed to assess how patients rate the importance of particular features of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), how this determines their preference for a particular treatment strategy, and whether particular personality characteristics influence this preference. Methods and resultsIn total, 1145 patients who visited the outpatient clinic of the Erasmus Medical Center for stable coronary artery disease were asked to complete a case vignette-questionnaire on a hypothetical significant LM stenosis amenable to PCI or CABG. To assess the individual's personality disposition and general distress level, each patient had to complete a set of 3 standardized, validated questionnaires with satisfactory psychometric properties. Overall 89% of patients preferred PCI to CABG. PCI was the preferred strategy despite a higher risk for repeat revascularization and need for more medication. Remarkably, the fact that a risk for repeat revascularization is more common in the PCI group is less important for the patients who opt for PCI. Risk for stroke and bleeding were the most important arguments to opt for PCI over CABG. Type D personality, depression, and anxiety were all associated with a relatively higher preference for CABG as revascularization strategy. ConclusionOverall, when given the choice patients seem to have a clear preference for PCI over CABG and consider stroke and bleeding important procedure-related complications. Patients with Type D personality, depression, or anxiety favor CABG.

Long term outcomes of drug-eluting stent versus coronary artery bypass grafting for left main coronary artery disease: a meta-analysis.

BackgroundIt is still controversial whether percutaneous coronary intervention with drug-eluting stent (DES) is safe and effective compared to coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (ULMCA) disease at long-term follow up (≥ 3 years).MethodsEligible studies were selected by searching PubMed, EMBASE, and Cochrane Library up to December 6, 2016. The primary endpoint was a composite of death, myocardial infarction (MI) or stroke during the longest follow-up. Death, cardiac death, MI, stroke and repeat revascularization were the secondary outcomes.ResultsFour randomized controlled trials and twelve adjusted observational studies involving 14,130 patients were included. DES was comparable to CABG regarding the occurrence of the primary endpoint (HR = 0.94, 95% CI: 0.86–1.03). Besides, DES was significantly associated with higher incidence of MI (HR = 1.56, 95% CI: 1.09–2.22) and repeat revascularization (HR = 3.09, 95% CI: 2.33–4.10) compared with CABG, while no difference was found between the two strategies regard as the rate of death, cardiac death and stroke. Furthermore, DES can reduce the risk of the composite endpoint of death, MI or stroke (HR = 0.80, 95% CI: 0.67–0.95) for ULMCA lesions with SYNTAX score ≤ 32.ConclusionsAlthough with higher risk of repeat revascularization, PCI with DES appears to be as safe as CABG for ULMCA disease at long-term follow up. In addition, treatment with DES could be an alternative interventional strategy to CABG for ULMCA lesions with low to intermediate anatomic complexity.

Percutaneous coronary intervention using drug-eluting stents versus coronary artery bypass graft surgery in left main coronary artery disease an updated meta-analysis of randomized clinical trials.

ObjectivesTo compare the safety and efficacy of percutaneous coronary intervention (PCI) using drug-eluting stent (DES) and coronary artery bypass graft (CABG) for the treatment of left main coronary artery (LMCA) disease.BackgroundSeveral new randomized trials have recently examined the clinical outcomes of PCI and CABG in LMCA disease. However, the results of these studies were inconsistent.Materials and MethodsWe searched five online electronic databases to identify all the randomized clinical trials assessing the outcomes of PCI using DES and CABG in patients with LMCA. The clinical outcomes were the major adverse cardiac and cerebrovascular event (MACCE), all-cause death, myocardial infarction (MI), stroke, and repeat revascularization (RR).ResultsA total of 5 randomized clinical trials with 4595 LMCA patients were included in this meta-analysis. For one year follow-up, the results indicated that PCI were associated with a lower risk of stroke (RR = 0.21, 95% CI = 0.07–0.65, P = 0.007), a higher risk of RR (RR = 1.72, 95% CI = 1.28–2.33, P < 0.001) than CABG. Moreover, for long-term follow-up, there were significant higher risks of MACCE and RR with PCI versus CABG (MACCE: HR = 1.26, 95% CI = 1.11–1.44, P = 0.001; RR: HR = 1.70, 95% CI = 1.42–2.05, P < 0.001). However, there were no significant differences between the two groups in all-cause death and MI risks, regardless of follow-up duration.ConclusionsPCI is noninferior to CABG in short term follow-up of patients with LMCA disease, but CABG is more safety and efficacy than PCI using DES in long-term follow-up.

Meta-Analysis of Randomized Controlled Trials of Percutaneous Coronary Intervention With Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Left Main Coronary Artery Disease

Few randomized controlled trials (RCTs) and observational studies had shown acceptable short-term efficacy and safety of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) compared with coronary artery bypass grafting (CABG) in selected patients with left main coronary artery disease (LMCAD). We aimed to evaluate long-term outcomes of PCI using DES compared with CABG in patients with LMCAD. On November 1, 2016, we searched available databases for published RCTs directly comparing DES PCI with CABG in patients with LMCAD. Odds ratios (ORs) were used as the metric of choice for treatment effects using a random-effects model. I-squared index was used to assess heterogeneity across trials. Prespecified end points were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, and repeat revascularization at maximal available follow-up. We identified 5 RCTs including a total of 4,595 patients, with a median follow-up of 60months. The risk of all-cause mortality (OR 1.01; 95% confidence interval [CI] 0.76 to 1.34) and cardiovascular mortality (OR 1.02; 95% CI 0.73 to 1.42) were comparable between PCI with DES and CABG. Similarly, there were no statistically significant differences between PCI with DES and CABG for MI (OR 1.45; 95% CI 0.87 to 2.40) and stroke (OR 0.87; 95% CI 0.38 to 1.98). Conversely, repeat revascularization was significantly higher with PCI compared with CABG (OR 1.82; 95% CI 1.51 to 2.21). In conclusion, in patients with LMCAD, PCI with DES appears to be a viable alternative to CABG at long-term follow-up, with similar risks of ischemic adverse events (mortality, MI, and stroke) but a higher risk of repeat revascularization.

Coronary Artery Bypass Grafting vs. Drug-Eluting Stent Implantation for Multivessel Disease in Patients with Chronic Kidney Disease.

Background and ObjectivesThere is currently a limited amount of data that demonstrate the optimal revascularization strategy for chronic kidney disease (CKD) patients with multivessel coronary artery disease (CAD). We compared the long-term outcomes of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass graft surgery (CABG) for multivessel CAD in patients with CKD.Subjects and MethodsWe analyzed 2108 CKD patients (estimated glomerular filtration rate <60 mL/min/1.73 m2) with multivessel CAD that were treated with PCI with DES (n=1165) or CABG (n=943). The primary outcome was a composite of all causes of mortality, myocardial infarction, or stroke. The mean age was 66.9±9.1 years.ResultsMedian follow-up duration was 41.4 (interquartile range 12.1-75.5) months. The primary outcome occurred in 307 (26.4%) patients in the PCI group compared with 304 (32.2%) patients in the CABG group (adjusted hazard ratio [HR], 0.941; 95% confidence interval [CI], 0.79–1.12; p=0.493). The two groups exhibited similar rates of all-cause mortality (adjusted HR, 0.91; 95% CI, 0.77–1.09; p=0.295), myocardial infarction (adjusted HR, 1.86; 95% CI, 0.85–4.07; p=0.120) and stroke (3.2% vs. 4.8%; HR, 0.93; 95% CI, 0.57–1.61; p=0.758). However, PCI was associated with significantly increased rates of repeat revascularization (adjusted HR, 4.72; 95% CI, 3.20–6.96; p<0.001).ConclusionAmong patients with CKD and multivessel CAD, PCI with DES when compared with CABG resulted in similar rates of composite outcome of mortality from any cause, MI, or stroke; however, a higher risk of repeat revascularization was observed.

Revascularization in Patients With Multivessel Coronary Artery Disease and Chronic Kidney Disease: Everolimus-Eluting Stents Versus Coronary Artery Bypass Graft Surgery

BackgroundRandomized trials of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) routinely exclude patients with chronic kidney disease (CKD). ObjectivesThis study evaluated outcomes of PCI versus CABG in patients with CKD. MethodsPatients with CKD who underwent PCI using everolimus-eluting stents were propensity-score matched to patients who underwent isolated CABG for multivessel coronary disease in New York. The primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization. ResultsOf 11,305 patients with CKD, 5,920 patients were propensity-score matched. In the short term, PCI was associated with a lower risk of death (hazard ratio [HR]: 0.55; 95% confidence interval [CI]: 0.35 to 0.87), stroke (HR: 0.22; 95% CI: 0.12 to 0.42), and repeat revascularization (HR: 0.48; 95% CI: 0.23 to 0.98) compared with CABG. In the longer term, PCI was associated with a similar risk of death (HR: 1.07; 95% CI: 0.92 to 1.24), higher risk of MI (HR: 1.76; 95% CI: 1.40 to 2.23), a lower risk of stroke (HR: 0.56; 95% CI: 0.41 to 0.76), and a higher risk of repeat revascularization (HR: 2.42; 95% CI: 2.05 to 2.85). In the subgroup with complete revascularization with PCI, the increased risk of MI was no longer statistically significant (HR: 1.18; 95% CI: 0.67 to 2.09). In the 243 matched pairs of patients with end-stage renal disease on hemodialysis, PCI was associated with significantly higher risk of death (HR: 2.02; 95% CI: 1.40 to 2.93) and repeat revascularization (HR: 2.44; 95% CI: 1.50 to 3.96) compared with CABG. ConclusionsIn patients with CKD, CABG is associated with higher short-term risk of death, stroke, and repeat revascularization, whereas PCI with everolimus-eluting stents is associated with a higher long-term risk of repeat revascularization and perhaps MI, with no long-term mortality difference. In the subgroup on dialysis, the results favored CABG over PCI.

Comparison of bypass surgery and drug-eluting stenting in diabetic patients with left main and/or multivessel disease: A systematic review and meta-analysis of randomized and nonrandomized studies.

With advances in theinterventional field, the choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention with drug-eluting stents (PCI-DES) for the diabetic subset with left main (LM) and/or multivessel disease (MVD) remains consistently controversial. We conducted a systematic review of randomized controlled trials (RCTs) and observational controlled trials (OCTs) comparing the two strategies for the diabetic subset with LM and/or MVD. PubMed, EMBASE, CENTRAL databases, Google Scholar and SinoMed were systematically searched for eligible studies without language and publication restrictions. We identified 19 trials (4 randomized and 15 nonrandomized), enrolling 5,805 patients in OCTs and 3,060 patients in RCTs, respectively. PCI-DES was associated with higher mortality compared with CABG (11.7% DES vs. 9.1% CABG, RR 1.23, 95% CI 1.00-1.53, p = 0.06). Patients after PCI-DES had higher prevalence of myocardial infarction (MI) when compared with CABG (8.5% DES vs. 4.6% CABG, RR 1.68, 95% CI 1.20-2.37, p = 0.003). PCI-DES patients were at substantially lower risk of stroke (2.0% DES vs. 3.9% CABG, RR 0.51, 95% CI 0.39-0.67, p < 0.00001), but at several-fold higher risk of repeat revascularization (19.0% DES vs. 6.3% CABG, RR 2.95, 95% CI 2.46-3.55, p < 0.00001). The OCT patients risked a lower mortality as compared to the RCT patients (9.6% OCTs vs. 11.9% RCTs, RR 0.81, 95% CI 0.71-0.92, p = 0.001). CABG for patients with diabetes mellitus and LM and/or MVD had advantages over PCI-DES in all-cause death, nonfatal MI, and repeat revascularization, but the substantial disadvantage in nonfatal stroke. The high-selected patients (RCTs) risked a higher mortality than the real-world patients (OCTs).

Optimal choice of coronary revascularization and stent type in diabetic patients with coronary artery disease.

Patients with diabetes mellitus (DM) are prone to a diffuse and accelerated form of coronary artery disease (CAD), which in turn is a major cause of cardiac-related morbidity and mortality. Compared with patients without diabetes, patients with diabetes undergoing coronary revascularization are at higher risk of procedural, short-, and long-term cardiovascular events and mortality. Although coronary artery bypass grafting (CABG) has been regarded as the primary revascularization strategy in diabetic patients with complex CAD, percutaneous coronary intervention (PCI) is an effective revascularization alternative, due to remarkable advances in stent devices and adjunctive drug therapies. Outcomes data, from subgroup analyses and small-sized clinical trials and large registries, have suggested that PCI with current stent technology showed comparable long-term risks of mortality and hard endpoints, but higher risk of repeat revascularization for the diabetic population compared to CABG. However, the recent landmark International Future REvascularization Evaluation in patients with diabetes mellitus: optimal management of Multivessel disease (FREEDOM) trial provides compelling evidence of the superiority of CABG over PCI in reducing the rates of death, myocardial infarction, at the expense of stroke, in patients with diabetes with advanced CAD. When opting for PCI in patients with diabetes, currently used drug-eluting stents (DES) are more efficient in reducing the risk of repeat revascularization without compromising safety outcomes, compared to bare-metal stents. The selection of a specific type of DES in patients with diabetes is controversial and therefore more data comparing second- and newer-generation DES for patients with diabetes are currently needed. Also, efforts to make more advanced DES platforms suitable for patients with diabetes with complicated angiographic features are still ongoing.

Is percutaneous coronary intervention as effective as bypass surgery in left main stem coronary artery stenosis?

Recent advances in percutaneous coronary intervention (PCI) have rekindled interest in this treatment modality also in the setting of unprotected left main stenosis. Randomized trials reported a similar risk of death or myocardial infarction between PCI and coronary artery bypass grafting (CABG). However, rates of stroke were higher after CABG, whereas patients undergoing PCI had a higher risk of repeat revascularization. Although CABG remains the standard of care for left main stenosis in current guideline recommendations, PCI is considered a reasonable alternative in patients with low to intermediate anatomical complexity and at increased surgical risk. An interdisciplinary assessment is indispensable in order to choose the best treatment option for each individual patient.

TCT-700 A Systematic Review and Meta-analysis of Ostial and Trunk versus Distal Lesions in Unprotected Left Main Coronary Artery Stenting

The effectiveness of left main coronary artery (LMCA) percutaneous coronary intervention (PCI) is inferior to coronary artery bypass surgery (CABG), mostly due to the higher risk of repeat revascularization. The LMCA has typically been treated as a single entity in studies comparing PCI and CABG.

Long-Term Outcome of Stents Versus Bypass Surgery in Diabetic and Nondiabetic Patients With Multivessel or Left Main Coronary Artery Disease

Coronary artery bypass grafting and percutaneous coronary intervention (PCI) are alternative treatments for complex multivessel or left main disease. However, the relative treatment effects in diabetic and nondiabetic patients remain uncertain. We performed a pooled analysis of 5775 patients from 3 clinical studies comparing PCI and coronary artery bypass grafting for multivessel or left main disease and compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and repeat revascularization) according to the diabetic status. Over a median follow-up of 5.5 years, risk-adjusted mortality after PCI relative to coronary artery bypass grafting was not different in diabetic (hazard ratio [HR], 1.15; 95% CI, 0.88-1.51) and nondiabetic (HR, 1.15; 95% CI, 0.88-1.50) patients. The adjusted risks of the composite outcome of death, Q-wave myocardial infarction, or stroke were also not different in diabetic (HR, 1.00; 95% CI, 0.79-1.26) and nondiabetic (HR, 0.99; 95% CI, 0.78-1.26) patients. However, PCI was significantly associated with higher risk of repeat revascularization both in diabetic (HR, 3.56; 95% CI, 2.62-4.83) and in nondiabetic (HR, 3.55; 95% CI, 2.61-4.83) patients. Significant interactions were absent between diabetic status and revascularization strategies for death (P=0.27), composite outcome of death, Q-wave myocardial infarction, or stroke (P=0.97), and repeat revascularization (P=0.08). For multivessel or left main disease, the long-term risks of mortality and composite serious outcomes were not different between PCI and coronary artery bypass grafting in diabetic and nondiabetic patients, but PCI was associated with higher risk of repeat revascularization. These relative treatment effects were not modified by diabetic status. These results are hypothesis generating and should be addressed in a randomized trial.

Bypass surgery versus percutaneous coronary intervention for the treatment of unprotected left main disease

We performed a meta-analysis of randomized controlled trials to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for the treatment of de novo unprotected left main disease. Although CABG is accepted to be standard of care for revascularization of unprotected left main stenosis, PCI is increasingly being used as an alternative primary approach. We searched for randomized, controlled trials comparing CABG and PCI for the treatment of unprotected left main disease. Major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeat revascularization) were analyzed. The search strategy identified 4 randomized controlled trials enrolling a total of 1,611 patients. Follow-up ranged between 1 and 2 years. There were no significant differences in the risk of death or myocardial infarction between the two treatment modalities. While the risk of stroke was significantly lower in patients undergoing PCI (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.10-0.69, p = 0.007), the risk of repeat revascularization was higher among patients undergoing PCI (RR 1.94, 95% CI 1.43-2.61, p < 0.001). No relevant statistical heterogeneity across studies could be found. In this largest series of randomized patients with unprotected left main stenosis to date, the risk of death and myocardial infarction was comparable between CABG and PCI. However, patients undergoing CABG had a higher risk of stroke, whereas patients undergoing PCI were at a higher risk for repeat revascularization.