Tullio Palmerini1, Patrick Serruys2, Arie Pieter Kappetein3, Philippe Genereux4, Diego Della Riva1, Letizia Bacchi Reggiani1, Evald Høj Christiansen5, Niels R Holm5, Leif Thuesen6, Timo Makikallio7, Marie Claude Morice8, Jung-Min Ahn9, Seung-Jung Park9, Holger Thiele10, Enno Boudriot11, Mario Sabatino1, Mattia Romanello1, Giuseppe Biondi-Zoccai12, Raphael Cavalcante13, Joseph F Sabik14, Gregg W Stone15. 1. Polo Cardio-Toraco-Vascolare, Policlinico S. Orsola, Bologna, Italy. 2. International Centre for Circulatory Health, NHLI, Imperial College London, London, United Kingdom. 3. Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, the Netherlands. 4. Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY; Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada; Morristown Medical Center, Morristown, NJ. 5. Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark. 6. Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark. 7. Department of Cardiology, Oulu University Hospital, Oulu, Finland. 8. MC Moriec Ramsay Générale de Santé, ICPS, Massy, France. 9. The Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea. 10. University Heart Center Lübeck and the German Center for Cardiovascular Research (DZHK), Lübeck, Germany. 11. Department of Internal Medicine/Cardiology, University Heart Center, Leipzig, Germany. 12. Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy. 13. Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands. 14. The Cleveland Clinic Foundation, Cleveland, OH. 15. Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY. Electronic address: gs2184@columbia.edu.
Abstract
Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. METHODS: Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS: Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95% CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction= .03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95% CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction < .0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95% CI 1.47-2.07). CONCLUSIONS: In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability.
Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. METHODS: Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS: Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95% CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction= .03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95% CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction < .0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95% CI 1.47-2.07). CONCLUSIONS: In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability.
Authors: Mohamed Rahouma; Ahmed Abouarab; Antonino Di Franco; Jeremy R Leonard; Christopher Lau; Mohamed Kamel; Lucas B Ohmes; Leonard N Girardi; Mario Gaudino Journal: Ann Cardiothorac Surg Date: 2018-07
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Authors: Karel M Van Praet; Markus Kofler; Timo Z Nazari Shafti; Alaa Abd El Al; Antonia van Kampen; Andrea Amabile; Gianluca Torregrossa; Jörg Kempfert; Volkmar Falk; Husam H Balkhy; Stephan Jacobs Journal: Interv Cardiol Date: 2021-05-19