Ben Indja1, Kei Woldendorp1,2,3, Deborah Black4, Paul G Bannon1,2,3, Michael K Wilson5, Michael P Vallely5. 1. Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia. 2. The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia. 3. Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia. 4. Faculty of Health Sciences, The University of Sydney, Camperdown, NSW, Australia. 5. Sydney Heart and Lung Surgeons, Camperdown, NSW, Australia.
Abstract
OBJECTIVES: There are a number of minimally invasive approaches to revascularization of coronary artery disease that involve the left main or proximal left anterior descending artery; however, studies to date provide mixed results. METHODS: A Bayesian network meta-analysis was performed to compare early and late postoperative outcomes between percutaneous coronary intervention with first- and second-generation drug-eluting stents (DESs), off-pump coronary artery bypass and minimally invasive direct coronary artery bypass (MIDCAB) in patients with involvement of left main or left anterior descending disease. RESULTS: A total of 37 studies with 31 728 patients were included in the analysis. There were no significant differences in early mortality rates, strokes or myocardial infarctions (MIs). The long-term all-cause mortality rate was equivalent between the groups. Patients who had off-pump coronary artery bypass had fewer late MI compared with those who had first-generation DES (DES1) [odds ratio (OR) 0.38, 95% confidence interval (CI) 0.20-0.72] and MIDCAB (OR 0.41, 95% CI 0.17-0.97) and reduced late target vessel revascularization compared with DES1 (OR 0.17, 95% CI 0.09-0.32) and second-generation DES (DES2) (OR 0.32, 95% CI 0.14-0.72). The rate of late major adverse cardiac events was lower with off-pump coronary artery bypass compared with that with DES1 (OR 0.33, 95% CI 0.26-0.43) and DES2 (OR 0.62, 95% CI 0.45-0.90). The rate of late major adverse cardiac events with MIDCAB was lower than that with DES1 (OR 0.43, 95% CI 0.31-0.62) as was that with DES2 compared with DES1 (OR 0.53, 95% CI 0.39-0.70). CONCLUSIONS: Surgical approaches to left main or proximal left anterior descending disease remain superior to first- or second-generation DES in terms of long-term freedom from MI and target vessel revascularization as well as improved overall long-term survival. Conflicting rates of late MI and target vessel revascularization in patients who underwent MIDCAB suggest disease in alternate vessels that may best be approached via hybrid techniques.
OBJECTIVES: There are a number of minimally invasive approaches to revascularization of coronary artery disease that involve the left main or proximal left anterior descending artery; however, studies to date provide mixed results. METHODS: A Bayesian network meta-analysis was performed to compare early and late postoperative outcomes between percutaneous coronary intervention with first- and second-generation drug-eluting stents (DESs), off-pump coronary artery bypass and minimally invasive direct coronary artery bypass (MIDCAB) in patients with involvement of left main or left anterior descending disease. RESULTS: A total of 37 studies with 31 728 patients were included in the analysis. There were no significant differences in early mortality rates, strokes or myocardial infarctions (MIs). The long-term all-cause mortality rate was equivalent between the groups. Patients who had off-pump coronary artery bypass had fewer late MI compared with those who had first-generation DES (DES1) [odds ratio (OR) 0.38, 95% confidence interval (CI) 0.20-0.72] and MIDCAB (OR 0.41, 95% CI 0.17-0.97) and reduced late target vessel revascularization compared with DES1 (OR 0.17, 95% CI 0.09-0.32) and second-generation DES (DES2) (OR 0.32, 95% CI 0.14-0.72). The rate of late major adverse cardiac events was lower with off-pump coronary artery bypass compared with that with DES1 (OR 0.33, 95% CI 0.26-0.43) and DES2 (OR 0.62, 95% CI 0.45-0.90). The rate of late major adverse cardiac events with MIDCAB was lower than that with DES1 (OR 0.43, 95% CI 0.31-0.62) as was that with DES2 compared with DES1 (OR 0.53, 95% CI 0.39-0.70). CONCLUSIONS: Surgical approaches to left main or proximal left anterior descending disease remain superior to first- or second-generation DES in terms of long-term freedom from MI and target vessel revascularization as well as improved overall long-term survival. Conflicting rates of late MI and target vessel revascularization in patients who underwent MIDCAB suggest disease in alternate vessels that may best be approached via hybrid techniques.
Authors: Matto Pettinari; Monica Gianoli; Meindert Palmen; Stepan Cerny; Burak Onan; Sandeep Singh; Patrique Segers; Cengiz Bolcal; Cem Alhan; Emiliano Navarra; Herbert De Praetere; Jan Vojacek; Theodor Cebotaru; Paul Modi; Fabien Doguet; Ulrich Franke; Ahmed Ouda; Ludovic Melly; Ghislain Malapert; Louis Labrousse; Alfonso Agnino; Tine Philipsen; Jean-Luc Jansens; Thierry Folliguet; Daniel Pereda; Francesco Musumeci; Piotr Suwalski; Koen Cathenis; Frank Van Praet; Johannes Bonatti; Wouter Oosterlinck Journal: Interact Cardiovasc Thorac Surg Date: 2022-09-09