Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting in Patients With Left Main Coronary Artery Stenosis: A Systematic Review and Meta-analysis.

Giacoppo D ，Colleran R ，Cassese S ，Frangieh AH ，Wiebe J ，Joner M ，Schunkert H ，Kastrati A ，Byrne RA ... -  《-》

Coronary Artery Bypass Surgery Versus Drug-Eluting Stent Implantation for Left Main or Multivessel Coronary Artery Disease: 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 3,280 patients 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 PCI with DES was particularly pronounced in those with multivessel CAD.

Lee CW ，Ahn JM ，Cavalcante R ，Sotomi Y ，Onuma Y ，Suwannasom P ，Tenekecioglu E ，Yun SC ，Park DW ，Kang SJ ，Lee SW ，Kim YH ，Park SW ，Serruys PW ，Park SJ ... -  《-》

Stroke Rates Following Surgical Versus Percutaneous Coronary Revascularization.

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI. This study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality. We performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored. The analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001). This individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.

Head SJ ，Milojevic M ，Daemen J ，Ahn JM ，Boersma E ，Christiansen EH ，Domanski MJ ，Farkouh ME ，Flather M ，Fuster V ，Hlatky MA ，Holm NR ，Hueb WA ，Kamalesh M ，Kim YH ，Mäkikallio T ，Mohr FW ，Papageorgiou G ，Park SJ ，Rodriguez AE ，Sabik JF 3rd ，Stables RH ，Stone GW ，Serruys PW ，Kappetein AP ... -  《-》

Percutaneous Coronary Intervention Using Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Stenosis: A Meta-Analysis of Randomized Trials.

Current guidelines suggest that coronary artery bypass grafting (CABG) should be the preferred revascularization method for unprotected left main coronary artery stenosis. In light of evidence from recent randomized trials, we assessed whether percutaneous coronary intervention (PCI) using drug-eluting stents is as safe and effective as CABG for the treatment of unprotected left main coronary artery disease. Digital databases and manual searches were performed for randomized trials comparing PCI and CABG for unprotected left main coronary artery stenosis. Among 3887 potentially relevant studies, 5 met inclusion criteria. The primary safety end point was defined as the composite of all-cause death, myocardial infarction, or stroke. Secondary end points included a clinical effectiveness composite, which was defined as all-cause death, myocardial infarction, stroke, or repeat revascularization. Summary estimates were obtained using random-effects modeling. In total, 4594 patients were included in the analysis. There was no significant difference in the primary safety end point between the revascularization strategies (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.79-1.17; P=0.73). However, when compared with CABG, PCI was less effective (OR, 1.36; 95% CI, 1.18-1.58; P<0.001) because of significantly higher rates of repeat revascularization (OR, 1.85; 95% CI, 1.53-2.23; P<0.001). The incidence of all-cause death (OR, 1.03; 95% CI, 0.78-1.35; P=0.61), myocardial infarction (OR, 1.46; 95% CI, 0.88-2.45; P=0.08), and stroke (OR, 0.88; 95% CI, 0.39-1.97; P=0.53) did not differ between PCI and CABG. PCI using drug-eluting stents and CABG are equally safe methods of revascularization for patients at low surgical risk with significant unprotected left main coronary artery stenosis. However, CABG is associated with significantly lower rates of repeat revascularization.

Nerlekar N ，Ha FJ ，Verma KP ，Bennett MR ，Cameron JD ，Meredith IT ，Brown AJ ... -  《-》

Left main coronary artery stenosis: a meta-analysis of drug-eluting stents versus coronary artery bypass grafting.

The goal of this study was to provide a systematic review comparing the long-term outcomes of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (UPLM) stenosis. One-year outcomes from randomized controlled trials, observational studies, and pooled analyses have demonstrated the safety and efficacy of PCI of the UPLM when compared with CABG. However, there remain concerns over the sustainability of PCI with DES at longer follow-up. Studies published between January 2000 and December 2012 of PCI versus CABG for UPLM stenosis were identified using an electronic search and reviewed using meta-analytical techniques. Twenty-four studies comprising 14,203 patients were included in the analysis. There was no significant difference for all-cause mortality between PCI or CABG at 1 year (odds ratio [OR]: 0.792, 95% confidence interval [CI]: 0.53 to 1.19), 2 years (OR: 0.920, 95% CI: 0.67 to 1.26), 3 years (OR: 0.94, 95% CI: 0.60 to 1.48), 4 years (OR: 0.84, 95% CI: 0.53 to 1.33), and 5 years (OR: 0.79, 95% CI: 0.57 to 1.08). The need for target vessel revascularization (TVR) was significantly higher in patients undergoing PCI at all time points. The occurrence of stroke, however, was significantly less frequent in patients treated with PCI. The occurrence of nonfatal myocardial infarction showed a statistically significant trend towards a lower incidence in CABG patients at 1 year (OR: 1.62, 95% CI: 1.05 to 2.50), 2 years (OR: 1.60, 95% CI: 1.09 to 2.35), and 3 years (OR: 2.06, 95% CI: 1.36 to 3.1). There was no significant difference in combined major adverse cardiovascular and cerebrovascular events between the 2 groups. Our findings suggest that PCI with DES is a safe and durable alternative to CABG for the revascularization of UPLM stenosis in select patients at long-term follow-up.

Athappan G ，Patvardhan E ，Tuzcu ME ，Ellis S ，Whitlow P ，Kapadia SR ... -  《-》