Intermediate and Late Outcomes With PCI vs CABG for Left Main Disease - Landmark Meta-Analysis of Randomized Trials

Severe Left Main Coronary Artery Stenosis as the First Finding in Newly Diagnosed Chronic Coronary Syndrome: Incidence and Clinical Predictors

Severe left main coronary artery (LMCA) lesions (≥50% stenosis) portend a poor prognosis and require urgent revascularization. In this study, we identified the incidence and clinical predictors of severe LMCA stenosis in patients with chronic coronary syndrome (CCS) who had undergone coronary angiography for the first time. Using a nationwide database registry, all the patients with CCS who had undergone coronary angiography were included. Patients were classified based on having severe LMCA stenosis and they were compared based on the recommended therapeutic strategy after angiography. A multivariable binary logistic regression model was developed to identify the potential predictors of a severe LMCA lesion. Among 40,161 patients with CCS, a severe LMCA lesion was detected in a total of 1556 participants (3.87% [3.69; 6.07]). The multivariable logistic regression identified age (odds ratio [OR]: 1.04 [1.03;1.04]), male gender (OR:2.56 [2.28; 2.89]), dyslipidemia (OR:1.19 [1.06; 1.34]), and peripheral arterial disease (PAD) (OR:3.68 [1.06;12.83]) as predictors of a severe LMCA stenosis. Approximately 4% of patients with newly diagnosed CCS may suffer from severe LMCA disease. Age, male gender, dyslipidemia, and PAD are among the predicting factors of a severe LMCA stenosis and can be utilized in risk stratification of patients with CCS at greater risk of severe LMCA stenosis.

Coronary Artery Bypass Graft Surgery Brings Better Benefits to Heart Failure Hospitalization for Patients with Severe Coronary Artery Disease and Reduced Ejection Fraction

Objectives: We compared the outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) for revascularization in patients with reduced ejection fraction (EF) and severe coronary artery disease (CAD). Methods: Between February 2006 and February 2020, a total of 797 patients received coronary angiograms due to left ventricular EF ≤ 40% at our hospital. After excluding diagnoses of dilated cardiomyopathy, valvular heart disease, prior CABG, acute ST-segment myocardial infarction, and CAD with low Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score (≤22), 181 patients with severe coronary artery disease (CAD) with SYNTAX score >22 underwent CABG or PCI for revascularization. Vascular characteristics as well as echocardiographic data were compared between CABG (n = 58) and PCI (n = 123) groups. Results: A younger age (62 ± 9.0 vs. 66 ± 12.1; p = 0.016), higher new EuroSCORE II (8.6 ± 7.3 vs. 3.2 ± 2.0; p < 0.001), and higher SYNTAX score (40.5 ± 9.8 vs. 35.4 ± 8.3; p < 0.001) were noted in the CABG group compared to those in the PCI group. The CABG group had a significantly higher cardiovascular mortality rate at 1-year (19.6% vs. 5.0%, p = 0.005) and 3-year (25.0% vs. 11.4%, p = 0.027) follow-ups but a lower incidence of heart failure (HF) hospitalization at 1-year (11.1% vs. 28.2%, p = 0.023) and 3-year (3.6% vs. 42.5%, p = 0.001) follow-ups compared to those of the PCI group. Conclusions: Compared with PCI, revascularization with CABG was related to a lower incidence of HF hospitalization but a worse survival outcome in patients with severe CAD and reduced EF. CABG-associated reduction in HF hospitalization was more notable when SYNTAX score ≥33.

Meta-Analysis of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Narrowing

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results. We performed a systematic review up to May 23, 2021, and 1-stage reconstructed individual patient data meta-analysis (IPDMA) to compare outcomes between both groups. The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke, and unplanned revascularization at 5 years. We performed individual patient data meta-analysis using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups. Of 583 articles retrieved, 5 RCTs were included. A total of 4,595 patients from these 5 RCTs were randomly assigned to PCI (n = 2,297) or CABG (n = 2,298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6%, respectively (hazard ratio [HR] 1.093, 95% confidence interval [CI] 0.925 to 1.292; p = 0.296). PCI conferred similar time-to-MI (restricted mean survival time ratio 1.006, 95% CI 0.992 to 1.021, p=0.391) and stroke (restricted mean survival time ratio 1.005, 95% CI 0.998 to 1.013, p = 0.133) at 5 years. Unplanned revascularization was more frequent after PCI than CABG (HR 1.807, 95% CI 1.524 to 2.144, p <0.001) at 5 years. This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.

Immunomodulation Strategies for the Successful Regeneration of a Tissue-Engineered Vascular Graft

Cardiovascular disease leads to the highest morbidity worldwide. There is an urgent need to solve the lack of a viable arterial graft for patients requiring coronary artery bypass surgery. The current gold standard is to use the patient's own blood vessel, such as a saphenous vein graft. However, some patients do not have appropriate vessels to use because of systemic disease or secondary surgery. On the other hand, there is no commercially available synthetic vascular graft available on the market for small diameter (<6 mm) blood vessels like coronary, carotid, and peripheral popliteal arteries. Tissue-engineered vascular grafts (TEVGs) are studied in recent decades as a promising alternative to synthetic arterial prostheses. Yet only a few studies have proceeded to a clinical trial. Recent studies have uncovered that the host immune response can be directed toward increasing the success of a TEVG by shedding light on ways to modulate the macrophage response and improve the tissue regeneration outcome. In this review, the basic concepts of vascular tissue engineering and immunoengineering are considered. The state-of-art of TEVGs is summarized and the role of macrophages in TEVG regeneration is analyzed. Current immunomodulatory strategies based on biomaterials are also discussed.

Left Main Coronary Artery Disease in Diabetics: Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting?

The choice between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for myocardial revascularization in patients with left main disease (LMD) is controversial. There is general agreement that CABG is appropriate for all patients, and PCI is acceptable for those with low-to-intermediate anatomic complexity. However, there is uncertainty about the relative safety and efficacy of PCI in patients with more complex LMD and with comorbidities such as diabetes. No direct comparison trial has focused on revascularization in diabetic patients with LMD, and thus conclusions on the topic are subject to the limitations of subgroup analysis, as well as the heterogeneous exclusion criteria, and methodologies of individual trials. The available evidence suggests that among diabetics, CABG is superior in patients with LMD with SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and dardiac surgery) score greater than 33, distal bifurcation disease, or multivessel disease. PCI may be appropriate in those with less-extensive disease or those with limited life expectancy or high surgical risk.