Robotically assisted coronary artery bypass graft surgery versus drug-eluting stents for patients with stable isolated proximal left anterior descending disease

Percutaneous Coronary Intervention or Minimally Invasive Coronary Bypass for Isolated Left Anterior Descending Artery Disease

The optimal revascularization strategy for isolated left anterior descending (LAD) artery disease, minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI), remains a subject of debate. This updated meta-analysis aimed to compare the long- term outcomes of MIDCAB versus PCI for patients with isolated LAD artery disease. Three databases were systematically searched to identify randomized controlled trials (RCTs) and adjusted studies. Primary outcomes included long-term survival and repeat target vessel revascularization (TVR). The secondary endpoint was long-term major adverse cardiovascular events (MACEs). Hazards ratios (HR) and Confidence Intervals (CI) were calculated for long-term outcomes and a random effects model was used. Sensitivity analyses included subgroups analysis of stent-type. Nine articles, comprising four RCTs, totaling 2,168 patients (MIDCAB=1,086 and PCI=1,080) were included. The weighted mean follow-up was 4.35±4.9 years. Long-term survival was comparable between MIDCAB and PCI (HR=0.76; 95% CI, 0.58-1.00; p=0.05). MIDCAB was associated with a significantly lower rate of repeat TVR (HR=0.35; 95% CI, 0.25-0.49; p<0.0001) and a reduced risk of MACEs (HR=0.59; 95% CI, 0.43-0.81; p<0.0001), although the difference was not evident in subgroup analysis comparing MIDCAB and PCI with drug-eluting stent (HR=0.66; 95% CI, 0.46-1.06; p=0.09). In conclusion, this meta-analysis of RCTs and adjusted studies shows that in patients with isolated LAD lesion, MIDCAB and PCI exhibit comparable long-term survival. However, MIDCAB is associated with a significantly reduced risk of long-term repeat TVR and MACEs compared to PCI.

Long-term outcomes of minimally invasive direct coronary artery bypass vs second generation drug eluting stent for management of isolated left anterior descending artery disease

INTRODUCTION

This study aimed to compare the long-term outcomes in a propensity matched population receiving either minimally invasive direct coronary artery bypass (MIDCAB) using left internal thoracic artery (LITA) to the left anterior descending artery (LAD) or percutaneous coronary intervention using second generation everolismus-eluting stents (DES-PCI) in patients treated for isolated proximal LAD stenosis.

METHODS

Between January 2012 and December 2017, 421 patients with a nonemergency status undergoing primary isolated proximal LAD revascularization were retrospectively analyzed and were divided into two groups: 111 patients receiving MIDCAB LITA to LAD and 310 patients receiving DES-PCI. Propensity score matching selected 111 pairs and both groups were comparable for all baseline characteristics and well balanced.

RESULTS

In the matched cohort, median follow-up time was 5.19 years (interquartile range, 3.50-6.96). MIDCAB and DES-PCI had comparable long-term outcomes in terms of mortality (Hazard ratio (HR) stratified on matched pairs: 1.60; 95 %CI; 0.58-4.37; P = 0.29), stroke (HR stratified on matched pairs: 0.44; 95 %CI; 0.04-5.13; P = 0.56) and major adverse cardiac and cerebral events (MACCE) (HR stratified on matched pairs:0.57; 95 %CI; 0.26-1.22; P = 0.21). However, MIDCAB was associated with reduced incidence of myocardial infarction (MI) (HR stratified on matched pairs:0.46; 95 %CI; 0.15-0.56; P = 0.001) as well as reduced incidence of target vessel repeat revascularization (TVR) (HR stratified on matched pairs: 0.12; 95 %CI; 0.001; P = 0.01).

CONCLUSION

MIDCAB LITA-LAD offers superior freedom from MI rate and TVR with similar mortality, stroke and MACCE compared with second generation DES-PCI in the treatment of isolated proximal LAD disease.

Alternative Approaches to Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention, How Do They Compare?: A Systematic Review and Meta-Analysis

Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.

Mortality after multivessel revascularisation involving the proximal left anterior descending artery

OBJECTIVE

We sought to investigate whether long-term clinical outcomes differ following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with three-vessel disease (3VD) and lesions in the proximal left anterior descending artery (P-LAD).

METHODS

This post-hoc analysis of the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) Extended Survival study included patients with 3VD who were classified according to the presence or absence of lesions located in the P-LAD. Ten-year all-cause death and 5-year major adverse cardiac or cerebrovascular events (MACCE) were assessed.

RESULTS

Among 1088 patients with 3VD, 559 (51.4%) had involvement of P-LAD and their 10-year mortality was numerically higher following PCI versus CABG (28.9% vs 21.9%; HR: 1.39, 95% CI 0.99 to 1.95). Although patients without P-LAD lesions had significantly higher 10-year mortality following PCI compared with CABG, there was no evidence of a treatment-by-subgroup interaction (28.8% vs 20.2%; HR: 1.47, 95% CI 1.03 to 2.09, pinteraction=0.837). The incidence of MACCE at 5 years was significantly higher with PCI than CABG, irrespective of involvement of P-LAD (with P-LAD: HR: 1.86, 95% CI 1.36 to 2.55; without P-LAD: HR: 1.54, 95% CI 1.11 to 2.12; pinteraction=0.408). Individualised assessment using the SYNTAX Score II 2020 established that a quarter of patients with P-LAD lesions had significantly higher mortality with PCI than CABG, whereas in the remaining three-quarters CABG had similar mortality.

CONCLUSIONS

Among patients with 3VD, the presence or absence of a P-LAD lesion was not associated with any treatment effect on long-term outcomes following PCI or CABG.

TRIAL REGISTRATION NUMBER

SYNTAXES: NCT03417050; SYNTAX: NCT00114972.

Minimally invasive surgery or stenting for left anterior descending artery disease - meta-analysis

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years' experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.