Coronary Artery Bypass Graft Surgery vs Percutaneous Interventions in Coronary Revascularization

Abstract

IMPORTANCE Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups. OBJECTIVE To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD). EVIDENCE REVIEW A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible. FINDINGS Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX Յ22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies. CONCLUSIONS AND RELEVANCE Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.

Association of Dialysis Duration with Outcomes after Transplantation in a Japanese Cohort

“…Sixty-one (7.8%) patients had histories of preoperative CVD events. Among these patients, 46 experienced CAD, which were acute myocardial infarction (12), PCI (15), coronary artery bypass grafting (three), and angina pectoris (16). Sixteen experienced cerebrovascular disease, which were cerebral infarction (11) and cerebral hemorrhage (five).…”

“…Coronary revascularization, either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting, may be indicated in patients with flow-limiting coronary stenosis to reduce myocardial ischemia and related adverse clinical manifestations (10)(11)(12). In addition to acute coronary syndrome, revascularization for stable coronary artery disease (CAD) was performed at our institution according to the 2014 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization (13).…”

One‐year clinical outcomes after sirolimus‐eluting coronary stent implantation in diabetics enrolled in the worldwide e‐SELECT registry

“…These mechanisms not only are implicated in the progression of clinically significant coronary artery disease but may also jeopardize long-term PCI results [29][30][31]. Accordingly, concerns have been raised regarding PCI in DM patients, especially in case of multivessel disease, which prompted extensive research exploring the potential superiority of surgical revascularization [32]. Although randomized controlled trials suggested a competitive efficacy of bypass surgery over PCI in diabetics with complex multivessel disease, it is routine practice worldwide to refer these patients to the catheterization laboratory in a significant proportion of cases [33].…”

Coronary surgery in elderly: it is never too late

“…The optimal revascularization strategy for patients with multivessel coronary artery disease (CAD) remains still debated (1)(2)(3). The decision to recommend coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) should be driven by a comparison of the short-term and long-term effect on outcomes.…”