Left Main Stenting in Comparison With Surgical Revascularization

Buszman, Paweł; Buszman, Piotr P.; Banasiewicz-Szkróbka, Iwona; Milewski, Krzysztof; Żurakowski, Aleksander; Orlik, Bartłomiej; Konkolewska, Magda; Trela, Blazej; Janas, Adam; Martin, Jack L.; Kiesz, R. Stefan; Bochenek, Andrzej

doi:10.1016/j.jcin.2015.10.044

Cited by 130 publications

(49 citation statements)

References 15 publications

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“…Interestingly, we observed that rates of 30-day MACCE reported in three RCTs 6,13,15 were 45% lower in PCI arm (RR 0.55, 95% CI 0.39–0.76). This was mainly driven by lower rates of stroke in the PCI arm when compared with CABG arm (RR 0.41, 95% CI 0.17–0.98) (Figure 4, Panel A ).…”

Section: Resultsmentioning

confidence: 74%

“…We identified six RCTs 5,6,10,13–15 (Figure 1) enrolling 4700 patients with LMD to study the role of PCI vs. CABG. All studies had at least 1 year of follow-up, with a range of 1 to 10 years.…”

Section: Resultsmentioning

confidence: 99%

“…Of the 4700 patients, 2349 patients underwent PCI and 2351 underwent CABG. All included studies 5,6,10,13,14 were categorized as good quality, except LE MANS trial, 15 based on the Jadad quality score scale (Table 3). …”

Section: Resultsmentioning

confidence: 99%

“…Pooled analysis of the six RCTs 5,6,10,13–15 demonstrated a statistically significant 21% higher risk of long-term MACCE in patients undergoing PCI when compared with CABG [RR 1.21, 95% confidence interval (CI) 1.05–1.40] (Figure 2). This higher risk of MACCE was primarily driven by a 61% higher long-term rates of repeat revascularization in patients undergoing PCI for LMD revascularization when compared with CABG (RR 1.61, 95% CI 1.34–1.95).…”

Section: Resultsmentioning

confidence: 99%

“…All discrepancies in data extraction were resolved by consensus among senior author and authors collecting the data. After examining 1169 relevant studies, we included six RCTs 5,6,10,13–15 that assessed and compared efficacy of the aforementioned revascularization approaches of LMD. Two authors (N.P.…”

Section: Methodsmentioning

confidence: 99%

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Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated meta-analysis

Bajaj

Patel

Kalra

et al. 2017

European Heart Journal - Quality of Care and Clinical Outcomes

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Aims The optimal revascularization strategy for left main coronary artery disease (LMD) remains controversial, especially with two recent randomized controlled trials showing conflicting results. We sought to address this controversy with our analysis. Methods and results Comprehensive literature search was performed. We compared percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMD revascularization using standard meta-analytic techniques. A 21% higher risk of long-term major adverse cardiac and cerebrovascular event [MACCE; composite of death, myocardial infarction (MI), stroke, and repeat revascularization] was observed in patients undergoing PCI in comparison with CABG [risk ratio (RR) 1.21, 95% confidence interval (CI) 1.05–1.40]. This risk was driven by higher rate of repeat revascularization in those undergoing PCI (RR 1.61, 95% CI 1.34–1.95). On the contrary, MACCE rates at 30 days were lower in PCI when compared with CABG (RR 0.55, 95% CI 0.39–0.76), which was driven by lower rates of stroke in the PCI arm (RR 0.41, 95% CI 0.17–0.98). At 1 year, lower stroke rates (RR 0.21, 95% CI 0.08–0.59) in the PCI arm were balanced by higher repeat revascularization rates in those undergoing PCI (RR 1.78, 95% CI 1.33–2.37), resulting in a clinical equipoise in MACCE rates between the two revascularization strategies. There was no difference in death or MI between PCI when compared with CABG at any time point. Conclusion Outcomes of CABG vs. PCI for LMD revascularization vary over time. Therefore, individualized decisions need to be made for LMD revascularization using the heart team approach.

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Section: Resultsmentioning

confidence: 74%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 3 more Smart Citations

Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated meta-analysis

Bajaj

Patel

Kalra

et al. 2017

European Heart Journal - Quality of Care and Clinical Outcomes

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Bayesian Interpretation of the EXCEL Trial and Other Randomized Clinical Trials of Left Main Coronary Artery Revascularization

Brophy

2020

JAMA Intern Med

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IMPORTANCEPatients with left main coronary artery disease have improved outcomes with coronary revascularization compared with medical therapy, but the choice of optimal revascularization technique is unresolved. OBJECTIVETo use bayesian methods to analyze the risk differences for patients with left main coronary artery disease randomized to treatment with coronary artery bypass surgery (CABG) compared with those randomized to percutaneous coronary intervention (PCI) in recent randomized clinical trials (RCTs). DESIGN, SETTING, AND PARTICIPANTSA systematic review using the PubMed database with the query string "(left main disease) and (PCI or CABG) and (5-year follow-up) and (clinical trial)" identified all RCTs from January 1996 to January 2020 comparing CABG to PCI for treatment of patients with left main coronary artery disease and with 5-year follow-up data. With the use of bayesian methods, the largest and most publicized RCT (EXCEL; Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization; 2019) was reanalyzed (1) as an isolated entity using noninformative priors and (2) in the context of previous knowledge using informative priors derived from similar trials. Published aggregate data were used with assignments from each trial following the original intention-to-treat principle. Combining EXCEL data with varying levels of prior information using Bayes theorem provided final (posterior) probability distributions for primary and secondary outcomes. MAIN OUTCOMES AND MEASURESA composite end point of death, nonfatal myocardial infarction, and stroke was the primary EXCEL outcome and was accordingly the primary outcome for this reanalysis. Secondary analyses were performed for isolated all-cause mortality and for the composite outcome along with repeated revascularization procedures. RESULTSWhen EXCEL data were analyzed using the originally stated noninferiority design, the 5-year primary outcome difference reported (2.8%; 95% CI, −0.9% to 6.5%) exceeded the predefined 4.2% noninferiority margin; thus, the null hypothesis of PCI inferiority could not be rejected. By contrast, the present bayesian analysis of the EXCEL primary outcome estimated 95% probability that the 5-year primary outcome difference was increased with PCI compared with CABG and 87% probability that this difference was greater than 1 extra event per 100 patients treated. Bayesian analyses also suggested 99% probability that EXCEL total mortality was increased with PCI and 94% probability that this absolute difference exceeded 1 extra deaths per 100 treated. A systematic review identified 3 other RCTs that studied the same question. The incorporation of this prior knowledge reduced the estimated probability of any excess mortality with PCI to 85%. For the secondary composite end point, which also included repeated revascularizations, there were estimated probabilities of 98% for at least 4 extra events and of 90% for at least 5 extra events per 100 patients treated with PCI.CONCLUSIONS AND RELEV...

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Overall and Cause-Specific Mortality in Randomized Clinical Trials Comparing Percutaneous Interventions With Coronary Bypass Surgery

et al. 2020

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IMPORTANCEMortality is a common outcome in trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG). Controversy exists regarding whether all-cause mortality or cardiac mortality is preferred as a study end point, because noncardiac mortality should be unrelated to the treatment. OBJECTIVE To evaluate the difference in all-cause and cause-specific mortality in randomized clinical trials (RCTs) comparing PCI with CABG for the treatment of patients with coronary artery disease.DATA SOURCES MEDLINE (1946 to the present), Embase (1974 to the present), and the Cochrane Library (1992 to the present) databases were searched on November 24, 2019. Reference lists of included articles were also searched, and additional studies were included if appropriate.STUDY SELECTION Articles were considered for inclusion if they were in English, were RCTs comparing PCI with drug-eluting or bare-metal stents and CABG for the treatment of coronary artery disease, and reported mortality and/or cause-specific mortality. Trials of PCI involving angioplasty without stenting were excluded. For each included trial, the publication with the longest follow-up duration for each outcome was selected.DATA EXTRACTION AND SYNTHESIS For data extraction, all studies were reviewed by 2 independent investigators, and disagreements were resolved by a third investigator in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were pooled using fixed-and random-effects models. MAIN OUTCOMES AND MEASURESThe primary outcomes were all-cause and cause-specific (cardiac vs noncardiac) mortality. Subgroup analyses were performed for PCI trials using drug-eluting vs bare-metal stents and for trials involving patients with left main disease.RESULTS Twenty-three unique trials were included involving 13 620 unique patients (6829 undergoing PCI and 6791 undergoing CABG; men, 39.9%-99.0% of study populations; mean age range, 60.0-71.0 years). The weighted mean (SD) follow-up was 5.3 (3.6) years. Compared with CABG, PCI was associated with a higher rate of all-cause (incidence rate ratio, 1.17; 95% CI, 1.05-1.29) and cardiac (incidence rate ratio, 1.24; 95% CI, 1.05-1.45) mortality but also noncardiac mortality (incidence rate ratio, 1.19; 95% CI, 1.00-1.41).CONCLUSIONS AND RELEVANCE Percutaneous coronary intervention was associated with higher all-cause, cardiac, and noncardiac mortality compared with CABG at 5 years. The significantly higher noncardiac mortality associated with PCI suggests that even noncardiac deaths after PCI may be procedure related and supports the use of all-cause mortality as the end point for myocardial revascularization trials.

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Left Main Stenting in Comparison With Surgical Revascularization

Cited by 130 publications

References 15 publications

Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated meta-analysis

Percutaneous coronary intervention vs. coronary artery bypass grafting for left main revascularization: an updated meta-analysis

Bayesian Interpretation of the EXCEL Trial and Other Randomized Clinical Trials of Left Main Coronary Artery Revascularization

Overall and Cause-Specific Mortality in Randomized Clinical Trials Comparing Percutaneous Interventions With Coronary Bypass Surgery

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