Revascularization strategies in patients with multivessel coronary artery disease: a Bayesian network meta-analysis

Abstract

Treatment modalities for multivessel disease have rapidly evolved, yet the preferred strategy remains controversial. This meta-analysis compared outcomes after on-pump (ONCAB), off-pump coronary artery bypass grafting (OPCAB), percutaneous coronary intervention (PCI) or hybrid coronary revascularization. A comprehensive search for observational studies and randomized controlled trials published by August 2020 was performed. A Bayesian network meta-analysis was conducted for early (<30 days) and late (>12 months) outcomes. A total of 119 studies were included (n = 700 458 patients). The main analysis was confined to 31 randomized controlled trials (n = 24 932 patients). PCI was associated with lower early mortality [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.31–0.79] and stroke (OR 0.22, 95% CI 0.06–0.60) rates compared with ONCAB, whereas a reduced risk of early myocardial infarction was observed with OPCAB compared with ONCAB (OR 0.53, 95% CI 0.32–0.83). Late target vessel revascularization and major adverse cardiac and cerebrovascular events were both increased with PCI compared with ONCAB, OPCAB and hybrid coronary revascularization (by 127–203% and 59–64%, respectively), and late major adverse cardiac events were increased in PCI compared with ONCAB and OPCAB (by 64% and 59%). However, PCI was associated with a significantly lower risk of late stroke compared with ONCAB (OR 0.70, 95% CI 0.52–0.89). Sensitivity analyses (i) including observational studies and (ii) limiting to studies with recent cohorts confirmed the findings of the main analysis. Surgical approaches for revascularization remain superior to PCI in patients with multivessel disease. Hybrid coronary revascularization might be viable for some patients, although more evidence from randomized controlled trials is warranted.

Reply to Gasparovic et al.

“…Another network meta-analysis compared conventional coronary artery bypass grafting (CABG) to either simultaneous or staged HCR and observed a lower rate of stroke in simultaneous HCR when compared to CABG [ 6 ]. This contrasts with the results of the randomized controlled trials, which did not observe a lower stroke rate in HCR [ 5 ]. The observational studies included in the latter meta-analysis might be influenced by residual confounding [ 6 ].…”

“…Combining the high patency of the left internal mammary artery to left anterior descending anastomosis with the less invasive nature of percutaneous coronary interventions, thereby avoiding a sternotomy, seems an attractive alternative to conventional surgery. Indeed, a recent network meta-analysis, comparing revascularization strategies and evaluating all 3 randomized trials on HCR, observed a lower need for target vessel revascularization in the long term, when compared with percutaneous coronary interventions [ 5 ]. Short-term outcomes were comparable to conventional revascularization, although the low number of patients might have led to a type II statistical error.…”

Hybrid coronary revascularization (HCR) versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease (MVCAD): A meta‐analysis of 14 studies comprising 4226 patients

“…In respect to postoperative MI, it is important to note that subgroup analysis consisting of RCTs found a higher risk of postoperative MI with HCR, although not significant. In contrast, Van den Eynde et al 45,59 in two separate meta‐analyses of both observational studies and RCTs found HCR to be associated with a significantly lower risk of MI both postoperatively 45 and on long‐term follow‐up 59 . Despite a relatively large study population, the authors did not conduct sensitivity analysis with only randomized trials, which typically have a more rigorous methodology compared to observational studies, and could have revealed a reliable and more accurate estimate of the risk of MI between HCR and CABG groups.…”

Minimally invasive surgical coronary artery revascularization—current status and future perspectives in an era of interventional advances

“…The undisputed excellent outcomes of conventional CABG utilizing internal thoracic artery (ITA) to the left anterior descending artery (LAD) and total arterial revascularization of other target vessels within various clinical scenarios and contemporary PCI technology have recently been reconfirmed . Van den Eynde and colleagues (86) recently performed a Bayesian network meta-analysis of 119 studies to compare early and late outcomes of contemporary coronary interventions in the setting of multi-vessel disease (MVD). They analysed 700,458 patients who underwent PCI (n=213,536), on-pump-CABG (P-CABG, n=438,443), off-pump-CABG (OPCABG, n=44,980) and hybrid coronary revascularization (HCR, n=3,199) with a median follow-up of 2.8 years (interquartile range, 1-5 years).…”