Left Main Disease PCI vs CABG: A Brief Review of Important Literature

2021 ◽  
Vol 8 (09) ◽  
pp. 5652-5655
Author(s):  
Usman Sarwar ◽  
Nikky Bardia ◽  
Ali Hussain ◽  
Muhammad Nadeem ◽  
Hassan Tahir
Keyword(s):  
Coronary Artery ◽  
Treatment Guidelines ◽  
Meta Analysis ◽  
Sudden Cardiac Arrest ◽  
Percutaneous Intervention ◽  
Class I ◽  
Syntax Score ◽  
Class Iii ◽  
Left Main ◽  
Left Main Disease

Left main coronary artery (LMCA) disease is defined as > 50% narrowing of vessel diameter; it is the disease of significant morbidity and mortality because it supplies 75% of the left ventricle, so any insult to the left main can lead to severe LV dysfunction, sudden cardiac arrest and arrhythmia. The incidence of left main disease in patients undergoing coronary angiography is 4-6%. The untreated left main disease has mortality around 20% at 1 year [1,2].Initially, the procedure of choice for the significant left main disease was coronary artery by-pass surgery (CABG), as medical therapy carries a high mortality rate as compared to CABG (36.5% vs 16.0%). Nevertheless, with the advancement in percutaneous intervention (PCI), there is a growing interest and passion in the percutaneous intervention of LMCA [3]. European [4] and American [5] guidelines recommend CABG (class I) as the treatment method of choice for LMCA in patients with all anatomical complexities. Current European treatment guidelines give PCI class I along with CABG if SYNTAX score < 22, class IIa if between 23-32, and class III (Harm) if SYNTAX > 33. Current US guidelines currently gives class IIa recommendation for PCI if syntax score is low, class IIb for a score between 23-32 and similar to European guideline's class III (Harm) for SYNTAX score > 33. We reviewed the major landmark trials that compare PCI vs CBAG as a treatment option for left main disease along with important meta-analysis

scholarly journals Long-term prediction of mortality and comparative treatment benefit following percutaneous or surgical revascularization

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
H Hara ◽  
H Shiomi ◽  
D Van Klaveren ◽  
D Kent ◽  
E W Steyerberg ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Absolute Risk ◽  
Artery Bypass ◽  
Risk Difference ◽  
Syntax Score ◽  
Left Main ◽  
Left Main Disease ◽  
Treatment Benefit ◽  
Vessel Disease ◽  
Prediction Of Mortality

Abstract Background The SYNTAX score II 2020 (SSII-2020), which was derived and externally validated from randomized trials, was designed to predict death following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel disease and/or left main disease. We aimed to investigate its value in identifying the safest modality of revascularization in a non-randomized setting. Methods Five-year mortality was assessed in 7362 patients with three-vessel disease and/or left main disease enrolled in a Japanese PCI/CABG registry. New-generation drug eluting stents and imaging guidance became the default PCI strategy during enrolment of the last cohort. The discriminative ability of the SSII-2020 for 5-year mortality was assessed using Harrell's C statistic (C-index). Agreement between observed and predicted rates of all-cause mortality following either PCI or CABG and treatment benefit (absolute risk difference) for this outcome were assessed by calibration plots. Results The SSII-2020 had helpful discrimination (C-index = 0.72) and good calibration (intercept = −0.11, slope = 0.92) for 5-year mortality. The absolute risk difference in mortality between CABG and PCI (treatment benefit) was well calibrated when the whole population was grouped into quarters according to the predicted absolute risk difference of 5-year mortality. The observed differences in survival in favor of CABG were 4.2% (0.1 to 8.2%, log-rank p=0.05) and 8.5% (3.8 to 13.2%, log-rank p&lt;0.01) in the respective third and fourth quarters. In contrast, the observed differences in survival were not significantly different in either the first (3.0% [−0.8 to 6.8%, log-rank p=0.12]) or the second quarter (1.3% [−2.4 to 5.1%, log-rank p=0.39]). Conclusions The SSII-2020 is well able to predict death at 5 years – and the mortality difference between PCI and CABG, and therefore has the potential to support decision making on revascularization in patients with three-vessel disease and/or left main coronary artery disease. FUNDunding Acknowledgement Type of funding sources: None.

P4733Risk of myocardial infarction with coronary artery bypass grafting versus percutaneous coronary intervention: a systematic review and meta-analysis of fifteen randomised trials

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
P H Lee ◽  
H B Park ◽  
J S Lee ◽  
S W Lee ◽  
C W Lee
Keyword(s):  
Coronary Artery ◽  
Meta Analysis ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Left Main ◽  
Left Main Disease ◽  
Percutaneous Coronary ◽  
Meta Regression ◽  
Artery Disease

Abstract Background It remains controversial whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is more effective in the prevention of myocardial infarction (MI). MI has been evaluated only as a secondary endpoint without a focused systematic review in multiple meta-analyses. Purpose To compare the risk of MI at the latest follow-up available between CABG versus PCI with stents in patients with multivessel or left main coronary artery disease in a pairwise meta-analysis of randomised controlled trials (RCT). Methods We searched EMBASE, Cochrane, and Pubmed databases for articles comparing CABG versus PCI for the treatment of multivessel or left main disease. We utilised random-effects model to calculate pooled risk ratio (RR) and 95% confidence interval (CI). Fifteen trials with a total of 13,592 patients treated with either CABG (n=6,596) or PCI (n=6,996) were eligible and included. A multivariable random-effects meta-regression model, including variables such as age, sex, diabetes mellitus, publication year, follow-up duration, type of stent used, and type of coronary artery disease, was used to explore the source of potential heterogeneity of the primary result. Results After a weighted follow-up of 4.3 years, patients treated with CABG had a significantly lower risk of MI than patients treated with PCI (RR 0.75, 95% CI 0.58–0.96, P=0.024, I2=66%). The lower risk of MI with CABG as compared to PCI was more evident during a longer duration of follow-up (≥3 years, RR 0.69, 95% CI 0.52–0.91, P=0.008; ≥5 years, RR 0.64, 95% CI 0.48–0.86, P=0.003) and in diabetic population (RR 0.55, 95% CI 0.44–0.70, P<0.001). There was a statistically meaningful trend toward fewer MIs with CABG with a similar magnitude of risk reduction across patients with left main disease (RR 0.74, 95% CI 0.47–1.15) and multivessel disease (RR 0.72, 95% CI 0.53–0.99). Moderate inter-study heterogeneity could not be explained by the clinical and trial-based variables tested in meta-regression, and is likely because of differences in definitions of MI, risk profile of enrolled patients, and procedural specifics. Forest plots Conclusions In patients undergoing revascularization for multivessel or left main disease, the risk of MI was lower with CABG compared to PCI. The quality assurance for MI definition and treatment-specific procedures should be emphasized for future RCTs.

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