Ten-year follow-up after combined coronary artery bypass grafting and transmyocardial laser revascularization in patients with disseminated coronary atherosclerosis (original) (raw)
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Kardiologia Polska, 2013
Background: Left main stenosis (LMS) occurs in 5-7% of patients with coronary artery disease. Half of patients with left main coronary artery (LMCA) disease die within few years after the diagnosis. Aim: To evaluate survival of patients with LMCA disease treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or managed medically due to lack of consent for CABG or being considered unsuitable candidates for CABG/PCI. Methods: In 2006-2008, a significant LMS was found in 257 (5.14%) patients, and 98.44% of these patients were followed up for on average 15.1 months. The patients were divided into 5 groups according to the treatment used. CABG was performed in 67% of patients, PCI of an unprotected LMS in 8% of patients, and 12% of patients were treated with PCI after a previous CABG (protected LMS). The remaining patients were managed medically: 4% were not considered suitable for CABG, and 9% did not give their consent for CABG. Results: Total mortality in the overall study group (n = 253) was 14.6%. Multivessel disease was more frequent in the CABG group (60.9% vs. 15.8%, p < 0.001). Mortality in CABG and PCI groups was comparable (11.4% vs. 15.8%). Patients in the PCI group were more frequently hospitalised due to recurrent angina (21.1% vs. 3.0%, p < 0.001) and the need for repeated revascularisation (15.8% vs. 1.2%, p < 0.001). Compared to the CABG group, patients considered not suitable for CABG had lower left ventricular ejection fraction (LVEF) (36.55% vs. 51.04%, p < 0.001) and a higher mortality risk as estimated by the EuroScore. Mortality among patients deemed unsuitable for CABG was 54.6% (p < 0.001) and myocardial infarctions were observed more frequently in this group (18.2% vs. 2.4%, p < 0.01). In comparison to the CABG group, patients who did not consent to CABG were older (71.04 vs. 65.99 years, p = 0.027), had lower LVEF (44.05% vs. 51.04%, p = 0.004), were less frequently hospitalised due to acute coronary syndromes (17.4% vs. 40.8%, p = 0.03), and had a smaller degree of LMS (63% vs. 71%, p = 0.027). Mortality in this group was comparable to the CABG group (17.4% vs. 11.4%). The majority of patients who underwent previous CABG needed repeated revascularisation: PCI of a protected LMS was performed in 27% of patients, PCI of other native coronary arteries in 39% of patients, and PCI of a bypass graft in 7% of patients. Conclusions: PCI of unprotected LMCA may be an equally effective revascularisation method as CABG. High mortality (55%) due to concomitant diseases was observed among patients with LMS who were deemed unsuitable candidates for CABG. Prognosis among patients who declined CABG was relatively good and might have been related to the small number of patients and different patient characteristics in this group.
Selection of Surgical or Percutaneous Coronary Intervention Provides Differential Longevity Benefit
2010
Methods. In this study, 18,481 patients with significant (>75% stenosis) CAD treated at a single center between 1986 and 2000 were assigned to one of three groups based on initial treatment strategy: medical therapy (MED) (n ؍ 6862), PCI (n ؍ 6292), or CABG (n ؍ 5327). Each group was categorized into 3 groups according to baseline severity of CAD: low-severity (predominantly 1-vessel), intermediate-severity (predominantly 2-vessel), and high-severity (all 3-vessel), and prospectively evaluated in Cox models for all-cause mortality adjusted for cardiac risk, comorbidity, and propensity for selection of a specific treatment. Treatments were compared for the entire period and three eras (1: 1986 to 1990; 2: 1991 to 1995; 3: 1996 to 2000), the last encompassing widespread availability of PCI with stenting.
Current Clinical Outcomes of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting
The Annals of Thoracic Surgery, 2008
Background. Randomized trials have compared coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). However, results of these trials in select patients may not accurately reflect current clinical practice using drug-eluting stents (DES) and off-pump CABG. We undertook a prospective registry of coronary revascularization by CABG on-pump and offpump, and PCI with or without DES, to determine clinical outcomes. Methods. All patients undergoing isolated coronary revascularization in 8 community-based hospitals were enrolled. Preprocedural, intraprocedural, and postprocedural data were captured, with outcomes obtained at 18 months by patient and physician contact, and the Social Security Death Index. Results. The study enrolled 4336 patients, 71.2% PCI and 28.8% CABG. DESs were used in 2249 PCIs (73.1%), and 596 CABG procedures (47.8%) were off-pump. Incidence of major adverse cardiac events at 18 months was 14.7% for CABG vs 23.3% for PCI (p < 0.001). Cardiac death and myocardial infarction had similar rates. The need for repeat revascularization was significantly less with CABG (6.2% vs 13.6%, p < 0.001). Hazard ratio of CABG to PCI was 0.76 (95% confidence interval, 0.571 to 0.872). CABG outcome was similar on-pump and offpump, as was repeat revascularization with DES (12.1%) vs BMS (14.9%; p ؍ 0.096). Overall event-free survival was 85.3% in CABG and 76.8% in PCI (p < 0.001). Conclusions. Rates of repeat revascularization were significantly higher for PCI than for CABG, but mortality and myocardial infarction were the same. There were no significant differences in outcomes between DES and BMS or between on-pump and off-pump CABG.
Circulation, 2010
Background-This study compared the 10-year follow-up of percutaneous coronary intervention (PCI), coronary artery surgery (CABG), and medical treatment (MT) in patients with multivessel coronary artery disease, stable angina, and preserved ventricular function. Methods and Results-The primary end points were overall mortality, Q-wave myocardial infarction, or refractory angina that required revascularization. All data were analyzed according to the intention-to-treat principle. At a single institution, 611 patients were randomly assigned to CABG (nϭ203), PCI (nϭ205), or MT (nϭ203). The 10-year survival rates were 74.9% with CABG, 75.1% with PCI, and 69% with MT (Pϭ0.089). The 10-year rates of myocardial infarction were 10.3% with CABG, 13.3% with PCI, and 20.7% with MT (PϽ0.010). The 10-year rates of additional revascularizations were 7.4% with CABG, 41.9% with PCI, and 39.4% with MT (PϽ0.001). Relative to the composite end point, Cox regression analysis showed a higher incidence of primary events in MT than in CABG (hazard ratio 2.35, 95% confidence interval 1.78 to 3.11) and in PCI than in CABG (hazard ratio 1.85, 95% confidence interval 1.39 to 2.47). Furthermore, 10-year rates of freedom from angina were 64% with CABG, 59% with PCI, and 43% with MT (PϽ0.001). Conclusions-Compared with CABG, MT was associated with a significantly higher incidence of subsequent myocardial infarction, a higher rate of additional revascularization, a higher incidence of cardiac death, and consequently a 2.29-fold increased risk of combined events. PCI was associated with an increased need for further revascularization, a higher incidence of myocardial infarction, and a 1.46-fold increased risk of combined events compared with CABG. Additionally, CABG was better than MT at eliminating anginal symptoms.
Coronary angioplasty versus CABG: review of randomized trials
Arquivos brasileiros de cardiologia, 2011
We carried out a review that included results of randomized trials that made a comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The 25 selected trials involved 12,305 patients, 11,103 of whom were from studies in patients with multi-vessel disease and 1,212 were from studies in patients with single lesion of the left anterior descending (LAD). In the studies of multi-vessel disease patients, the PCI showed a trend towards lower early mortality (1.2% versus 2%) and lower incidence of stroke: 0.7% versus 1.65%. There was no difference in the intermediate mortality (3.8% versus 3.8%). There was a trend towards the superiority of CABG in late mortality (10.5% versus 9.6%). The difference was exclusively due to "balloon era" studies, with a trend towards an inversion in the "stent era" (9.6% versus 9.9%). In studies of single lesion of LAD, there was no…
Baseline characteristics of patients in the Coronary Artery Bypass Graft (CABG) Patch Trial
American Heart Journal, 1997
Background Patients with left ventricular dysfunction who undergo coronary artery bypass graft (CABG) surgery frequently have late sudden cardiac death. The CABG Patch Trial is a prospective, randomized, multicenter clinical trial that randomized patients at high risk at the completion of CABG surgery to implantation of an epicardial implantable cardioverter defibrillator (ICD) or to no antiarrhythmic treatment. The trial was designed to determine whether prophylactic implantation of an ICD at the time of CABG surgery would result in a lower total mortality in long-term follow-up.
Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2010
Objectives: Transmyocardial revascularization (TMR) has been used as an isolated or adjunctive revascularization therapy in patients presumed to have nonbypassable coronary artery disease. The purpose of this study is to evaluate the short-and midterm mortality for patients with complete revascularization using TMR and coronary artery bypass grafting (CABG) compared with those patients with incomplete CABG revascularization and to document longterm follow-up in patients receiving TMR ϩ CABG. Methods: Seventy TMR ϩ CABG patients were cohort matched with 70 patients undergoing isolated CABG with circumflex coronary artery disease, but with no bypassable distal targets, from 1999 to 2005 at Emory University Hospital. The data were retrospectively reviewed from a database after being prospectively entered. Results are presented in mean Ϯ standard deviation, and Kaplan-Meier curves were created for long-term all-cause mortality. Results: The TMR ϩ CABG patients had a similar incidences to the CABG only group for preoperative ejection fraction (50.9 Ϯ 11.2% vs. 50.7 Ϯ 10.3%, P ϭ 0.93), number of grafts (2.6 Ϯ 1.1 vs. 2.5 Ϯ 1.3, P ϭ 0.5), and number of diseased vessels (2.8 Ϯ 0.3 vs. 2.9 Ϯ 0.4, P ϭ 0.26). Off-pump surgery was used more often in the CABG alone group versus the TMR combined with CABG group (74.3% vs. 41.4%, P Ͻ 0.001). Postoperatively, there was no statistical difference among the TMR ϩ CABG and the CABG alone groups for intensive care unit length of stay (4.3 Ϯ 7.8 days vs. 2.6 Ϯ 3.4 days, P ϭ 0.026), postsurgical length of stay (7.6 Ϯ 6.1 days vs. 6.8 Ϯ 4.5 days, P ϭ 0.31), stroke events (1.4% vs. 1.4%, P ϭ 1.00), myocardial infarction (4.3% vs. 2.9%, P ϭ 0.65), and 30-day mortality (5.7% vs. 4.3%, P ϭ 0.70). Long-term survival rate was not statistically significant. In addition, 4-year follow-up in the TMR ϩ CABG group had symptom improvement with reduction in New York Heart Association classification for class III/IV (P Ͻ 0.0001, baseline vs. 4-year follow-up). Conclusions: The combination of TMR and CABG for complete revascularization is safe and carries no further risk to patients compared with CABG only. CABG ϩ TMR patients tend to have increased resource utilization. Long-term follow-up shows similar survival between the groups. TMR can be a useful adjunct to CABG for complete revascularization.