A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery (original) (raw)
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The Journal of Thoracic and Cardiovascular Surgery, 2014
Objective: To compare the outcomes between minimally invasive coronary artery bypass (MINI-CAB) and drug-eluting stent (DES) implantation for isolated left anterior descending artery disease. Methods: Randomized and observational comparative publications were identified using MEDLINE and Google Scholar databases (January 2003 to December 2013). Studies without outcomes data, without DES use, or using conventional bypass surgery were excluded. The outcomes of interest were cardiac death, myocardial infarction, target vessel revascularization, and periprocedural stroke. Data were compared using the Mantel-Haenszel methods and are presented as odds ratios (ORs), 95% confidence intervals (CIs), and number needed to treat. Results: From 230 publications, we identified 4 studies (2 randomized and 2 observational) with 941 patients (478 had undergone MINICAB and 463 DES implantation). The incidence of target vessel revascularization at maximum follow-up (range, 6-60 months) was significantly lower in the MINICAB group (OR, 0.16; 95% CI, 0.08-0.30; P <.0001; number needed to treat, 13). The incidence of cardiac mortality and MI was similar between the MINICAB and DES groups during follow-up (OR, 1.05; 95% CI, 0.44-2.47; and OR, 0.83; 95% CI, 0.43-1.58, respectively). In addition, a similar incidence of periprocedural death (OR, 0.85; 95% CI, 0.21-3.47; P ¼ .82), myocardial infarction (OR, 0.98; 95% CI, 0.38-2.58; P ¼ .97), and stroke (OR, 1.36; 95% CI, 0.28-6.70; P ¼ .70) was observed between the 2 treatment modalities. Conclusions: Given the available evidence, MINICAB will result in lower target vessel revascularization rates but otherwise similar clinical outcomes compared with DESs in patients with left anterior descending artery disease.
Journal of the American College of Cardiology, 2002
OBJECTIVES This study was done to identify the best treatment for an isolated high-grade stenosis of the proximal left anterior descending coronary artery (LAD). BACKGROUND Percutaneous transluminal coronary angioplasty with stenting (PCI) and off-pump coronary artery bypass grafting (surgery) are used to treat single-vessel disease of a high-grade stenosis of the proximal LAD. Midterm results of both treatments are compared in this prospective randomized study. METHODS In a single-center prospective trial, we randomly assigned 102 patients with a high-grade stenosis of the proximal LAD (American College of Cardiology/American Heart Association classification type B2 or C) to PCI (n ϭ 51) or surgery (n ϭ 51). Primary composite end point was freedom from Major Adverse Cardiac and Cerebrovascular Events (MACCE) at follow-up, including death, myocardial infarction, cerebrovascular accident, and repeat target vessel revascularization (TVR). Secondary end points were angina pectoris class and need for antianginal medication at follow-up. Analysis was by intention-to-treat (ITT) and received treatment (RT). RESULTS Mean follow-up time was three years (90% midrange, two to four years). Incidence of MACCE was 23.5% after PCI and 9.8% after surgery; p ϭ 0.07 ITT (24.1% vs. 8.3%; p ϭ 0.04 RT). After surgery a significantly lower angina pectoris class (p ϭ 0.02) and need for antianginal medication (p ϭ 0.01) was found compared to PCI. Target vessel revascularization was 15.7% after PCI and 4.1% after surgery (p ϭ 0.09). CONCLUSIONS At three-year follow-up (range, two to four years), a trend in favor of surgery is observed in regard to MACCE-free survival with a significantly lower angina pectoris status and significantly lower need for antianginal medication.
European Journal of Cardio-Thoracic Surgery, 2019
OBJECTIVES There are a number of minimally invasive approaches to revascularization of coronary artery disease that involve the left main or proximal left anterior descending artery; however, studies to date provide mixed results. METHODS A Bayesian network meta-analysis was performed to compare early and late postoperative outcomes between percutaneous coronary intervention with first- and second-generation drug-eluting stents (DESs), off-pump coronary artery bypass and minimally invasive direct coronary artery bypass (MIDCAB) in patients with involvement of left main or left anterior descending disease. RESULTS A total of 37 studies with 31 728 patients were included in the analysis. There were no significant differences in early mortality rates, strokes or myocardial infarctions (MIs). The long-term all-cause mortality rate was equivalent between the groups. Patients who had off-pump coronary artery bypass had fewer late MI compared with those who had first-generation DES (DES1) ...
Health Technology Assessment, 2004
Background: Various lipid measurements in monitoring/screening programmes can be used, alone or in cardiovascular risk scores, to guide treatment for prevention of cardiovascular disease (CVD). Because some changes in lipids are due to variability rather than true change, the value of lipid-monitoring strategies needs evaluation. Objective: To determine clinical value and cost-effectiveness of different monitoring intervals and different lipid measures for primary and secondary prevention of CVD. Data sources: We searched databases and clinical trials registers from 2007 (including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, the Clinical Trials Register, the Current Controlled Trials register, and the Cumulative Index to Nursing and Allied Health Literature) to update and extend previous systematic reviews. Patient-level data from the Clinical Practice Research Datalink and St Luke's Hospital, Japan, were used in statistical modelling. Utilities and health-care costs were drawn from the literature. Methods: In two meta-analyses, we used prospective studies to examine associations of lipids with CVD and mortality, and randomised controlled trials to estimate lipid-lowering effects of atorvastatin doses. Patient-level data were used to estimate progression and variability of lipid measurements over time, and hence to model lipid-monitoring strategies. Results are expressed as rates of true-/false-positive and true-/false-negative tests for high lipid or high CVD risk. We estimated incremental costs per quality-adjusted life-year.
European Journal of Cardio-Thoracic Surgery, 2013
OBJECTIVES: The spread of drug-eluting stents (DES) has reduced the incidence of early restenosis following percutaneous coronary interventions (PCI). Meanwhile, development of minimally invasive coronary artery bypass surgery (MIDCAB) has offered a valuable alternative to conventional sternotomy with preservation of the benefit of the internal mammary artery use. Therefore, the revascularization of the left anterior descending (LAD) artery is suitable for both techniques. However, few data with long-term comparison of these two techniques exist. METHODS: Prospective data were collected for 456 patients undergoing isolated LAD revascularization between 1997 and 2011. Two hundred and sixty patients were treated with MIDCAB and 196 with first-generation DES implantation. A propensity score model was created to adjust for 19 relevant confounding variables. Primary and secondary end-points were, respectively, 5-year survival and freedom from major adverse cerebro-cardiovascular events (MACCE). RESULTS: Both groups were similar in age, EuroSCORE and mean duration of follow-up. Five-year survival was similar after MIDCAB or DES (hazard ratio (HR): 0.95; P = 0.89). Freedom from MACCE was significantly in favour of the MIDCAB group (HR: 0.32, P < 0.0001), mainly triggered by high subsequent need for revascularization of the targeted vessel in the DES group (HR: 0.17, P < 0.0001). CONCLUSIONS: MIDCAB and DES implantation showed similar rates of survival but despite an expected lower rate of reintervention on the targeted vessel with DES use, a highly significant higher MACCE rate was observed in the PCI group at 5-year follow-up.
The Journal of Thoracic and Cardiovascular Surgery, 2014
a on behalf of the Harefield Cardiac Outcomes Research Group Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) has been proposed to reduce surgical morbidity and improve long-term outcomes compared with stenting in the treatment of isolated proximal left anterior descending artery. However, the survival benefit from MIDCAB still needs to be demonstrated, in particular, because percutaneous coronary intervention with drug-eluting stents (DES-PCI) continues to be considered the initial treatment strategy. We conducted a 10-year follow-up, single-center, propensity score-matched MIDCAB versus DES-PCI comparison. Methods: A total of 1033 patients (303 MIDCAB and 730 DES-PCI) with isolated proximal left anterior descending disease were included. Propensity score matching was used to compare 303 pairs of MIDCAB and DES-PCI patients. Results: MIDCAB and DES-PCI presented with comparable 30-day mortality (2 of 303 [0.6%] vs 1 of 303 [0.3%]; P ¼ 1.0). At 10 years, DES-PCI was associated with a 2.19-fold increased risk of late death (95% confidence interval, 1.15-4.17), a 2.0-fold increased risk of repeat revascularization (95% confidence interval, 1.20-3.47), and a 2.14-fold increased risk of the composite of death and repeat revascularization (95% confidence interval, 1.41-3.24). Conclusions: These findings strongly support a survival benefit from MIDCAB at long-term follow-up compared with DES-PCI in the treatment of isolated left anterior descending disease.
Treatment of left anterior descending coronary artery stenosis: stent or surgery
Asian Cardiovascular and Thoracic Annals, 2013
Background: Drug-eluting stents have emerged as a solution to the problem of restenosis after bare-metal stent implantation, as an alternative to off-pump coronary bypass, for isolated left anterior descending coronary artery lesions at short-term follow-up. However, long-term follow-up is yet to be defined. Methods: From January to December 2004, 64 consecutive patients underwent myocardial revascularization: 31 by drug-eluting stents and 33 by off-pump coronary bypass. The primary endpoint was angiographic outcome, and the secondary endpoint was clinical outcome at 5 years.
New England Journal of Medicine, 2002
Background Minimally invasive bypass surgery and coronary-artery stenting are both accepted treatments for isolated stenosis of the proximal left anterior descending coronary artery. We compared the clinical outcomes after these two procedures. Methods A total of 220 symptomatic patients with high-grade lesions in the proximal left anterior descending coronary artery were randomly assigned to treatment-110 to surgery and 110 to stenting. The combined clinical end point was freedom from major adverse cardiac events, such as death from cardiac causes, myocardial infarction, and the need for repeated revascularization of the target lesion within six months. Results A major adverse cardiac event occurred in 31 percent of patients after stenting, as compared with 15 percent in the surgery group (P=0.02). The difference was predominantly due to a higher rate of repeated revascularization of the target vessel for restenosis after stenting (29 percent vs. 8 percent, P=0.003). The combined rates of death and myocardial infarction did not differ significantly between groups (3 percent in the stenting group and 6 percent in the surgery group, P=0.50). Adverse events occurred more frequently after surgery. The percentage of patients free from angina after six months was 79 percent in the surgery group, as compared with 62 percent in the stenting group (P=0.03). Conclusions In patients with isolated high-grade lesions of the proximal left anterior descending artery, both minimally invasive bypass surgery and stenting are effective. Stenting yields excellent short-term results with fewer periprocedural adverse events, but surgery is superior with regard to the need for repeated intervention in the target vessel and freedom from angina at six months of follow-up.
The American Journal of Cardiology, 2004
The purpose of this study was to compare the clinical outcomes of stenting and minimally invasive coronary artery bypass grafting (MIDCAB) in patients with proximal left anterior descending (LAD) coronary artery disease. The Patency, Outcome, Economics of Minimally invasive direct coronary bypass (POEM) study demonstrated that MIDCAB had similar safety and long-term efficacy for LAD revascularization compared with conventional coronary artery bypass grafting. Although LAD stenting is superior to conventional balloon angioplasty, whether it is comparable to MIDCAB is not known. We identified a matched population of 429 consecutive patients with 1-vessel disease who underwent elective proximal LAD stenting and compared their clinical outcomes with those of the 152 patients in the MIDCAB group of the POEM study. The in-hospital event rate was similar in both groups, except for a shorter