Comparison of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Disease　– 5-Year Outcome From CREDO-Kyoto PCI/CABG Registry Cohort-2 –

Background:The synergy between percutaneous coronary intervention (PCI) with TAXUS and Cardiac Surgery (SYNTAX) score is an angiographic tool which is used to determine the complexity of coronary artery disease (CAD). We aimed to compare PCI versus coronary artery bypass surgery (CABG) in patients with a high SYNTAX score in order to confirm with evidence whether the former is really association with worse clinical outcomes.Methods:The National database of medical research articles (MEDLINE/PubMed), EMBASE database, and the Cochrane library were searched for publications comparing PCI versus CABG in patients with a high SYNTAX score, respectively. Death, myocardial infarction (MI), stroke, repeated revascularization, and a combined outcome death/stroke/MI were considered as the clinical endpoints. RevMan software was used to analyze the data, whereby odds ratios (OR) with 95% confidence intervals (CI) were used as the statistical parameters.Results:A total number of 1074 patients were included (455 patients with a high SYNTAX score were classified in the PCI group and 619 other patients with a high SYNTAX score were classified in the CABG group). A SYNTAX score cut-off value of ≥33 was considered relevant. Compared with CABG, mortality was significantly higher with a high SYNTAX score following PCI with OR: 1.79, 95% CI: 1.18 to 2.70; P = .006, I2 = 0%. The combined outcome death/stroke/MI was also significantly higher following PCI with a high SYNTAX score, with OR: 1.69, 95% CI: 1.24 to 2.30; P = .0009, I2 = 0%. In addition, PCI was also associated with significantly higher MI and repeated revascularization when compared with CABG, with OR: 3.72, 95% CI: 1.75 to 7.89; P = .0006, I2 = 0% and OR: 4.33, 95% CI: 1.71 to 10.94; P = .002, I2 = 77%, respectively. However, stroke was not significantly different.Conclusions:Compared with CABG, worse clinical outcomes were observed following PCI in patients with a high SYNTAX score, confirming with evidence, published clinical literatures. Therefore, CABG should be recommended to CAD patients who have been allotted a high SYNTAX score.

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“…Finally, only 4 studies [8–11] satisfied the inclusion and exclusion criteria and were selected for this analysis (Fig. 1).…”

Section: Resultsmentioning

confidence: 99%

Worse clinical outcomes following percutaneous coronary intervention with a high SYNTAX score

2017

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“…The recently published CREDO-Kyoto PCI/CABG Registry Cohort-2 results showed that the adjusted risk for death/MI/stroke was not signifi cantly different between the group of patients with unprotected LMS stenosis treated by PCI versus the group treated by CABG in patients with low (< 23) or intermediate (23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33) SYNTAX score, whereas it was signifi cantly higher in the PCI group than in the CABG group in patients with high (≤ 33) SYNTAX score [60].…”

Section: Registry Datamentioning

confidence: 91%

Current treatment of left main coronary artery disease

et al. 2016

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SOUHRNPacienti s těžkou stenózou kmene levé koronární tepny (left main stem, LMS) jsou vzhledem k rozsahu postižení myokardu ve velmi vysokém riziku závažných kardiovaskulárních příhod. Po třech letech dosahuje mortalita farmakologicky léčených nemocných s významnou stenózou LMS 50 %. Za zlatý standard léčby významné stenózy LMS, zvláště při současném postižení několika koronárních tepen, je považován aortokoronární bypass (CABG). Řada studií prokázala, že perkutánní koronární intervence (PCI) může u pacientů pečlivě vybraných týmem kardiologů a kardiochirurgů představovat bezpečnou a účinnou alternativu CABG, s podobnou výslednou mortalitou. Výsledky PCI na LMS se díky neustále dále vyvíjeným technikám PCI a používáním novějších generací lékových stentů trvale zlepšují. Tyto výsledky mohou navíc dále zlepšovat nově zaváděné různé invazivní zobrazovací metody (intravaskulární ultrazvuk nebo optická koherenční tomografi e), případně různé způsoby vyšetření hemodynamických poměrů (frakční průtoková rezerva). Tyto novinky v oblasti PCI LMS mohou v budoucnu vést ke změnám současných doporučených postupů v léčbě postižení kmene levé koronární tepny. ABSTRACTThe patients with severe left main stem (LMS) stenosis have a very high risk of major cardiovascular events because of the extent of ischaemic myocardium. At 3rd year, the mortality rate for patients with signifi cant LMS stenosis treated medically is 50%. Coronary artery bypass grafting (CABG) is considered the gold standard for the treatment of complex LMS stenosis, especially if it is associated with multivessel coronary disease. Many studies have showed that percutaneous coronary interventions (PCI) can be a safe and effi cient alternative to CABG in carefully selected patients by the Heart Team, with similar mortality rates. The LMS PCI results have been continuously improved by the new PCI techniques developed and by the use of newer generation drug eluting stents. Furthermore, different invasive imagistic methods (intravascular ultrasound or optical coherence tomography) or haemodynamic assessment tools (fractional fl ow reserve) can improve the LMS PCI results. With those new developments in the technique of LMS PCI, the current guidelines about the treatment of left main coronary artery disease can be modifi ed in the future. Klíčová slova: Aortokoronární bypass Intravaskulární ultrazvuk Kmen levé koronární tepny Lékový stent Perkutánní koronární intervence Please cite this article as: L.M. Predescu, et al., Current treatment of left main coronary artery disease, Cor et Vasa 58 (2016) e328-e339 as published in the online version of Cor et Vasa available at

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“…5 The authors reported that the 3-year composite endpoint of all-cause death, myocardial infarction (MI) and stroke was comparable between PCI with drug-eluting stent (DES) and CABG (off-pump CABG;…”

Section: Article P 1282mentioning

confidence: 99%

Is an Appropriate Revascularization Selected for Unprotected Left Main Coronary Artery Disease?

Naito

Miyauchi

2015

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp 65%). In patients with low or intermediate SYNTAX scores, the rate of serious cardiovascular events was not different between PCI and CABG. However, the risk of events was markedly higher in the PCI group with high SYNTAX scores compared with the CABG group.In this issue of the Journal, Shiomi et al 6 report the 5-year extended follow-up data. The cumulative 5-year incidence of the primary endpoints (death, MI and stroke) was significantly higher in the PCI group than in the CABG group (34.5 vs. 24.1%, P<0.001). The adjusted hazard ratio (HR) for the primary endpoint in the PCI group was 1.48 (95% confidence interval (CI) 1.07-1.93, P=0.02). No difference was observed in the adjusted HR for all-cause mortality between the groups (adjusted HR 1.32, 95% CI 0.90-1.93, P=0.16), whereas the adjusted HR for the following outcomes were significantly higher in the PCI group (cardiac death: adjusted HR 2.00, 95% CI 1.10-3.63, P=0.02; MI: adjusted HR 2.25, 95% CI 1.04-4.88, P=0.04; revascularization: adjusted HR 4.31, 95% CI 2.97-6.26, P<0.001). Subgroup analyses stratified by SYNTAX score (low: <23, intermediate: 23-32, high: >32) were performed for 92.7% of the whole study population. The adjusted HR for the primary endpoint was not different in patients with a low or intermediate SYNTAX score. The event rate in patients with a high SYNTAX score was significantly higher in the PCI group (adjusted HR 2.09, 95% CI 1.26-3.46, P=0.004). The results from this relatively large-scale, prospecmproved devices related to percutaneous coronary intervention (PCI) and increased operator skill have expanded the indications for PCI to a wide range of coronary artery disease (CAD), such as multivessel CAD or unprotected left main CAD (ULMCAD). Specifically, ULMCAD was previously a contraindication for PCI. Several recent clinical trials demonstrated favorable results following PCI for the treatment of ULMCAD compared with coronary artery bypass grafting (CABG). 1-3 This evidence prompted updating of the guidelines for the treatment of ULMCAD. However, the number of patients in those trials was not sufficient and, furthermore, most of the trials were conducted in Western countries. Therefore, it is of great interest to examine the clinical outcomes of patients with ULMCAD treated with PCI or CABG in a Japanese population, which differs from populations in Western countries regarding dietary habits, various comorbid diseases, and the incidence of CAD. 4 Article p 1282Previously, Shiomi and colleagues reported the 3-year follow-up data from a large-scale Japanese database, the CREDO-Kyoto PCI/CABG Registry. 5 The authors reported that the 3-year composite endpoint of all-cause death, myocardial infarction (MI) and stroke was comparable between PCI with drug-eluting stent (DES) and CABG (off-pump CABG; IThe opinions expressed in this article are not necessarily those of the editors or of the Japanese Circulation Society.

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Comparison of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Disease　– 5-Year Outcome From CREDO-Kyoto PCI/CABG Registry Cohort-2 –

Cited by 43 publications

References 23 publications

Worse clinical outcomes following percutaneous coronary intervention with a high SYNTAX score

Worse clinical outcomes following percutaneous coronary intervention with a high SYNTAX score

Current treatment of left main coronary artery disease

Is an Appropriate Revascularization Selected for Unprotected Left Main Coronary Artery Disease?

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Comparison of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Disease – 5-Year Outcome From CREDO-Kyoto PCI/CABG Registry Cohort-2 –

Cited by 43 publications

References 23 publications

Worse clinical outcomes following percutaneous coronary intervention with a high SYNTAX score

Worse clinical outcomes following percutaneous coronary intervention with a high SYNTAX score

Current treatment of left main coronary artery disease

Is an Appropriate Revascularization Selected for Unprotected Left Main Coronary Artery Disease?

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Comparison of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Disease　– 5-Year Outcome From CREDO-Kyoto PCI/CABG Registry Cohort-2 –