What is better for a patient with stable coronary artery disease — bypass surgery or percutaneous coronary intervention?

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Abstract


Background: The main methods of treating patients with stable coronary artery disease (CAD) are myocardial revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI). These are two fundamentally different in technique and volume of surgical interventions; PCI is associated with rapid rehabilitation of the patient, and only CABG demonstrated effective in survival benefit.

Aims: Comparison of the long-term results of myocardial revascularization with CABG and PCI in patients with stable CAD.

Methods: The results of a prospective one-center cohort study of 369 patients with stable CAD are presented, the average age is 60.1 ± 5.4 years. Patients were randomized into 2 groups by the «Heart Team»: CABG (n = 196) and PCI (n = 173). In each group, subgroups were identified depending on the severity of the coronary lesion, and the CABG group was also separately studied in according to CABG technique ― beating-heart (off-pump) and with cardiopulmonary bypass (on-pump). The average follow-up was 54.3 ± 7 months. The main outcomes of the study were major adverse cardiac and cerebral events (MACCE): death from all causes, cardiac mortality, nonfatal myocardial infarction (MI), nonfatal stroke and repeated coronary revascularization.

Results: Over the 5-year follow-up period, no differences were found between the CABG and PCI groups with a low complexity of coronary artery lesions (SYNTAX Score 14.2 ± 4.8) in terms of survival, cardiac mortality, nonfatal MI and stroke, and the need for repeated myocardial revascularization. Patients with stenosis of the left main coronary artery (LMCA) and/or multivascular CA disease (SYNTAX Score 25.8 ± 5.0) in the long-term follow-up after CABG and PCI did not differ in MACCE, but the CABG group demonstrated a significant advantage in repeated myocardial revascularization. No significant differences were found in any study endpoint in patients after CABG on-pump versus off-pump.

Conclusions: Our study demonstrates the advantage of CABG in patients with stable CAD with stenosis of the LMCA and/or multivascular CA disease, and which CABG technique should depends on the comorbidity of the patient, the experience of the surgeon and the surgical center.


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About the authors

Nalalya Yu. Sokolova

Regional Clinical Hospital; A.N. Bakulev National Medical Research Center of Cardiovascular Surgery

Author for correspondence.
Email: nsokolova1711@gmail.com
ORCID iD: 0000-0002-5720-304X
SPIN-code: 6801-7937

Russian Federation, 105, Peterburgskoe h., Tver region, Tver, 170036; 135, Roublevskoye shosse, 121552 Moscow

MD, PhD

Elena Z. Golukhova

A.N. Bakulev National Medical Research Center of Cardiovascular Surgery

Email: egolukhova@yahoo.com
ORCID iD: 0000-0002-6252-0322
SPIN-code: 9334-5672
135, Roublevskoye shosse, 121552 Moscow

MD, PhD, Professor

References

  1. Соколова Н.Ю., Голухова Е.З. Реваскуляризация миокарда у больных стабильной ишемической болезнью сердца: стратификация периоперационных и отдаленных рисков // Креативная кардиология. ― 2016. ― Т.10. ― №1. ― С. 25−36. [Sokolova NYu, Golukhova EZ. Myocardial revascularization in patients with stable coronary artery disease: the stratification of perioperative and long-term risks. Creative cardiology. 2016;10(1): 25−36. (In Russ).] doi: 10.15275/kreatkard.2016.01.03.
  2. Соколова Н.Ю. Пятилетние результаты реваскуляризации миокарда больных стабильной ишемической болезнью сердца со стенозом ствола левой коронарной артерии и/или многососудистым поражением коронарного русла // Креативная кардиология. ― 2018. ― Т.12. ― №4. ― С. 316−327. [Sokolova NYu. Five-year results of myocardial revascularization in patients with stable coronary artery disease with stenosis of the left coronary artery and/or multivessel coronary disease. Creative cardiology. 2018;12(4):316−327. (In Russ).] doi: 10.24022/1997-3187-2018-12-4-316-327.
  3. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165. doi: 10.1093/eurheartj/ehy394.
  4. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery vs. percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381(9867):629–638. doi: 10.1016/S0140-6736(13)60141-5.
  5. Соколова Н.Ю., Шумков К.В., Кузнецова Е.В., Голухова Е.З. Результаты реваскуляризации миокарда у больных стабильной ишемической болезнью сердца с высоким SYNTAX Score // Креативная кардиология. ― 2017. ― Т.11. ― №2. ― С. 109−117. [Sokolova NYu, Shumkov KV, Kuznetsova EV, Golukhova EZ. Results of myocardial revascularization in patients with stable coronary artery disease with high SYNTAX Score. Creative cardiology. 2017;11(2):109–117 (In Russ).] doi: 10.24022/1997-3187-2017-11-2-109-117.
  6. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35(37):2541−2619. doi: 10.1093/eurheartj/ehu278.
  7. Doenst T, Haverich A, Serruys P, et al. PCI and CABG for treating stable coronary artery disease: JACC review topic of the week. J Am Coll Cardiol. 2019;73(8):964−976. doi: 10.1016/j.jacc.2018.11.053.
  8. McKeown LA. The case for collateralization: CABG’s mechanism for survival in stable cad underappreciated by patients [Internet]. Heart Beat; 2019 [cited 2019 February 26]. Available from: https://www.tctmd.com/news/case-collateralization-cabgs-mechanism-survival-stable-cad-underappreciated-patients.
  9. Hassanabad AF, MacQueen KT, Ali I. Surgical Treatment for Ischemic Heart Failure (STICH) trial: a review of outcomes. J Card Surg. 2019;34(10):1075−1082. doi: 10.1111/jocs.14166.
  10. McCarthy PM. Outcomes after coronary artery bypass: getting better all the time. J Am Coll Cardiol. 2019;73(15):1887−1889. doi: 10.1016/j.jacc.2019.01.060.
  11. Голухова Е.З. Аортокоронарное шунтирование и чрескожное коронарное вмешательство при стабильной ишемической болезни сердца: современный этап // Креативная кардиология. ― 2019. ― Т.13. ― №2. ― С. 91−97. [Golukhova EZ. Coronary artery bypass grafting and percutaneous coronary intervention in stable ischemic heart disease: contemporary approach. Creative cardiology. 2019;13(2):91–97. (In Russ).] doi: 10.24022/1997-3187-2019-13-2-91-97.
  12. Modolo R, Chichareon P, Kogame N, et al. Contemporary outcomes following coronary artery bypass graft surgery for left main disease. J Am Coll Cardiol. 2019;73(15):1877−1886. doi: 10.1016/j.jacc.2018.12.090.
  13. Hannan EL, Zhong Y, Berger PB, et al. Association of coronary vessel characteristics with outcome in patients with percutaneous coronary interventions with incomplete revascularization. JAMA Cardiol. 2018;3(2):123−130. doi: 10.1001/jamacardio.2017.4787.
  14. Milojevic M, Head SJ, Parasca CA, et al. Causes of death following PCI versus CABG in complex CAD: 5-year follow-up of SYNTAX. J Am Coll Cardiol. 2016;67(1):42−55. doi: 10.1016/j.jacc.2015.10.043.
  15. Nappi F, Sutherland FW, Al-Attar N, et al. Incomplete revascularization in PCI and CABG: when two plus two does not make four. J Am Coll Cardiol. 2016;68(8):877−878. doi: 10.1016/j.jacc.2016.04.068.
  16. Benedetto U, Gaudino M, Di Franco A, et al. Incomplete revascularization and long-term survival after coronary artery bypass surgery. Int J Cardiol. 2018;254:59−63. doi: 10.1016/j.ijcard.2017.08.005.
  17. Rastan AJ, Walther T, Falk V, et al. Does reasonable incomplete surgical revascularization affect early or long-term survival in patients with multivessel coronary artery disease receiving left internal mammary artery bypass to left anterior descending artery? Circulation. 2009;120(11 Suppl):S70−77. doi: 10.1161/CIRCULATIONAHA.108.842005.
  18. Tarr FI, Sasvari M, Tarr M, et al. Evidence of nitric oxide produced by the internal mammary artery graft in venous drainage of the recipient coronary artery. Ann Thorac Surg. 2005;80(5):1728−1731. doi: 10.1016/j.athoracsur.2005.05.005.
  19. Spadaccio C, Benedetto U. Coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease: quo vadis? A review of the evidences on coronary artery disease. Ann Cardiothorac Surg. 2018;7(4):506−515. doi: 10.21037/acs.2018.05.17.
  20. Spadaccio C, Nappi F, Nenna A, et al. Is it time to change how we think about incomplete coronary revascularization? Int J Cardiol. 2016;224:295−298. doi: 10.1016/j.ijcard.2016.09.055.
  21. Бокерия Л.А., Глянцев С.П. Профессор Василий Иванович Колесов: парад приоритетов (К 50-летию первой в мире операции маммарно-коронарного анастомоза и 110-летию со дня рождения ее автора ― В.И. Колесова) // Анналы хирургии. ― 2014. ― №3. ― С. 53−62. [Bockeria LA, Glyantsev SP. Professor Vasily Ivanovich Kolesov: parade of priorities (to the 50th anniversary of the wold`s first of mammary-coronary artery anastomosis and the 110th anniversary of birth it`s author ― V.I. Kolesov). Annals of surgery. 2014;(3):53−62. (In Russ).]
  22. Ascione R, Angelini GD. Off-pump coronary artery bypass surgery: the implications of the evidence. J Thorac Cardiovasc Surg. 2003;125(4):779–781. doi: 10.1067/mtc.2003.11.
  23. Lamy A, Devereaux PJ, Prabhakaran D, et al. Five-year outcomes after off-pump or on-pump coronary-artery bypass grafting. N Engl J Med. 2016;375(24):2359–2368. doi: 10.1056/NEJMoa1601564.
  24. Altarabsheh SE, Deo SV, Rababa’h AM, et al. Off-pump coronary artery bypass reduces early stroke in octogenarians: a meta-analysis of 18,000 patients. Ann Thorac Surg. 2015;99(5):1568–1575. doi: 10.1016/j.athoracsur.2014.12.057.
  25. Takagi H, Umemoto T; All-Literature Investigation of Cardiovascular Evidence (ALICE) Group. Worse long-term survival after off-pump than on-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2014;148(5):1820–1829. doi: 10.1016/j.jtcvs.2014.05.034.
  26. Deppe AC, Arbash W, Kuhn EW, et al. Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16,900 patients investigated in randomized controlled trialsdagger. Eur J Cardiothorac Surg. 2016;49(4):1031–1041. doi: 10.1093/ejcts/ezv268.
  27. Kirmani BH, Holmes MV, Muir AD. Long-term survival and freedom from reintervention after off-pump coronary artery bypass grafting: a propensity-matched study. Circulation. 2016;134(17):1209–1220. doi: 10.1161/CIRCULATIONAHA.116.021933.
  28. Matkovic M, Tutus V, Bilbija I, et al. Long term outcomes of the ofpump and on-pump coronaryartery bypass grafting in a highvolume center. Sci Rep. 2019;9(1):8567. doi: 10.1038/s41598-019-45093-3.
  29. Panesar SS, Athanasiou T, Nair S, et al. Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing coronary artery bypass grafting-comparison between off-pump and on-pump techniques. Heart. 2006;92(12):1808–1816. doi: 10.1136/hrt.2006.088450.
  30. Sharony R, Bizekis CS, Kanchuger M, et al. Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study. Circulation. 2003;108(Suppl 1):15−20. doi: 10.1161/01.cir.0000087448.65888.21.

Supplementary files

Supplementary Files Action
1.
Fig. Freedom curves from repeated myocardial revascularization in patients with stable coronary heart disease with stenosis of the left coronary artery and / or multivascular lesion of the coronary arteries after CABG and PCI, constructed according to the Kaplan – Meyer method

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