Myocardial Revascularization/mortality

ABC

Editorial

Evidence based decision making between PCI and CABG

For the last five decades, coronary artery bypass grafting (CABG) surgery has been recommended for patients with unprotected left main (ULM) and multivessel coronary artery disease (MVD). In these populations, CABG reduces mortality compared to medical management. In patients with MVD, several randomized clinical trials established the superiority of CABG over percutaneous coronary interventions (PCI) in terms of hard clinical endpoints.^, In the ULM subgroup of the SYNTAX I trial, comparable outcomes between PCI and CABG were observed at five years. This finding triggered the design and execution of the EXCEL and NOBLE trials that confirmed equipoise in major adverse cardiovascular and cerebral events between PCI and CABG in patients with ULM coronary artery disease (CAD).^,

The accumulation of evidence has allowed to better understand which patients may benefit from a determined revascularization strategy. In the current issue of the Journal, Negreiros de Andrade et al. present a study-level meta-analysis comparing clinical outcomes after PCI and CABG in patients with ULMCAD and MVD. The authors should be commended for the stratified analysis aiming at providing practical information for the cardiovascular community. Based on the current state of evidence we can state that 1) in patients with ULMCAD, PCI can be considered an alternative to CABG in patients with low anatomical complexity, and 2) patients with MVD have better clinical outcomes when treated with CABG. When these two populations were combined, the present meta-analysis showed an early (<30 days) benefit of PCI in terms of mortality and stroke, and long-term advantage of CABG in death and myocardial infarction.

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ABC

Original Article

Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation

Pedro José Negreiros de Andrade et al. João Luiz de Alencar Araripe Falcão Breno de Alencar Araripe Falcão Hermano Alexandre Lima Rocha

Abstract

Background:

Comparison between percutaneous coronary intervention (PCI) using stents and Coronary Artery Bypass Grafting (CABG) remains controversial.

Objective:

To conduct a systematic review with meta-analysis of PCI using Stents versus CABG in randomized controlled trials.

Methods:

Electronic databases were searched to identify randomized trials comparing PCI using Stents versus CABG for multi-vessel and unprotected left main coronary artery disease (LMCAD). 15 trials were found and their results were pooled. Differences between trials were considered significant if p < 0.05.

Results:

In the pooled data (n = 12,781), 30 days mortality and stroke were lower with PCI (1% versus 1.7%, p = 0.01 and 0.6% versus 1.7% p < 0.0001); There was no difference in one and two year mortality (3.3% versus 3.7%, p = 0.25; 6.3% versus 6.0%, p = 0.5). Long term mortality favored CABG (10.6% versus 9.4%, p = 0.04), particularly in trials of DES era (10.1% versus 8.5%, p = 0.01). In diabetics (n = 3,274) long term mortality favored CABG (13.7% versus 10.3%; p < 0.0001). In six trials of LMCAD (n = 4,700) there was no difference in 30 day mortality (0.6%versus 1.1%, p = 0.15), one year mortality (3% versus 3.7%, p = 0.18), and long term mortality (8.1% versus 8.1%) between PCI and CABG; the incidence of stroke was lower with PCI (0.3% versus 1.5%; p < 0.001). Diabetes and a high SYNTAX score were the subgroups that influenced more adversely the results of PCI.

Conclusion:

Compared with CABG, PCI using Stents showed lower 30 days mortality, higher late mortality and lower incidence of stroke. Diabetes and a high SYNTAX were the subgroups that influenced more adversely the results of PCI.

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IJCS

Original Article

Clinical Course of Patients Undergoing Myocardial Revascularization Surgery in a Public Cardiology Referral Hospital in Pará, Brazil

Patrick Hernani Matias Lobato et al. Feliciano Mendes Vieira Junior Mário Barbosa Guedes Nunes Valleria Adriana Queiroz Lima Galucio Ercielem da Lima Barreto

Abstract

Background:

Myocardial revascularization surgery (MRS) is the most frequently performed cardiac surgery in Brazil. However, data on mortality rates among patients undergoing MRS in hospitals other than the main referral centers in the northern Brazil are scarce.

Objective:

To describe the clinical course of patients that submitted to MRS in the major public cardiology referral hospital in the Brazilian Amazon.

Methods:

Retrospective cohort analysis, by review of medical records of patients who had undergone MRS at Hospital das Clínicas Gaspar Vianna (FHCGV) from January 2013 to June 2014.

Results:

A total of 179 patients were evaluated. Mortality rate was 11.7% until 30 days after surgery. Waiting time for surgery ≥ 30 days (OR 2.59, 95%CI 1.02 – 6.56, p = 0.039), infection during hospitalization (OR 3.28, 95%CI 1.15 – 9.39, p = 0.021) and need for hemodialysis after surgery (OR 9.06 95%CI 2.07 – 39.54, p = 0.001) were predictors of mortality after CABG.

Conclusion:

A high mortality rate in the study population was found, higher than that reported in the literature and in other regions of Brazil.

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ABC

Editorial

Better Technology, More Spending, Worse Outcomes

Whady Hueb

Since its beginning, myocardial revascularization has suffered substantial technological changes. In fact, early techniques with no physiological basis were used to increase blood supply to the ischemic myocardium. These included pericardial talc insufflation, coronary sinus ligation, Beck surgical procedure, and the Vineberg procedure. Nevertheless, due to their frustrating results that did not meet the expectations, these techniques were abandoned.

The emergence of a new, more rational technique – the coronary artery bypass surgery using venous grafts (later substituted with arterial grafts) – enabled the provision of greater blood flow to the ischemic myocardium.

[…]

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Evidence based decision making between PCI and CABG

Stent versus Coronary Artery Bypass Surgery in Multi-Vessel and Left Main Coronary Artery Disease: A Meta-Analysis of Randomized Trials with Subgroups Evaluation

Abstract

Background:

Objective:

Methods:

Results:

Conclusion:

Clinical Course of Patients Undergoing Myocardial Revascularization Surgery in a Public Cardiology Referral Hospital in Pará, Brazil

Abstract

Background:

Objective:

Methods:

Results:

Conclusion:

Better Technology, More Spending, Worse Outcomes

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