Abstract
Objective
We performed a meta-analysis of randomized controlled trials to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for the treatment of de novo unprotected left main disease.
Background
Although CABG is accepted to be standard of care for revascularization of unprotected left main stenosis, PCI is increasingly being used as an alternative primary approach.
Methods
We searched for randomized, controlled trials comparing CABG and PCI for the treatment of unprotected left main disease. Major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeat revascularization) were analyzed.
Results
The search strategy identified 4 randomized controlled trials enrolling a total of 1,611 patients. Follow-up ranged between 1 and 2 years. There were no significant differences in the risk of death or myocardial infarction between the two treatment modalities. While the risk of stroke was significantly lower in patients undergoing PCI (risk ratio (RR) 0.26, 95% confidence interval (CI) 0.10–0.69, p = 0.007), the risk of repeat revascularization was higher among patients undergoing PCI (RR 1.94, 95% CI 1.43–2.61, p < 0.001). No relevant statistical heterogeneity across studies could be found.
Conclusion
In this largest series of randomized patients with unprotected left main stenosis to date, the risk of death and myocardial infarction was comparable between CABG and PCI. However, patients undergoing CABG had a higher risk of stroke, whereas patients undergoing PCI were at a higher risk for repeat revascularization.
Zusammenfassung
Einführung
Die Bypass-Chirurgie ist in der Behandlung der ungeschützten Hauptstammstenose das etablierte Standardverfahren. In den letzten Jahren hat allerdings auch die perkutane Koronarintervention bei geeigneten Patienten als Alternative zunehmende Verbreitung gefunden. Ziel der vorliegenden Arbeit war eine Metaanalyse randomisierter kontrollierter Studien, die beide Revaskularisationsstrategien miteinander vergleichen.
Methode
In die Analyse eingeschlossen wurden Studien, die folgende Kriterien erfüllten: 1) randomisierter Vergleich von Bypass-Chirurgie und perkutaner Koronarintervention bei Patienten mit ungeschützter Hauptstammstenose, 2) Konsens zwischen Herzchirurg und Interventionalist, dass beide Verfahren möglich sind, und 3) klinisches Follow-up von mindestens 12 Monaten. Die Suche nach geeigneten Studien erfolgte nach Empfehlungen der Cochrane Collaboration. Es wurden die klinischen Endpunkte Tod jedweder Ursache, Myokardinfarkt, erneute Revaskularisation und zerebrovaskuläres Ereignis analysiert. Hierbei wurden die Definitionen der Primärstudien zugrunde gelegt.
Ergebnisse
Es wurden 4 Studien mit einer Gesamtzahl von 1611 Patienten gefunden, die die Einschlusskriterien erfüllten. Die Nachbeobachtungsdauer lag zwischen 1 und 2 Jahren. Das Risiko für Tod oder Myokardinfarkt war zwischen Bypass-Operation und perkutaner Koronarintervention nicht signifikant unterschiedlich. Das Risiko einer erneuten Revaskularisation war bei perkutanem Vorgehen erhöht (relatives Risiko, RR: 1,94,95%-Konfidenzintervall, KI: 1,43, 2,61; p<0,001), während das Schlaganfallrisiko im Vergleich zur Bypasschirurgie signifikant niedriger war (RR: 0,26,95%-KI: 0,10, 0,69; p=0,007).
Limitationen
Die Analyse spiegelt nur die Ergebnisse für Patienten wider, die für beide Therapieverfahren als geeignet eingestuft wurden. Die Resultate sollten daher nicht auf Patienten angewendet werden, die für beide oder eines der Verfahren nicht in Frage kommen. Es können aufgrund der Natur der Analyse keine Aussagen zu speziellen Subgruppen abgeleitet werden (z. B. nach speziellen anatomischen Kritierien). Der Nachbeobachtungszeitraum von 1 bis2 Jahren ist relativ kurz. Es sollte berücksichtigt werden, dass die Endpunktdefinitionen sich zwischen den Studien geringfügig unterscheiden.
Fazit
In dieser bisher größten Serie randomisierter Patienten mit ungeschützter Hauptstammstenose waren das Mortalitätsrisiko und das Risiko für einen Myokardinfarkt zwischen beiden Revaskularisationsstrategien nicht signifikant unterschiedlich. Patienten mit perkutaner Hauptstammrevaskularisation haben im Verlauf allerdings ein etwa doppelt so hohes Risiko einer erneuten Revaskularisation. Die Bypass-Operation wiederum ist mit einem signifikant höheren Risiko eines zerebrovaskulären Ereignisses assoziiert.
Abbreviations
- CABG:
-
Coronary artery bypass surgery
- PCI:
-
Percutaneous coronary intervention
- MI:
-
Myocardial infarction
- IQR:
-
Interquartile range
- M-H:
-
Mantel–Haenszel
- CI:
-
Confidence interval
- CK:
-
Creatine kinase
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Disclosures
E. Boudriot, H. Thiele, S. Desch, F.W. Mohr, and G. Schuler are investigators and authors of the final publication of the Leipzig trial. F.W. Mohr is principal investigator of the SYNTAX trial and coauthor of several publications relating to the Syntax trial. P.E. Buszman and A. Bochenek are investigators and authors of the final publication of the LeMans trial.
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Desch, S., Boudriot, E., Rastan, A. et al. Bypass surgery versus percutaneous coronary intervention for the treatment of unprotected left main disease. Herz 38, 48–56 (2013). https://doi.org/10.1007/s00059-012-3596-y
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DOI: https://doi.org/10.1007/s00059-012-3596-y
Keywords
- Left main stenosis
- Coronary artery bypass surgery
- Percutaneous coronary intervention
- Stent
- Meta-analysis