Falk, Volkmar

RERO DOC Digital Library

EditorialThe ‘real world’ asks for coronary artery bypass graftingKeywords: Coronary artery bypass grafting; Scoring; Coronary stentingwww.elsevier.com/locate/ejctsEuropean Journal of Cardio-thoracic Surgery 36 (2009) 609—6101 SYNTAX supplemental data. Accessible @ http://content.nejm.org/cgi/data/NEJMoa0804626/DC1/1.In this issue of the European Journal of CardiothoracicSurgery, a meta-analysis to compare coronary artery bypassgrafting (CABG) versus drug-eluting stents (DESs) in multi-vessel coronary disease is presented. The authors claim thatthe original observational studies that were included in theirmeta-analysis would reflect ‘the real world clinical practice’and should therefore be used to support the results ofrandomised trials and determine the standard of care [1].Without going into the details, the authors pool the data ofnine different studies that show only one thing in common: asubstantial variation with regard to patient characteristics.To give only an example, Table 1 (see Ref. [1]) summarises thenumber and percentage of patients with double-vesseldisease, triple-vessel disease and left main stem stenosisin each group. From this summary, it is obvious that there wasno similarity in the patients treated in any of the originalstudies. While most patients in the CABG groups had triple-vessel disease, more involvement of the left anteriordescending coronary artery (LAD), more chronic occlusionsand a higher prevalence of left main disease, most patients inthe DES groups had double-vessel disease alone, a substantialnumber without involvement of the LAD.It is important to note that the quoted retrospectivestudies used for this (and other) meta-analysis used differentinclusion criteria and definitions with often substantialvariations. According to a study [2], the definition ofmulti-vessel percutaneous coronary intervention (PCI) wasas follows: ‘PCI in two or more major epicardial coronaryarteries or one major artery and a branch originating fromanother major epicardial artery supplying different myocar-dial regions.’ By this definition, stenting of a small diagonalbranch as well as the distal circumflex artery could be definedas ‘multi-vessel stenting’. This is clearly not the surgicalunderstanding of treating multi-vessel disease. For years,Taggart has pointed out that in almost all studies comparingCABG and PCI there was no equal distribution with regard tothe extent of disease [3,4]. Since the early days of PCI, it isknown, that in patients with double-vessel disease andnormal left ventricular function, there is no immediatesurvival benefit for CABG over PCI. It is the patients withtriple-vessel disease involving the LAD who have the largestbenefit of CABG [5].1010-7940/$ — see front matter # 2009 European Association for Cardio-Thoracicdoi:10.1016/j.ejcts.2009.03.070The largest study so far on this subject by Hannan et al.comprises 69.3% of the CABG (7437 out of 10 728) and 73.6%of the stent patients (9963 out of 13 540) used for the meta-analysis by Benedetto et al. [6]. The added value of poolingthese well-defined data with eight much smaller sources thatused different data sets and outcome measures remainsuncertain. All the authors of the original studies quoted in themeta-analysis agree that the original population of theirretrospective analyses differed for the two groups forseverity of illness and many variables including diabetes,age and other confounding factors. Thus, propensity analysisand adjustments to account for differences in periproceduralrisk were applied in some but not all studies. Few studies usedproportional hazard Cox regression models or other less well-accepted statistics to correct for the underlying risk. It is notknown how and if the extent of coronary artery disease wasalways used as a confounding variable, but certainly it wasnot used uniformly as an independent risk factor.The SYNTAX score describes the coronary vasculature withrespect to the number and complexity of lesions. A highSYNTAX score (or more complex disease) is a predictor for anincreased rate of re-intervention after primary PCI and stentimplantation [7] In contrast, CABG does not only treat theculprit lesion but also deals with ‘future culprit lesions’because the graft is usually placed to the mid or distal vessel[4]. As a result, lesion complexity has less of an impact on the1-year results after CABG for triple-vessel disease [8].1The presented meta-analysis does not provide newevidence that could guide clinical decision making for thetreatment of patients with multi-vessel disease. Therefore,we should continue to refer to the best-available evidenceprovided by the study of Hannan et al. who arrived at a clear-cut conclusion: already after 18 months CABG is associatedwith lower mortality rates and lower rates for death ormyocardial infarction and repeat re-vascularisation thantreatment with DESs [4]. Since we already know from theARTS trial that the gap between PCI and CABG tends to getlarger in favour of CABG over time, this statement will mostlikely get stronger as time goes by.Surgery. Published by Elsevier B.V. All rights reserved.Editorial / European Journal of Cardio-thoracic Surgery 36 (2009) 609—610610The other piece of meaningful information from ‘the realworld’ comes from the all-comers randomised SYNTAX trialthat concluded with the statement that CABG remains thestandard of care for patients with three-vessel or left maincoronary artery disease, since the use of CABG, as comparedto PCI with DES, resulted in lower rates of the combined endpoint of major adverse cardiac events (MACE) at 1 year [9].This is in line with the recently published ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronaryre-vascularisation for patients with advanced CAD and thenecessity for coronary re-vascularisation [10]. CABG wasrated as appropriate in all of the clinical scenariosdeveloped, whereas PCI was rated appropriate only inpatients with two-vessel CAD with involvement of theproximal LAD and rated uncertain in patients with three-vessel disease. For patients with left main stenosis and/orleft main stenosis andmulti-vessel CAD, CABG but not PCI wasrated appropriate and likely to improve patients’ healthoutcomes or survival (see Fig. 1 in Ref. [10]).References[1] Benedetto U, Melina G, Angeloni E, Refice S, Roscitano A, Fiorani B,Domenico G, Sinatra R. Coronary artery bypass grafting versus drug-eluting stents in multivessel coronary disease. A meta-analysis on24,268 patients. Eur J Cardiothorac Surg 2009;36:611—5.[2] Lee MS, Jamal F, Kedia G, Chang G, Kapoor N, Forrester J, Czer L, ZimmerR, DeRobertis M, Trento A, Makkar RR. Comparison of bypass surgery withdrug eluting stents for diabetic patients with multivessel disease. Int JCardiol 2007;123:34—42.[3] Taggart DP. Coronary revascularisation. Br Med J 2007;334:593—4.[4] Taggart DP. Thomas B. Ferguson Lecture. Coronary artery bypass graftingis still the best treatment for multivessel and left main disease, butpatients need to know. Ann Thorac Surg 2006;82:1966—75.[5] Taggart DP. PCI or CABG in coronary artery disease? Lancet2009;373:1150—2.[6] Hannan EL, Wu C, Walford G, Culliford AT, Gold JP, Smith CR, Higgins RS,Carlson RE, Jones RH. Drug-eluting stents vs. coronary-artery bypassgrafting in multivessel coronary disease. N Engl J Med 2008;358:331—41.[7] Valgimigli M, Serruys PW, Tsuchida K, Vaina S, Morel MA, van den Brand MJ,Colombo A, Morice MC, Dawkins K, de Bruyne B, Kornowski R, de Servi S,Guagliumi G, Jukema JW, Mohr FW, Kappetein AP, Wittebols K, Stoll HP,Boersma E, Parrinello G, ARTS II. Cyphering the complexity of coronaryartery disease using the syntax score to predict clinical outcome inpatients with three-vessel lumen obstruction undergoing percutaneouscoronary intervention. Am J Cardiol 2007;99:1072—81.[8] Lemesle G, Bonello L, de Labriolle A, Steinberg DH, Roy P, Slottow TL,Torguson R, Kaneshige K, Xue Z, Suddath WO, Satler LF, Kent KM, LindsayJ, Pichard AD, Waksman R. Prognostic value of the syntax score in patientsundergoing coronary artery bypass grafting for three-vessel coronaryartery disease. Catheter Cardiovasc Interv 2008;73:612—7.[9] Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ,Sta˚hle E, Feldman TE, van den Brand M, Bass EJ, Van Dyck N, Leadley K,Dawkins KD, Mohr FW, and SYNTAX Investigators. Percutaneous coronaryintervention versus coronary-artery bypass grafting for severe coronaryartery disease. N Engl J Med 2009;360:961—72.[10] Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary revas-cularization: a report of the American College of Cardiology FoundationAppropriateness Criteria Task Force, Society for Cardiovascular Angio-graphy and Interventions, Society of Thoracic Surgeons, American Asso-ciation for Thoracic Surgery, American Heart Association, and theAmerican Society of Nuclear Cardiology: endorsed by the AmericanSociety of Echocardiography, the Heart Failure Society of America, andthe Society of Cardiovascular ComputedTomography. Circulation2009;119:1330—52.Volkmar Falk*Universita¨tsspital Zu¨rich, Ra¨mistrasse,Zu¨rich, Switzerland*Corresponding author. Address: Klinikdirektor,Klinik fu¨r Herz- und Gefa¨sschirurgie, Universita¨tsspitalZu¨rich, Ra¨mistrasse 100, CH-8091 Zu¨rich,Switzerland.Tel.: +41 44 255 3298; fax: +41 44 255 4446E-mail address: volkmar.falk@usz.chAvailable online 14 July 2009

The ‘real world' asks for coronary artery bypass grafting

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library