Percutaneous Coronary Intervention versus Coronary Artery Bypass Graft Among Patients with Coronary Artery Disease and Left Ventricular Systolic Dysfunction: a Meta-analysis
Keywords:Percutaneous coronary intervention, Coronary artery bypass graft, Left ventricular systolic dysfunction, Meta-analysis
Background: There is an absence of randomized controlled trials (RCTs) comparing types of revascularization in patients with coronary artery disease (CAD) in the presence of left ventricular systolic dysfunction (LVSD). Our aim was to compare the outcomes of percutaneous coronary intervention (PCI) versus coronary artery graft bypass (CABG) among patients with CAD and LVSD.
Methods: The PubMed online database (from 1976 to November, 2014) and EMbase (from 1974 to November, 2014) were searched. Studies comparing the outcomes of PCI versus CABG among patients with left ventricular dysfunction (ejection fraction <50%) were included. Random- and fixed-effect models were used depending on between-study heterogeneity.
Results: Due to absence of RCTs on this topic, twelve observational studies including 5,494 patients were included. PCI was associated with a lower risk of short-term mortality (Risk ratio [RR], 0.51, 95% confidence interval [CI], 0.26-1.00) but a higher risk of long-term mortality (RR, 1.21, 95%CI, 1.05-1.40) and repeat revascularization (RR, 4.18, 95%CI, 1.92-9.12) compared with CABG. No significant difference in composite outcomes (RR, 1.26, 95%CI, 0.92-1.73), myocardial infarction (RR, 0.63, 95% CI, 0.17-2.41) and cerebrovascular accident ((RR, 0.61, 95%CI, 0.18-2.01) was observed between PCI vs. CABG.
Conclusions: Due to the absence of any RCTs on this topic, a meta-analysis of observational studies was performed. It suggested PCI was associated with a better short-term prognosis but an increased risk of long-term mortality compared with CABG. Further well-designed RCT’s are needed to verify this conclusion.
Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. Journal of the American College of Cardiology 2002; 39:1151-1158.
Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus 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 (London, England) 2013; 381:629-638. DOI: 10.1016/S0140-6736(13)60141-5
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). European heart journal 2014; 35:2541-2619. DOI: 10.1093/ejcts/ezu366
Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. The New England journal of medicine 2011; 364:1607-1616. DOI: 10.1056/NEJMoa1100356
Wells GA, Shea B, O Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2000.
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 2013; 62:e147-239. doi: 10.1016/j.jacc.2013.05.019
Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. The Annals of thoracic surgery 2013; 96:2038-2044. DOI: 10.1016/j.athoracsur.2013.06.052
Yang JH, Choi SH, Song YB, et al. Long-term outcomes of drug-eluting stent implantation versus coronary artery bypass grafting for patients with coronary artery disease and chronic left ventricular systolic dysfunction. The American journal of cardiology 2013; 112:623-629. DOI: 10.1016/j.amjcard.2013.04.035
Cleland JG, Calvert M, Freemantle N, et al. The Heart Failure Revascularisation Trial (HEART). European journal of heart failure 2011; 13:227-233. DOI: 10.1093/eurjhf/hfq230
Gioia G, Matthai W, Gillin K, et al. Revascularization in severe left ventricular dysfunction: outcome comparison of drug-eluting stent implantation versus coronary artery by-pass grafting. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2007; 70:26-33.
Buszman P, Szkrobka I, Gruszka A, et al. Comparison of effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in patients with ischemic cardiomyopathy. The American journal of cardiology 2007; 99:36-41.
Saakyan YM, Polyakov RS, Puretsky MV, Sankov OV, Abugov SA, Zhbanov IV. Myocardial revascularization in CAD patients with left ventricular ejection fraction below 35%. Angiol Sosud Khir 2005; 11:83-95.
Toda K, Mackenzie K, Mehra MR, et al. Revascularization in severe ventricular dysfunction (15% < OR = LVEF < OR = 30%): a comparison of bypass grafting and percutaneous intervention. The Annals of thoracic surgery 2002; 74:2082-2087; discussion 2087.
O'Keefe JH, Jr., Allan JJ, McCallister BD, et al. Angioplasty versus bypass surgery for multivessel coronary artery disease with left ventricular ejection fraction < or = 40%. The American journal of cardiology 1993; 71:897-901.
Sedlis SP, Ramanathan KB, Morrison DA, Sethi G, Sacks J, Henderson W. Outcome of percutaneous coronary intervention versus coronary bypass grafting for patients with low left ventricular ejection fractions, unstable angina pectoris, and risk factors for adverse outcomes with bypass (the AWESOME Randomized Trial and Registry). The American journal of cardiology 2004; 94:118-120.
Buszman P, Tendera M, Bochenek A, et al. A prospective evaluation of early and late results of percutaneous and surgical revascularisation in patients with ischaemic left ventricular dysfunction. 2002; 56:57-61.
Ahn J-M, Oh J-H, Sun BJ, et al. AS-230 Comparisons of Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting for Patients with Multi-Vessel Disease and Severely Compromised Ventricular Dysfunction. The American journal of cardiology 2011; 107:87A.
Kim MS, Ahn JM, Park HS, et al., Percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main stenosis with severe left ventricular dysfunction: Data from Asan main registry. Elsevier USA, 2014: B66-B67.
Takahashi J, Sakata Y, Nochioka K, et al., Prognostic impact of coronary revascularization therapy in patients with ischemic heart failure. Lippincott Williams and Wilkins, 2013.
Nagendran J, Norris CM, Graham MM, et al., Coronary artery bypass grafting versus percutaneous coronary intervention for patients with severe left ventricular dysfunction: Superior outcomes with surgery. Lippincott Williams and Wilkins, 2011.
Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L. Contour-enhanced meta-analysis funnel plots help distinguish publication bias from other causes of asymmetry. Journal of clinical epidemiology 2008; 61:991-996. DOI: 10.1016/j.jclinepi.2007.11.010
Beanlands RS, Nichol G, Huszti E, et al. F-18-fluorodeoxyglucose positron emission tomography imaging-assisted management of patients with severe left ventricular dysfunction and suspected coronary disease: a randomized, controlled trial (PARR-2). Journal of the American College of Cardiology 2007; 50:2002-2012.
Shah BN, Khattar RS, Senior R. The hibernating myocardium: current concepts, diagnostic dilemmas, and clinical challenges in the post-STICH era. European heart journal 2013; 34:1323-1336. DOI: 10.1093/eurheartj/eht018.
Kunadian V, Pugh A, Zaman AG, Qiu W. Percutaneous coronary intervention among patients with left ventricular systolic dysfunction: a review and meta-analysis of 19 clinical studies. Coronary artery disease 2012; 23:469-479.
Garcia S, Sandoval Y, Roukoz H, et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. Journal of the American College of Cardiology 2013; 62:1421-1431. DOI: 10.1016/j.jacc.2013.05.033.
Windecker S, Stortecky S, Stefanini GG, et al. Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis. Bmj 2014; 348:g3859. DOI: 10.1136/bmj.g3859
Ben-Gal Y, Mohr R, Feit F, et al. Surgical versus percutaneous coronary revascularization for multivessel disease in diabetic patients with non-ST-segment-elevation acute coronary syndrome: analysis from the Acute Catheterization and Early Intervention Triage Strategy trial. Circulation Cardiovascular interventions 2015; 8. doi: 10.1161/CIRCINTERVENTIONS.114.002032
Edwards FH, Shahian DM, Grau-Sepulveda MV, et al. Composite outcomes in coronary bypass surgery versus percutaneous intervention. The Annals of thoracic surgery 2014; 97:1983-1988; discussion 1988-1990. DOI: 10.1016/j.athoracsur.2014.01.087.
Ben-Gal Y, Finkelstein A, Banai S, et al. Surgical myocardial revascularization versus percutaneous coronary intervention with drug-eluting stents in octogenarian patients. The heart surgery forum 2012; 15:E204-209. DOI: 10.1532/HSF98.20111190.
Verhaegh AJ, Accord RE, van Garsse L, Maessen JG. Hybrid coronary revascularization as a safe, feasible, and viable alternative to conventional coronary artery bypass grafting: what is the current evidence? Minimally invasive surgery 2013; 2013:142616. DOI: 10.1155/2013/142616.
Shen L, Hu S, Wang H, et al. One-stop hybrid coronary revascularization versus coronary artery bypass grafting and percutaneous coronary intervention for the treatment of multivessel coronary artery disease: 3-year follow-up results from a single institution. Journal of the American College of Cardiology 2013; 61:2525-2533. DOI: 10.1016/j.jacc.2013.04.007
Bonatti JO, Zimrin D, Lehr EJ, et al. Hybrid coronary revascularization using robotic totally endoscopic surgery: perioperative outcomes and 5-year results. The Annals of thoracic surgery 2012; 94:1920-1926; discussion 1926. DOI: 10.1016/j.athoracsur.2012.05.041
Kon ZN, Brown EN, Tran R, et al. Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass. The Journal of thoracic and cardiovascular surgery 2008; 135:367-375. doi: 10.1016/j.jtcvs.2007.09.025
Shewan LG, Coats AJS, Henein M. Requirements for ethical publishing in biomedical journals. International Cardiovascular Forum Journal 2015;2:2 DOI: 10.17987/icfj.v2i1.4
Authors who publish with this journal agree to the following terms:
a. The authors will retain copyright under a Creative Commons Attribution License (CC-BY 4.0) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
b. Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
c. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).