New-generation stents compared with coronary bypass surgery for unprotected left main disease: A word of caution

The Journal of Thoracic and Cardiovascular Surgery

Umberto Benedetto¹  Miguel Sousa-Uva²  Lucas B. Ohmes³  Mohamed Rahouma⁴  Antonino Di Franco⁵  Giuseppe Biondi-Zoccai⁶  David P. Taggart⁷ 

[1] Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom;Cardiac Surgery Department, Hospital Cruz Vermelha, Lisbon, Portugal;Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy;Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY;Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy;Department of Surgery and Physiology Cardiovascular Research Centre, Faculdade de Medicina Universidade do Porto, Porto, Portugal;Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom

关键词: coronary artery bypass grafting;    percutaneous coronary intervention;    coronary stenting;    left main disease;   

DOI  :  10.1016/j.jtcvs.2017.11.066

学科分类：心脏病和心血管学

来源: Mosby, Inc.

【 摘 要 】

BackgroundWith the advent of bare metal stents and drug-eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta-analysis of available randomized controlled trials.MethodsAll randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug-eluting stents of first- and second-generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head-to-head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization.ResultsNine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow-up ranged from 6 months to 5 years. Second-generation drug-eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1-1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27-1.4), and first-generation drug-eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65-1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1-14), whereas first-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) and second-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) were comparable.ConclusionsThe introduction of new-generation drug-eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting.

【 授权许可】

Unknown