Author + information
- Femi Philip, MD∗ ( and )
- Jeffrey A. Southard, MD
- ↵∗Department of Internal Medicine, Interventional Cardiology, Cardiovascular Medicine, University of California, Davis, 4860 Y Street, Suite 2820, Sacramento, California 95817
We read with much interest the recent paper and editorial by Habib et al. (1) and Guyton (2) evaluating longer-term outcomes in 8,402 patients using multiarterial coronary artery bypass graft (MA-CABG), single-arterial CABG (SA-CABG) compared with percutaneous coronary intervention (PCI) using either bare metal stents (BMS) or drug-eluting stents (DES) from 1994 to 2009. The authors found that BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p < 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years’ surgery advantage (HR: 1.06; p < 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p < 0.001). The authors concluded that MA-CABG, compared with BMS-PCI or DES-PCI, resulted in substantially enhanced death and re-intervention–free survival.
Their work is in keeping with recent research efforts that have focused on optimizing patient outcomes when selecting coronary revascularization strategies. However, this single-center study has some limitations. First, the majority of PCI revascularization used either BMS or first-generation DES, neither of which are used extensively in contemporary clinical practice in the U.S. In fact, several large registries have shown an increased risk for mortality with the use of first-generation DES when compared with BMS (3). Additionally, first-generation DES maintain a constant hazard for risk for very late stent thrombosis, a factor that may be related to permanent polymer. There is a large body of literature that has demonstrated that permanent polymers used in Cyper SES and Taxus PES can precipitate medial necrosis, vascular inflammation, granuloma formation, and stent thrombosis. Additionally, Taxus PES have been shown to have inferior safety and efficacy when compared with Cyper SES. Additionally, in the SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries) study, the inferior performance of the Taxus PES performance may have contributed to the overall cardiac mortality between the 2 groups in long-term follow-up (4). Second, the majority of the second-generation DES that were used were the Endeavor ZES, given the timing of the U.S. Food and Drug Administration approval of this stent platform. The Endeavor ZES was designed with a “biomimetic” polymer, but released 95% zotarolimus within 14 days of deployment. Given these drug elution properties, this stent showed inferior safety and efficacy when compared with first-generation DES that resulted in a reengineering of the stent drug elution properties. Last, in the propensity-matched cohort there was no mention of the use of the SYNTAX score to quantify the degree of angiographic complexity to determine which revascularization strategy would be best. Given the robust evidence, angiographic complexity should be an important arbiter of the revascularization strategy (5).
These factors are striking limitations and will dampen the enthusiasm for the use of MA-CABG as a default strategy for multivessel revascularization. There is a need for randomized trials with adequate power to compare revascularization strategies using the best available surgical versus best available percutaneous coronary revascularization. Only then will we be able to delineate the boundaries between CABG and PCI for individual patients with complex coronary disease.
Please note: Dr. Southard has received speakers’ fees from St. Jude Medical and Edwards Lifesciences. Dr. Philip has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2016 American College of Cardiology Foundation
- Habib R.H.,
- Dimitrova K.R.,
- Badour S.A.
- Guyton R.A.
- Garg S.,
- Serreys P.W.