Author + information
- Robert F. Tranbaugh, MD∗ (, )
- Thomas A. Schwann, MD and
- Robert H. Habib, PhD
- ↵∗Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York Methodist Hospital, 506 6th Street, Brooklyn, New York 11215
We thank Drs. Philip and Southard for their comments on our study comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) outcomes (1). They raised 2 concerns or limitations that they suggest “will dampen the enthusiasm for the use of multiple arterial coronary artery bypass grafting (MA-CABG) as a default strategy for multivessel revascularization.” We disagree with their conclusion and wish to address their concerns and reaffirm our calibrated study conclusions.
First, the authors reiterate the already recognized and discussed issue that the SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries trial) scores were not calculated on our patients (1). All patients in our study had multivessel coronary artery disease (CAD), including left anterior descending artery disease. Our CABG and PCI patients were matched extensively to minimize the heterogeneity between groups so that the matched MA-CABG and drug-eluting stent (DES) patients (546 pairs) had an 84% rate of triple vessel CAD. Indeed, although otherwise matched, the fact that MA-CABG patients had substantially greater frequency of left main disease may indicate more severe CAD (higher SYNTAX scores) than DES counterparts. This point was addressed specifically in our paper.
Second, Drs. Philip and Southard are concerned that stent technology—particularly DES—has changed substantially over the course of our study. The authors nicely review and chronicle the risks associated with various types and generations of stents, and how patterns of stent use have subsequently changed in clinical practice. The cardiology community has enthusiastically embraced these various generations of stents, which, in fact, resulted in a massive change in clinical practice nationwide and beyond. In New York State, the 50% decrease in CABG volumes from 2000 to 2010 was primarily led by the results of 4 randomized controlled CABG versus PCI trials (2) that used these earlier generations of stents in patients primarily with double vessel CAD. Very few patients had MA-CABG. Our study of patients with mostly triple vessel disease is the first to point out the unique finding of the impact of conduit selection on CABG versus PCI outcomes (1).
We certainly agree with Drs. Philip and Southard that a randomized controlled trial comparing newer PCI platforms with contemporary MA-CABG is needed. However, pending such a trial, our study is the best available evidence comparing outcomes of MA-CABG over DES or bare-metal stent PCI. Our results strongly support MA-CABG as the optimal treatment of patients with advanced multivessel CAD. Compared with single artery CABG, MA-CABG significantly improves survival relative to both bare-metal stent and DES patients. Patients with advanced CAD are best served by a heart team approach incorporating the choice of conduits in the discussion of which revascularization option will provide the best, safest, and most durable long-term outcomes.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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