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Coronary Artery Bypass Graft Surgery vs Percutaneous Interventions in Coronary Revascularization:  A Systematic Review

Saswata Deb, MD1,2; Harindra C. Wijeysundera, MD1,2,3; Dennis T. Ko, MD1,2,3; Hideki Tsubota, MD1; Samantha Hill, MD1; Stephen E. Fremes, MD1,2
[+] Author Affiliations
1Schulich Heart Centre, Division of Cardiology and Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
2Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
3Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
JAMA. 2013;310(19):2086-2095. doi:10.1001/jama.2013.281718.
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Importance  Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups.

Objective  To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD).

Evidence Review  A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible.

Findings  Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies.

Conclusions and Relevance  Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.

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Figure.
Flow Diagram of the RCTs Included in the Review Comparing CABG Surgery With PCI

CABG indicates coronary artery bypass graft; PCI, percutaneous coronary intervention; RCTs, randomized clinical trials. A formal search was also conducted for current meta-analysis involving randomized studies, observational studies, or both. The most current meta-analysis for each topic was selected. Five meta-analyses resulted from our search (1 for left main disease, 1 for multivessel disease, 1 for diabetes, and 2 for left ventricular dysfunction). Altogether, the left main section included 6 studies, multivessel disease included 6 studies, diabetes included 6 studies, and left ventricular dysfunction included 2 studies.

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