ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2009;87:1651-1652. doi:10.1016/j.athoracsur.2008.10.087
© 2009 The Society of Thoracic Surgeons
This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Hisato Takagi
Takuya Umemoto
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Takagi, H.
Right arrow Articles by Umemoto, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Takagi, H.
Right arrow Articles by Umemoto, T.
Related Collections
Right arrow Coronary disease
Right arrowRelated Article

Correspondence

Unprotected Left Main Coronary Artery Stenting Versus Coronary Artery Bypass Graft Surgery

Hisato Takagi, MD, PhD, Hideaki Manabe, MD, Norikazu Kawai, MD, Shin-nosuke Goto, MD, Takuya Umemoto, MD, PhD

Department of Cardiovascular Surgery, Shizuoka Medical Center, 762-1 Nagasawa, Shimizu-cho, Sunto-gun, Shizuoka, 411-8611 Japan

(Email: kfgth973{at}ybb.ne.jp).

To the Editor:

In their observational study, Wu and colleagues [1] found that coronary artery bypass grafting (CABG) was associated with a significantly lower risk of 2-year mortality relative to percutaneous coronary intervention with stents (PCI-S) (hazard ratio, 0.32; 95% confidence interval, 0.14 to 0.71; p = 0.005) in 135 matched pairs (on baseline characteristics identified by a propensity model as predictors of type of procedure received) of patients with unprotected left main coronary artery (LMCA) disease. Our recent meta-analysis [2] of five comparative studies (not including the study by Wu and colleagues [1]), however, demonstrated no significant difference in 1-year to 3-year mortality between CABG and PCI-S for unprotected LMCA disease. To compare the treatment of unprotected LMCA disease with CABG versus PCI-S, we herein performed a meta-analysis of up-to-date comparative studies, including the study by Wu and colleagues [1], for prevention of death at follow-up.

All comparative studies of CABG (conventional or off-pump) versus PCI-S (with bare-metal or drug-eluting stents), which enrolled patients with unprotected LMCA disease, were identified using a two-level search strategy. First, a public domain database (MEDLINE) was searched using a Web-based search engine (PubMed). Second, relevant studies were identified through a manual search of secondary sources, including references of initially identified articles and a search of reviews and commentaries. The MEDLINE database was searched from January 1966 to September 2008. MeSH keywords included coronary artery bypass, angioplasty, transluminal, percutaneous coronary, and stents. Studies considered for inclusion met the following criteria: the design was a comparative (randomized controlled or nonrandomized observational) study; the study population was patients with unprotected LMCA disease; patients were assigned to CABG versus PCI-S; and main outcomes included death at follow-up. Adjusted risk estimates for nonrandomized controlled comparisons and crude risk ratios for randomized controlled comparisons were pooled after logarithmic transformation, according to a random-effects model with generic inverse variance weighting.

Our search identified six comparative studies [1, 3–7] of CABG versus PCI-S enrolling patients with unprotected LMCA disease. These included one randomized, controlled trial, [4] and five nonrandomized observational studies [1, 3, 5–7]. We excluded three nonrandomized observational studies by Hsu and colleagues (2008) [8], Brener and colleagues (2008) [9], Sanmartín and colleagues (2007) [10], because adjusted risk estimates could not be abstracted. In total, our meta-analysis included data on 2,278 patients with unprotected LMCA disease assigned to CABG (n = 1,187) or PCI-S (n = 1,091). For death at follow-up, only the study by Wu and colleagues [1] demonstrated a statistically significant benefit of CABG in comparison with PCI-S and two other studies [3, 6] that had a statistically nonsignificant benefit of CABG in comparison with PCI-S, whereas 3 studies [4, 5, 7] had a statistically nonsignificant benefit of PCI-S in comparison with CABG. Pooled analysis of the six studies demonstrated no significant difference in mortality between CABG and PCI-S (pooled risk estimate, 0.92; 95% CI, 0.54–1.57; p = 0.77) (Fig 1). Despite the results of the study by Wu and colleagues [1], the present meta-analysis of up-to-date comparative studies demonstrated that CABG was not likely to provide better results than PCI-S in terms of 1-year to 3-year mortality.


Figure 1
View larger version (14K):
[in this window]
[in a new window]

  		Fig 1. Risk estimates of mortality at follow-up and meta-analysis. (CABG = coronary artery bypass grafting; CI = confidence interval; LMCA = left main coronary artery; PCI-S = percutaneous coronary intervention with stents; SE = standard error.)

 


   References
Top
 References
 

  1. Wu C, Hannan EL, Walford G, Faxon DP. Utilization and outcomes of unprotected left main coronary artery stenting and coronary artery bypass graft surgery Ann Thorac Surg 2008;86:1153-1159.[Abstract/Free Full Text]
  2. Takagi H, Kawai N, Umemoto T. Stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: a meta-analysis of comparative studies J Thorac Cardiovasc Surg 2009;137:e54-e57.[Free Full Text]
  3. Seung KB, Park DW, Kim YH, et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease N Engl J Med 2008;358:1781-1792.[Medline]
  4. Buszman PE, Kiesz SR, Bochenek A, et al. Acute and late outcomes of unprotected left main stenting in comparison with surgical revascularization J Am Coll Cardiol 2008;51:538-545.[Abstract/Free Full Text]
  5. Palmerini T, Barlocco F, Santarelli A, et al. A comparison between coronary artery bypass grafting surgery and drug eluting stent for the treatment of unprotected left main coronary artery disease in elderly patients (aged ≥ 75 years) Eur Heart J 2007;28:2714-2719.[Abstract/Free Full Text]
  6. Palmerini T, Marzocchi A, Marrozzini C, et al. Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry) Am J Cardiol 2006;98:54-59.[Medline]
  7. Chieffo A, Morici N, Maisano F, et al. Percutaneous treatment with drug-eluting stent implantation versus bypass surgery for unprotected left main stenosis: a single-center experience Circulation 2006;113:2542-2547.[Abstract/Free Full Text]
  8. Hsu JT, Chu CM, Chang ST, Kao CL, Chung CM. Percutaneous coronary intervention versus coronary artery bypass graft surgery for the treatment of unprotected left main coronary artery stenosis: in-hospital and one year outcome after emergent and elective treatments Int Heart J 2008;49:355-370.[Medline]
  9. Brener SJ, Galla JM, Bryant 3rd R, Sabik 3rd JF, Ellis SG. Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients Am J Cardiol 2008;101:169-172.[Medline]
  10. Sanmartín M, Baz JA, Claro R, et al. Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease Am J Cardiol 2007;100:970-973.[Medline]

Related Article

Reply
Chuntao Wu, Edward L. Hannan, Gary Walford, and David P. Faxon
Ann. Thorac. Surg. 2009 87: 1652-1653. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
C. Wu, E. L. Hannan, G. Walford, and D. P. Faxon
Reply.
Ann. Thorac. Surg., May 1, 2009; 87(5): 1652 - 1653.
[Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Hisato Takagi
Takuya Umemoto
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Takagi, H.
Right arrow Articles by Umemoto, T.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Takagi, H.
Right arrow Articles by Umemoto, T.
Related Collections
Right arrow Coronary disease
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS