Ann Thorac Surg 2009;87:1652-1653. doi:10.1016/j.athoracsur.2009.02.025
© 2009 The Society of Thoracic Surgeons
Correspondence
Reply
Chuntao Wu, MD, PhDa,
Edward L. Hannan, PhDb,
Gary Walford, MDc,
David P. Faxon, MDd
a Department of Public Health Sciences, A210, Penn State Hershey College of Medicine, 600 Centerview Dr, Ste 2200, Hershey, PA 17033
b State University of New York at Albany, Albany, NY
c St. Joseph's Hospital, Syracuse, NY
d Brigham and Women's Hospital, Boston, MA
(Email: chuntao.wu{at}psu.edu).
To the Editor:
We would like to thank Dr Takagi and colleagues [1] for their interest in our study [2]. Their meta-analysis found that 1- to 3-year mortality was not statistically different between coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) for patients with unprotected left main coronary artery disease [1]. We note, however, that the results on mortality from individual studies included in their analysis were not consistent. The relative risks for death after CABG vs PCI ranged from 0.32 to 3.92 [1].
One reason why our study [2] demonstrates a significant difference in mortality in favor of CABG may be related to angiographic follow-up. Utilization of follow-up angiography for PCI patients in real-life practice, as in our study, might be less frequent than in other studies included in the meta-analysis [1], in which routine angiographic follow-up within 4 to 10 months was performed. Although information on utilization of follow-up angiography was not available to us, it is likely that less frequent utilization may have an adverse effect on survival after PCI in real-life practice [2].
Although mortality was examined in the meta-analysis by Takagi and colleagues, other adverse outcomes were not studied. Five of the six studies reviewed in the meta-analysis [1] showed that PCI was associated with a statistically significantly higher risk of repeat revascularization than CABG for patients with unprotected left main coronary artery disease. The relative risks for repeat revascularization after CABG vs PCI were 0.10 to 0.24. Such evidence should also be considered when selecting treatment strategy for patients who are good candidates for CABG.
It is worth noting that the average length of follow-up in current studies was about 2 years [1]. A recent observational study by Rodés-Cabau and colleagues [3] included 249 patients with an average length of follow-up of 2 years. They reported that the respective 30-day mortality rates for CABG and PCI were 8.3% and 6.7%; mortality rates after 30 days were 4.5% for CABG and 10.3% for PCI; and cumulative mortality rates were 12.4% for CABG and 16.3% for PCI. These results demonstrate that longer length of follow-up is needed to better examine differences in mortality after CABG and PCI.
In short, the debate on whether CABG and PCI provide comparable outcomes for patients with unprotected left main coronary disease is still ongoing, and more studies of larger sample sizes and longer follow-up are needed to further examine differences in long-term mortality.
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References
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- Takagi H, Manabe H, Kawai N, Goto S, Umemoto T. Unprotected left main coronary artery stenting versus coronary artery bypass graft surgery (letter) Ann Thorac Surg 2009;87:1651-1652.[Free Full Text]
- 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]
- Rodés-Cabau J, Deblois J, Bertrand OF, et al. Nonrandomized comparison of coronary artery bypass surgery and percutaneous coronary intervention for the treatment of unprotected left main coronary artery disease in octogenarians Circulation 2008;118:2374-2381.[Abstract/Free Full Text]
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