Article Impact Level: HIGH Data Quality: STRONG Summary of European Heart Journal, 43(13), 1334–1344. https://doi.org/10.1093/eurheartj/ehab537 Dr. Piroze Davierwala et al
Points
- The study is a post hoc analysis of a multicenter randomized controlled SYNTAXES trial comprising left main coronary artery disease (LMCAD) and three-vessel coronary artery disease (3VD) patients
- The patients were randomized to receive coronary artery bypass grafting (CABG) using single arterial grafting (SAG) or multiple arterial grafting (MAG); or percutaneous coronary intervention (PCI)
- CABG with MAG manifests as significantly lower all-cause mortality in 3VD patients than in PCI
- CABG with MAG is an optimal coronary revascularization strategy in 3VD and LMCAD patients and has improved long-term all-cause mortality
Summary
The optimal coronary revascularization strategy in left main coronary artery disease (LMCAD) and three-vessel disease (3VD) is highly debatable among medical professionals. Coronary artery bypass grafting (CABG) is demonstrated by several studies, to be associated with lower mortality as compared to percutaneous coronary intervention (PCI) in 3VD patients. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial is a randomized trial designed to assess the survival with CABG vs. PCI and drug-eluting stents in de novo 3VD or LMCAD patients. The trial concluded that both PCI and CABG groups have similar all-cause mortality rates. Nonetheless, CABG significantly promotes survival in 3VD patients. In the SYNTAX trial, CABG performed using multiple arterial grafting (MAG) is found to be superior to single arterial grafting (SAG). However, it is unclear whether MAG is responsible for long-term survival outcomes of CABG as compared to PCI or CABG using SAG is a useful approach as compared to PCI.
This is a post hoc analysis of the SYNTAX Extended Survival (SYNTAXES) trial. In the initial multicenter randomized controlled SYNTAX trial, a total of 85 hospitals in European and North American countries, with 1800 study participants (3VD or LMCAD patients) were included. 903 study participants were to receive PCI with paclitaxel-eluting stents whereas 897 study participants were to undergo CABG. Out of 1766 participants, 22 received venous grafts while 1 received synthetic material grafts, rendering 1743 participants in the given analyses. The PCI cohort group comprised 901 participants. The CABG cohort group included 842 participants, among which, 310 received MAG and 532 received SAG. The primary endpoint of this study is all-cause mortality of patients at maximum follow-up, the median duration of which was 11.9 years in the survivors. The analysis included only those patients who underwent revascularization of the right coronary artery, left anterior descending (LAD) artery, and circumflex artery territories of the myocardium.
This post hoc analysis demonstrated all-cause death in 305 patients in the PCI group, 70 patients in the MAG group, and 175 patients in the SAG group. In contrast to PCI, MAG was attributed to lower all-cause mortality, however, there is no significant association between SAG and all-cause mortality when compared to PCI. There is a lower mortality rate in 3VD patients who received SAG and MAG, however, there is no significant difference in mortality rate in LMCAD patients who received MAG or SAG and PCI. There is a positive correlation between survival outcomes and the number of myocardial territories which undergo revascularization using arterial grafts.
The study proposes that CABG with MAG is an optimal strategy for reducing all-cause mortality over a longer period, in LMCAD and 3VD patients.
Link to the article: https://academic.oup.com/eurheartj/article/43/13/1334/6354120
References Davierwala, P. M., Gao, C., Thuijs, D. J. F. M., Wang, R., Hara, H., Ono, M., Noack, T., Garg, S., O’leary, N., Milojevic, M., Kappetein, A. P., Morice, M.-C., Mack, M. J., van Geuns, R.-J., Holmes, D. R., Gaudino, M., Taggart, D. P., Onuma, Y., Mohr, F. W., … for the SYNTAX Extended Survival Investigators. (2022). Single or multiple arterial bypass graft surgery vs. Percutaneous coronary intervention in patients with three-vessel or left main coronary artery disease. European Heart Journal, 43(13), 1334–1344. https://doi.org/10.1093/eurheartj/ehab537
