Revascularization of left anterior descending artery with drug-eluting stents: comparison with minimally invasive direct coronary artery bypass surgery.

BACKGROUND: The proximal left anterior descending artery (LAD) is a challenging area for percutaneous interventions; therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the proximal LAD. This study compares mid-term results of LAD revascularization using drug-eluting stents (Cypher) with minimally invasive direct coronary artery bypass grafting (MIDCAB). METHODS: From May 2002 to December 2003, 376 consecutive patients underwent myocardial revascularization of the LAD, 272 by Cypher and 104 by MIDCAB. After matching for age, sex, and extent of coronary artery disease, two groups of 83 patients each were used to compare the two revascularization modalities. The groups were similar; however, ejection fraction of less than 0.35 was more prevalent in the MIDCAB group and prior percutaneous coronary intervention in the Cypher group. RESULTS: Thirty-day mortality was 1.1% in the MIDCAB and 0% in the Cypher group. Mean follow-up was 22.5 months. Two late cardiac deaths occurred in the MIDCAB group and one in the Cypher group (p = NS). Angina returned in 35% of the Cypher group and in 8.4% of the MIDCAB group (p < 0.001). There were 14 (16.8%) reinterventions in the Cypher compared with three (3.6%) in the surgical group (p = 0.005). Cox proportional hazard model showed that assignment to the Cypher group was the only independent predictor of reangina (hazard ratio [HR], 6.17, 95% confidence interval [CI], 2.46 to 15.4). Treatment with Cypher was also an independent predictor of reintervention (HR 8.26, 95% CI, 1.68 to 40). CONCLUSIONS: Despite improved results of percutaneous interventions with Cypher to the LAD, mid-term clinical outcome of patients treated with MIDCAB was better.

Drug-eluting stents versus arterial myocardial revascularization in patients with diabetes mellitus.

OBJECTIVE: The introduction of drug-eluting stents significantly reduced restenosis and reinterventions in patients undergoing percutaneous coronary interventions. This study compares results of Cypher stenting with those of surgical arterial revascularization in patients with diabetes mellitus. METHODS: From May 2002 through May 2005, 523 consecutive diabetic patients underwent myocardial revascularization: 244 underwent percutaneous coronary interventions incorporating drug-eluting stents, and 279 were treated surgically. All single-vessel patients in the surgical group were treated with the left internal thoracic artery, and most multivessel patients were treated with 2 internal thoracic arteries. After propensity score matching, 2 groups (93 patients each) were used to compare the 2 revascularization modalities. RESULTS: The number of coronary vessels treated per patient was higher in the surgical group (2.72 vs 1.75, P < .001). Follow-up ranged between 6 and 42 months (mean, 19 months). Overall mortality (early and late) was 3.2% in the surgical group and 2.2% in the Cypher group (P = .65). Two-year angina-free survival and reintervention-free survival (Kaplan-Meier) of the surgical group were 88% and 95%, respectively, compared with 47.8% (P = .001) and 83.6% (P = .01), respectively, in the percutaneous coronary intervention group. Cox proportional hazards modeling revealed assignment to the Cypher group to be the only predictor of reintervention (odds ratio, 3.86; 95% confidence interval, 1.25-11.9). Assignment to the Cypher group (hazard ratio, 5.92; 95% confidence interval, 2.96-11.87) and insulin treatment (hazard ratio, 2.06; 95% confidence interval, 1.06-4.02) were independent predictors of angina recurrence. CONCLUSIONS: The midterm clinical outcome of diabetic patients who underwent surgical arterial revascularization is better than that of patients undergoing percutaneous coronary intervention treated with drug-eluting stents.

Off-pump coronary revascularization of the circumflex system: comparison between sequential and nonsequential arterial grafts.

BACKGROUND: Sequential grafting increases the availability of arterial grafts. This study aims to determine the safety and efficacy of sequential grafting of the circumflex coronary distribution performed off-pump. METHODS: Between 2000 and 2003, 136 patients undergoing off-pump sequential arterial grafting of the circumflex territory were compared to 278 patients who received nonsequential grafts to the same area. RESULTS: The grafts/patient ratio was higher in the sequential than the nonsequential group (3.2 +/- .4 and 2.3 +/- .2, respectively, P < .0001). Radial artery conduits and T-grafts were used more often in the sequential group; conversely, bilateral internal thoracic artery configurations were more frequent in the nonsequential groups (P < .0001). There were 1.2 sequential anastomoses per patient. Early mortality (2.2% versus 2.5%), myocardial infarction (2.2% versus 1.1%) and stroke (.7% versus none) rates were comparable. Use of sequentials or other operative confounders had no independent effect on the occurrence of early adverse events (stepwise logistic regression). At 3.5 years, survival was 95.9% and 84.2% in the sequential and nonsequential groups, respectively (P = .231, log-rank). Despite comparable incidence of major adverse cardiac events (MACE) (6.6% versus 8.6%, P = .470) and similar 3.5-year freedom from MACE (88.7% for both groups, P = .682), Cox regression analysis identified sequential grafting as an independent predictor of MACE (P < .0001, HR 19.9), increasing this risk by 20-fold. CONCLUSIONS: Off-pump sequential grafting of the circumflex system may be safely performed. The use of sequentials, however, had an independent effect on increased midterm MACE. The distribution of events suggests culpability of surgical factors and may reflect a learning curve.