番茄社区

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SAN DIEGO -- Surgery and stenting procedures done more than 10 years ago for complex coronary artery disease (CAD) turned out to produce similar survival rates over the long term -- yet certain groups tended to do better by some measures with coronary artery bypass grafting (CABG), according to separate randomized and registry data presented here.

Ten-year death rates were 29.4% and 25.6%, respectively, among patients randomized to percutaneous coronary intervention (PCI) with the Taxus paclitaxel-eluting stent and those getting CABG (P=0.11). These were patients with three-vessel or left main disease enrolled in the SYNTAX trial.

The latter group survived in equal rates regardless of the treatment modality (29.7% PCI versus 31.9% CABG, P=0.43), whereas those with three-vessel disease experienced less mortality over the study period if they had received surgery (29.2% versus 21.9%, P=0.007), showed Daniel Thuijs, MSc, MD, of Erasmus Medical Center in the Netherlands, from his group's late-breaking trial at the (TCT) annual conference.

Also trending toward better survival after CABG were patients with higher SYNTAX scores (scores 33 or higher, P=0.050 for interaction).

The current analysis represents 72% of the full 1,301-person SYNTAX cohort. More 1o-year data are to come, with the full study expected to be completed by the end of 2018.

Already the sample size is "pretty good" for a subgroup analysis, suggested Morton Kern, MD, of the University of California in Irvine, during a TCT press conference. He emphasized that not all left main disease is the same.

"I'm reluctant to take on highly complex PCI -- even though it's feasible, it's not the best approach and we do surgery on these patients," he said. "This study supports this approach as well."

Thuijs noted that his group did not look at cardiovascular mortality in particular because of limited resources for their investigator-initiated study.

Another TCT late-breaker showed that long-term outcomes were also comparable between PCI and CABG for patients with unprotected left main disease with one exception: target lesion revascularization.

The following are the 10-year outcomes of 2,240 individuals treated at 12 major cardiac centers in Korea between PCI and CABG groups (after inverse-probability-of-treatment weighting to adjust for baseline differences between groups):

• All-cause death: 22.2% PCI versus 21.4% CABG (P=0.64)
• Death, Q-wave MI, or stroke: 25.0% versus 24.6% (P=0.43)
• Target vessel revascularization (TVR): 22.6% versus 5.4% (P<0.001)

In the early phase of the MAIN-COMPARE study, PCI done exclusively with bare metal stents (BMS) placed patients at a non-significant disadvantage for death (23.0% versus 21.7% CABG, P=0.05); the combined endpoint trended higher (24.8% versus 24.6%, P=0.06); and TVR was substantially more common than among the CABG group (23.7% versus 5.6%, P<0.001).

Later PCIs performed with drug-eluting stents (DES) did not put patients at higher risk of death, but the combined endpoint and TVR rates did favor CABG, according to Seung-Jung Park, MD, PhD, of Seoul's University of Ulsan College of Medicine.

The observational study was also published .

MAIN-COMPARE boasted a median 12 years of follow-up. The choice of revascularization strategy lay at the discretion of the treating physician. Park and colleagues collected mortality data from the National Population Registry of the Korea National Statistical Office.

The early BMS period spanned 2000 to mid-2003, after which DES was the device of choice in PCI. Overall, CABG was done off-pump in 42% of cases with 2.9 grafts per patient on average. The PCI group saw 71% of patients getting DES with means of 1.2 stents per left main lesion and 1.9 per patient.

Overall results largely stayed the same when adjusted by propensity-score matching, except that the combined endpoint did favor CABG over stenting across the BMS and DES periods.

Session discussant Bernard Gersh, MB, ChB, DPhil, of Mayo Clinic in Rochester, Minn., praised MAIN-COMPARE for its "amazing follow-up."

"It would be interesting to look at 10-year data of patients being treated now," he said, as over time the studies show left main CAD patients dying more and more from non-cardiac deaths. "Now cardiac outcomes are better, but the patients are sicker. It'll be interesting to look at later data and see if this changes. I think it will."

EXCEL and NOBLE were two recent trials of note investigating stenting versus surgery in left main CAD. The former gave neither strategy the win, whereas the latter suggested that CABG was the better choice.