The Eternal Debate With a Consistent Answer: CABG vs PCI.

An ongoing debate exists over the role of percutaneous coronary intervention and coronary artery bypass grafting for revascularization in patients with multivessel or left main disease. Despite improvements in stent technology, bypass surgery still provides the best long-term results in the majority of patients. The present review focuses on randomized controlled trials and a meta-analysis published over the last 4 years.

Saphenous vein: advances.

Although the saphenous vein (SV) is a widely used conduit for coronary artery bypass graft surgery (CABG), lower long-term graft patency rates and worse clinical outcomes have been reported after CABG performed with SV grafts compared with CABG performed with internal thoracic artery (ITA) grafts. Of various efforts to overcome the limitations of SV that are resulting from structural and functional differences from arterial conduit, recent improvement in harvesting techniques including no-touch technique, surgical strategy of using the SV as part of a composite graft over an aortocoronary bypass graft, and external stenting of the SV will be discussed in this topic.

Safety and efficacy of miniaturized extracorporeal circulation when compared with off-pump and conventional coronary artery bypass grafting: evidence synthesis from a comprehensive Bayesian-framework network meta-analysis of 134 randomized controlled trials involving 22 778 patients.

OBJECTIVES: Coronary artery bypass grafting (CABG) remains the standard of care in patients with extensive coronary artery disease. Yet the use of cardiopulmonary bypass (CPB) is believed to be a major determinant of perioperative morbidity. Novel techniques are sought to tackle the shortcomings of CPB, among them off-pump coronary artery bypass (OPCAB) and miniaturized extracorporeal circulation (MECC) systems have been extensively tested in randomized controlled trials (RCTs). To assess perioperative safety and efficacy of MECC and OPCAB when compared with conventional extracorporeal circulation (CECC). METHODS: Published literature and major congress proceedings were screened for RCTs evaluating the safety and efficacy of MECC, OPCAB and CECC. Selected end-points such as 30-day all-cause mortality, myocardial infarction (MI), cerebral stroke, postoperative atrial fibrillation (POAF) and renal dysfunction were assessed in a Bayesian-framework network meta-analysis. RESULTS: A total of 134 studies with 22 778 patients were included. When compared with CECC, both OPCAB and MECC significantly reduced 30-day all-cause mortality [odds ratios (95% credible intervals): 0.75 (0.51-0.99) and 0.46 (0.22-0.91)], respectively. No differences in respect to MI were demonstrated with either strategy. OPCAB, when compared with CECC, reduced the odds of cerebral stroke [0.57 (0.34-0.80)]; 60% reduction was observed with MECC when compared with CECC [0.40 (0.19-0.78)]. Both OPCAB and MECC reduced the odds of POAF [0.66 (0.48-0.90) and 0.62 (0.35-0.98), respectively] when compared with CECC. OPCAB conferred over 30% reduction of renal dysfunction when compared with CECC [0.69 (0.46-0.92)]. MECC reduced these odds by more than 50% [0.47 (0.24-0.89)]. Ranking of treatments emerging from the probability analysis (highest to lowest SUCRA values) was MECC followed by OPCAB and CECC. CONCLUSIONS: MECC and OPCAB both improve perioperative outcomes following coronary bypass surgery when compared with conventional CABG performed with extracorporeal circulation. MECC may represent an attractive compromise between OPCAB and CECC.

Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: Meta-analysis.

OBJECTIVES: To assess the benefits and risks of off-pump coronary artery bypass (OPCAB) versus coronary artery bypass grafting (CABG) through a meta-analysis of randomized controlled trials (RCTs), and to investigate the relationship between outcomes and patient risk profile. METHODS: PubMed, Embase, the Cumulative Index of Nursing and Allied Health Literature, Scopus, Web of Science, Cochrane Library, and major conference proceedings databases were searched for RCTs comparing OPCAB and CABG and reporting short-term (≤ 30 days) outcomes. Endpoints assessed were all-cause mortality, myocardial infarction (MI), and cerebral stroke. RESULTS: The meta-analysis included 100 studies, with a total of 19,192 subjects. There was no difference between the 2 techniques with respect to all-cause mortality and MI (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.71-1.09; P = .25; I(2) = 0% and OR, 0.90; 95% CI, 0.77-1.05; P = .19; I(2) = 0%, respectively). OPCAB was associated with a significant 28% reduction in the odds of cerebral stroke (OR, 0.72; 95% CI, 0.56-0.92; P = .009; I(2) = 0%). A significant relationship between patient risk profile and benefits from OPCAB was found in terms of all-cause mortality (P < .01), MI (P < .01), and cerebral stroke (P < .01). CONCLUSIONS: OPCAB is associated with a significant reduction in the odds of cerebral stroke compared with conventional CABG. In addition, benefits of OPCAB in terms of death, MI, and cerebral stroke are significantly related to patient risk profile, suggesting that OPCAB should be strongly considered in high-risk patients.