Commentary: Another glimpse of light for patients with Marfan syndrome Gallingani, Alan; Maestri, Francesco; Nicolini, Francesco ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
July 2023, 2023-07-00, 20230701, Letnik:
166, Številka:
1
Journal Article
Abstract Background The study compares five-year clinical outcomes of CABG vs PCI in a real world population of diabetic patients with multivessel coronary disease since it is not clear whether to ...prefer surgical or percutaneous revascularization. Methods Between July 2002 and December 2008, 2885 multivessel coronary diabetic patients underwent revascularization (1466 CABG and 1419 PCI) at hospitals in Emilia-Romagna Region, Italy and were followed for 1827 ± 617 days by record linkage of two clinical registries with the regional administrative database of hospital admissions and the mortality registry. Five-year incidences of MACCE (mortality, acute myocardial infarction AMI, stroke, and repeat revascularization TVR) were assessed with Kaplan–Meier estimates, Cox proportional hazards regression and cumulative incidence functions of death and TVR, to evaluate the competing risk of AMI on death and TVR. The same analyses were applied to the propensity score matched subgroup of patients undergoing CABG or PCI with DES and with complete revascularization. Results PCI had higher mortality for all causes (HR: 1.8, 95% CI 1.4–2.2 p < 0.0001), AMI (HR: 3.3, 95% CI 2.4–4.6 p < 0.0001) and TVR (HR: 4.5, 95% CI 3.4–6.1 p < 0.0001). No significant differences emerged for stroke (HR: 0.8, 95% CI 0.5–1.2 p = 0.26). The higher incidence of AMI caused higher mortality in PCI group. Results did not change comparing CABG with PCI patients receiving complete revascularization or DES only. Conclusions Diabetics show a higher incidence of MACCE with PCI than with CABG: thus diabetes and its degree of control should be considered when choosing the type of revascularization.
PURPOSE OF REVIEWThe aim of this study was to review recent literature reporting the results of coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass ...grafting (CABG) in patients older than 80 years.
RECENT FINDINGSThe review of recent studies on octogenarians demonstrates a surgical CABG advantage in the case of patients with increasing baseline coronary risk, such as severe multivessel disease, chronic total occlusions, and left ventricular dysfunction. PCI seems to be more appropriate for less severe degree and distribution of coronary lesions, and for subgroups of patients with higher surgical risk, such as acute coronary syndromes, reoperations, malignancy, dementia, poor mobility, frailty, and serious comorbidities contraindicating extracorporeal circulation.
SUMMARYIt is not the case that CABG is indicated only when there are contraindications to PCI. CABG confers more benefit than PCI in patients with increasing baseline cardiac risk, in the absence of serious systemic diseases that can reasonably reduce their life expectancy.CABG and PCI, with proper selection, should be considered complementary rather than competitive procedures in the therapy of octogenarians affected by coronary artery disease.
It is well known that graft patency determines prognosis in coronary artery bypass grafting. Numerous reports over the past 20 years have documented superior patency and prognosis when multiple ...arterial grafts are used. The use of the left internal thoracic artery to graft the left anterior descending artery has been widely accepted as the gold standard for surgical treatment of coronary disease for over 40 years. A considerable body of evidence suggests that the right internal thoracic artery behaves in the same way. Radial artery grafts are being studied in several randomized trials, but observational studies suggest a performance comparing favorably with the saphenous vein. The right gastroepiploic artery has been recognized as a suitable and reliable conduit for coronary bypass surgery. However, the use of multiple other arterial grafts is performed in less than 10% of surgical procedures, probably because of perceptions of technical complexity, prolonged time for conduit harvesting, and increased perioperative complications. As a result, most patients with multivessel coronary artery disease do not benefit from extensive revascularization with arterial conduits. The aim of this review is to summarize the current evidence for the extensive use of arterial conduits in the revascularization of multivessel coronary artery disease.
The purpose of this study was to investigate retrospectively early and late outcomes of coronary artery bypass grafting (CABG) in a large series of octogenarians. We retrospectively reviewed the data ...of 241 octogenarian patients who underwent CABG between April 2002 and April 2009 at our institution. Mean age was 84.7 ± 1.8 years. Patients affected by concomitant coexistent organic aortic, mitral, or tricuspid valve disease were excluded from the study. Patients with functional secondary ischemic mitral incompetence were included in the study. The majority of the patients were male. Angina pectoris functional class III/IV accounted for 164 patients (68%). Left ventricular ejection fraction ≤35% was diagnosed in 38 patients (15.8%). Early mortality rate was 5.8% (14 patients). Causes of death were cardiac related in 10 patients. Preoperative independent predictors of in-hospital mortality obtained with multivariate analysis were extracardiac arteriopathy, New York Heart Association class III/IV, and previous percutaneous transluminal coronary angioplasty (PTCA). The overall mean follow-up was 41.6 ± 25.9 months (range 1–87.6 months). Among the 222 contacted survivors, there were 16 (7.2%) deaths during the follow-up. The actuarial survival was 91.9% at 1 year and 83.5% at 5 years. On multivariate analysis, time to late death was adversely affected by preoperative extracardiac arteriopathy and previous PTCA. Advanced age alone should not be a deterrent for CABG if it has been determined that the benefits outweigh the potential risk. A careful selection of optimal candidates, based on the evaluation of their systemic comorbidities, appears mandatory in order to obtain the greatest benefit for these high-risk patients.
Surgical coronary revascularization and percutaneous coronary intervention were demonstrated to be effective treatments for coronary artery disease. However, the optimal revascularization strategy ...remains unclear in certain patient subsets. The recently published Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial is a randomized study evaluating the use of CABG versus PCI in diabetic patients with multivessel coronary disease. The purpose of this study was to review the available literature based on randomized trials and observational studies in order to allow clinicians to make evidence-based decisions when treating diabetic patients with multivessel coronary disease. The current evidence suggests that CABG should remain the standard of care for this patient population.
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