Two revascularization strategies in patients with coronary heart disease and left ventricular systolic dysfunction: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Bo ¹ ,  WU Chunrong ² , FU Shiquan ¹ , CHEN Qingmei ¹ , LI Yuanjing ¹

1. Department of Cardiology, Chongqing Jiangjin Central Hospital, Chongqing, 402260, P.R.China;
2. Department of Oncology, Chongqing Jiangjin Central Hospital, Chongqing, 402260, P.R.China;

Corresponding author：

WU Chunrong, Email: lbwhu123@163.com

Keywords：

Coronary artery bypass grafting; percutaneous coronary intervention; coronary heart disease; left ventricular systolic dysfunction

DOI：

10.7507/1007-4848.201712068

Video：

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Objective To compare the clinical efficacy of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with coronary heart disease and left ventricular systolic dysfunction. Methods A computer-based search in PubMed, The Cochrane Library and EMbase up to October 2017, together with reference screening, was performed to identify eligible clinical trials, cohort studies and case-control studies. The outcomes of this meta-analysis included all-cause mortality, myocardial infarction, revascularization and stroke, and the effect sizes for them were presented as relative risk (RR) with its 95% confidence intervals (CI). Results Fifteen cohort studies and 2 randomized controlled trials were finally included with a total of 11 985 patients, of whom 6 322 were in the CABG group and 5 663 in the PCI group. The result of meta-analysis showed that all-cause mortality was significantly lower in the CABG group than that in the PCI group (18.6% vs. 23.0%, RR=0.87, 95% CI 0.81 to 0.94, P<0.001). In addition, CABG was associated with a remarkably reduced risk of revascularization (RR=0.28, 95% CI 0.19 to 0.42, P<0.001) compared with PCI, with no significant difference in incidence of myocardial infarction (RR=0.78, 95% CI 0.47 to 1.32, P=0.36) and stroke (RR=1.28, 95% CI 0.89 to 1.86, P=0.18). Conclusion CABG is superior to PCI in the treatment for patients with coronary heart disease and left ventricular systolic dysfunction. Owing to the limited quality of included studies, additional large, randomized controlled trails are still required to confirm this finding.

Citation： LI Bo, WU Chunrong, FU Shiquan, CHEN Qingmei, LI Yuanjing. Two revascularization strategies in patients with coronary heart disease and left ventricular systolic dysfunction: A systematic review and meta-analysis. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(2): 158-164. doi: 10.7507/1007-4848.201712068 Copy

1.	GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet, 2016, 388(10053): 1459-1544.
2.	Piccolo R, Giustino G, Mehran R, et al. Stable coronary artery disease: revascularisation and invasive strategies. Lancet, 2015, 386(9994): 702-713.
3.	Qian C, Feng H, Cao J, et al. Meta-analysis of randomized control trials comparing drug-eluting stents versus coronary artery bypass grafting for significant left main coronary narrowing. Am J Cardiol, 2017, 119(9): 1338-1343.
4.	Benedetto U, Gaudino M, Ng C, et al. Coronary surgery is superior to drug eluting stents in multivessel disease. Systematic review and meta-analysis of contemporary randomized controlled trials. Int J Cardiol, 2016, 210: 19-24.
5.	Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 2009, 339: b2535.
6.	Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 3rd Symposium on Systematic Reviews: Beyond the basics, 2000.
7.	Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials, 1996, 17(1): 1-12.
8.	Ahn JM, Oh JH, Sun BJ, et al. Comparisons of drug-eluting stents vs. Coronary artery bypass grafting for patients with multi-vessel disease and severely compromised ventricular dysfunction. Am J Cardiol, 2011, 8(suppl): 87A.
9.	Bangalore S, Guo Y, Samadashvili Z, et al. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation, 2016, 133(22): 2132-2140.
10.	Buszman P, Szkróbka I, Gruszka A, et al. Comparison of effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in patients with ischemic cardiomyopathy. Am J Cardiol, 2007, 99(1): 36-41.
11.	Cleland JG, Calvert M, Freemantle N, et al. The Heart Failure Revascularisation Trial (HEART). Eur J Heart Fail, 2011, 13(2): 227-233.
12.	Cummings I, Lucchese G, Husain M, et al. Off-pump coronary artery bypass crafting confers a prognostic benefit compared to percutaneous coronary intervention in patients with poor left ventricular function: a single centre 10-year experience. Circulation, 2016, 134: A17960.
13.	Fortuna D, Nicolini F, Guastaroba P, et al. Coronary artery bypass grafting vs percutaneous coronary intervention in a ’real-world’ setting: a comparative effectiveness study based on propensity score-matched cohorts. Eur J Cardiothorac Surg, 2013, 44(1): e16-e24.
14.	Gioia G, Matthai W, Gillin K, et al. Revascularization in severe left ventricular dysfunction: outcome comparison of drug-eluting stent implantation versus coronary artery by-pass grafting. Catheter Cardiovasc Interv, 2007, 70(1): 26-33.
15.	Hannan EL, Wu C, Walford G, et al. Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med, 2008, 358(4): 331-341.
16.	Kang SH, Lee CW, Baek S, et al. Comparison of outcomes of coronary artery bypass grafting versus drug-eluting stent implantation in patients with severe left ventricular dysfunction. Am J Cardiol, 2017, 120(1): 69-74.
17.	Kim MS, Kang SH, Park H, et al. Left main revascularization for patients with reduced left ventricular ejection fraction; comparison of outcome after PCI versus CABG from ASAN-MAIN registry. J Am Coll Cardiol, 2015, 65(suppl): S18.
18.	Marui A, Kimura T, Nishiwaki N, et al. Comparison of five-year outcomes of coronary artery bypass grafting versus percutaneous coronary intervention in patients with left ventricular ejection fractions≤50% versus >50% (from the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol, 2014, 114(7): 988-996.
19.	Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg, 2013, 96(6): 2038-2044.
20.	Park HS, Roh JH, Lee PH, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for left main coronary disease with reduced left ventricular ejection fraction. J Am Coll Cardiol, 2016, 67(suppl): S21.
21.	Sedlis SP, Ramanathan KB, Morrison DA, et al. Outcome of percutaneous coronary intervention versus coronary bypass grafting for patients with low left ventricular ejection fractions, unstable angina pectoris, and risk factors for adverse outcomes with bypass (the AWESOME Randomized Trial and Registry). Am J Cardiol, 2004, 94(1): 118-120.
22.	Toda K, Mackenzie K, Mehra MR, et al. Revascularization in severe ventricular dysfunction (15% < OR = LVEF < OR = 30%): a comparison of bypass grafting and percutaneous intervention. Ann Thorac Surg, 2002, 74(6): 2082-2087.
23.	Yang JH, Choi SH, Song YB, et al. Long-term outcomes of drug-eluting stent implantation versus coronary artery bypass grafting for patients with coronary artery disease and chronic left ventricular systolic dysfunction. Am J Cardiol, 2013, 112(5): 623-629.
24.	Velazquez EJ, Bonow RO. Revascularization in severe left ventricular dysfunction. J Am Coll Cardiol, 2015, 65(6): 615-624.
25.	Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J, 2014, 35(37): 2541-2619.
26.	Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol, 2012, 60(24): e44-e164.
27.	中华医学会心血管病学分会介入心脏病学组, 中国医师协会心血管内科医师分会血栓防治专业委员会, 中华心血管病杂志编辑委员会. 中国经皮冠状动脉介入治疗指南(2016). 中华心血管病杂志, 2016, 44(5): 382-400.
28.	Sandoval Y, Brilakis ES, Canoniero M, et al. Complete versus incomplete coronary revascularization of patients with multivessel coronary artery disease. Curr Treat Options Cardiovasc Med, 2015, 17(3): 366.
29.	Pyka Ł, Hawranek M, Gąsior M. Revascularization in ischemic heart failure with reduced left ventricular ejection fraction. The impact of complete revascularization. Kardiochir Torakochirurgia Pol, 2017, 14(1): 37-42.
30.	Pepper J. Managing heart failure patients with multivessel disease - coronary artery bypass graft versus percutaneous coronary intervention. Card Fail Rev, 2015, 1(2): 118-122.
31.	Yee NP, Siu AM, Davis J, et al. Recovery of left ventricular function after percutaneous coronary intervention compared to coronary artery bypass grafting in patients with multi-vessel coronary disease and left ventricular dysfunction. Hawaii J Med Public Health, 2016, 75(9): 273-277.
32.	Ronco C, McCullough P, Anker SD, et al. Cardio-renal syndromes: report from the consensus conference of the acute dialysis quality initiative. Eur Heart J, 2010, 31(6): 703-711.
33.	Athappan G, Chacko P, Patvardhan E, et al. Late stroke: comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: a meta-analysis and review of literature. Stroke, 2014, 45(1): 185-193.
34.	Mack MJ, Head SJ, Holmes DR Jr, et al. Analysis of stroke occurring in the SYNTAX trial comparing coronary artery bypass surgery and percutaneous coronary intervention in the treatment of complex coronary artery disease. JACC Cardiovasc Interv, 2013, 6(4): 344-354.
35.	Gheorghiade M, Vaduganathan M, Fonarow GC, et al. Anticoagulation in heart failure: current status and future direction. Heart Fail Rev, 2013, 18(6): 797-813.

1. GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet, 2016, 388(10053): 1459-1544.
2. Piccolo R, Giustino G, Mehran R, et al. Stable coronary artery disease: revascularisation and invasive strategies. Lancet, 2015, 386(9994): 702-713.
3. Qian C, Feng H, Cao J, et al. Meta-analysis of randomized control trials comparing drug-eluting stents versus coronary artery bypass grafting for significant left main coronary narrowing. Am J Cardiol, 2017, 119(9): 1338-1343.
4. Benedetto U, Gaudino M, Ng C, et al. Coronary surgery is superior to drug eluting stents in multivessel disease. Systematic review and meta-analysis of contemporary randomized controlled trials. Int J Cardiol, 2016, 210: 19-24.
5. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ, 2009, 339: b2535.
6. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 3rd Symposium on Systematic Reviews: Beyond the basics, 2000.
7. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials, 1996, 17(1): 1-12.
8. Ahn JM, Oh JH, Sun BJ, et al. Comparisons of drug-eluting stents vs. Coronary artery bypass grafting for patients with multi-vessel disease and severely compromised ventricular dysfunction. Am J Cardiol, 2011, 8(suppl): 87A.
9. Bangalore S, Guo Y, Samadashvili Z, et al. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction: everolimus-eluting stents versus coronary artery bypass graft surgery. Circulation, 2016, 133(22): 2132-2140.
10. Buszman P, Szkróbka I, Gruszka A, et al. Comparison of effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in patients with ischemic cardiomyopathy. Am J Cardiol, 2007, 99(1): 36-41.
11. Cleland JG, Calvert M, Freemantle N, et al. The Heart Failure Revascularisation Trial (HEART). Eur J Heart Fail, 2011, 13(2): 227-233.
12. Cummings I, Lucchese G, Husain M, et al. Off-pump coronary artery bypass crafting confers a prognostic benefit compared to percutaneous coronary intervention in patients with poor left ventricular function: a single centre 10-year experience. Circulation, 2016, 134: A17960.
13. Fortuna D, Nicolini F, Guastaroba P, et al. Coronary artery bypass grafting vs percutaneous coronary intervention in a ’real-world’ setting: a comparative effectiveness study based on propensity score-matched cohorts. Eur J Cardiothorac Surg, 2013, 44(1): e16-e24.
14. Gioia G, Matthai W, Gillin K, et al. Revascularization in severe left ventricular dysfunction: outcome comparison of drug-eluting stent implantation versus coronary artery by-pass grafting. Catheter Cardiovasc Interv, 2007, 70(1): 26-33.
15. Hannan EL, Wu C, Walford G, et al. Drug-eluting stents vs. coronary-artery bypass grafting in multivessel coronary disease. N Engl J Med, 2008, 358(4): 331-341.
16. Kang SH, Lee CW, Baek S, et al. Comparison of outcomes of coronary artery bypass grafting versus drug-eluting stent implantation in patients with severe left ventricular dysfunction. Am J Cardiol, 2017, 120(1): 69-74.
17. Kim MS, Kang SH, Park H, et al. Left main revascularization for patients with reduced left ventricular ejection fraction; comparison of outcome after PCI versus CABG from ASAN-MAIN registry. J Am Coll Cardiol, 2015, 65(suppl): S18.
18. Marui A, Kimura T, Nishiwaki N, et al. Comparison of five-year outcomes of coronary artery bypass grafting versus percutaneous coronary intervention in patients with left ventricular ejection fractions≤50% versus >50% (from the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol, 2014, 114(7): 988-996.
19. Nagendran J, Norris CM, Graham MM, et al. Coronary revascularization for patients with severe left ventricular dysfunction. Ann Thorac Surg, 2013, 96(6): 2038-2044.
20. Park HS, Roh JH, Lee PH, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for left main coronary disease with reduced left ventricular ejection fraction. J Am Coll Cardiol, 2016, 67(suppl): S21.
21. Sedlis SP, Ramanathan KB, Morrison DA, et al. Outcome of percutaneous coronary intervention versus coronary bypass grafting for patients with low left ventricular ejection fractions, unstable angina pectoris, and risk factors for adverse outcomes with bypass (the AWESOME Randomized Trial and Registry). Am J Cardiol, 2004, 94(1): 118-120.
22. Toda K, Mackenzie K, Mehra MR, et al. Revascularization in severe ventricular dysfunction (15% < OR = LVEF < OR = 30%): a comparison of bypass grafting and percutaneous intervention. Ann Thorac Surg, 2002, 74(6): 2082-2087.
23. Yang JH, Choi SH, Song YB, et al. Long-term outcomes of drug-eluting stent implantation versus coronary artery bypass grafting for patients with coronary artery disease and chronic left ventricular systolic dysfunction. Am J Cardiol, 2013, 112(5): 623-629.
24. Velazquez EJ, Bonow RO. Revascularization in severe left ventricular dysfunction. J Am Coll Cardiol, 2015, 65(6): 615-624.
25. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J, 2014, 35(37): 2541-2619.
26. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol, 2012, 60(24): e44-e164.
27. 中华医学会心血管病学分会介入心脏病学组, 中国医师协会心血管内科医师分会血栓防治专业委员会, 中华心血管病杂志编辑委员会. 中国经皮冠状动脉介入治疗指南(2016). 中华心血管病杂志, 2016, 44(5): 382-400.
28. Sandoval Y, Brilakis ES, Canoniero M, et al. Complete versus incomplete coronary revascularization of patients with multivessel coronary artery disease. Curr Treat Options Cardiovasc Med, 2015, 17(3): 366.
29. Pyka Ł, Hawranek M, Gąsior M. Revascularization in ischemic heart failure with reduced left ventricular ejection fraction. The impact of complete revascularization. Kardiochir Torakochirurgia Pol, 2017, 14(1): 37-42.
30. Pepper J. Managing heart failure patients with multivessel disease - coronary artery bypass graft versus percutaneous coronary intervention. Card Fail Rev, 2015, 1(2): 118-122.
31. Yee NP, Siu AM, Davis J, et al. Recovery of left ventricular function after percutaneous coronary intervention compared to coronary artery bypass grafting in patients with multi-vessel coronary disease and left ventricular dysfunction. Hawaii J Med Public Health, 2016, 75(9): 273-277.
32. Ronco C, McCullough P, Anker SD, et al. Cardio-renal syndromes: report from the consensus conference of the acute dialysis quality initiative. Eur Heart J, 2010, 31(6): 703-711.
33. Athappan G, Chacko P, Patvardhan E, et al. Late stroke: comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: a meta-analysis and review of literature. Stroke, 2014, 45(1): 185-193.
34. Mack MJ, Head SJ, Holmes DR Jr, et al. Analysis of stroke occurring in the SYNTAX trial comparing coronary artery bypass surgery and percutaneous coronary intervention in the treatment of complex coronary artery disease. JACC Cardiovasc Interv, 2013, 6(4): 344-354.
35. Gheorghiade M, Vaduganathan M, Fonarow GC, et al. Anticoagulation in heart failure: current status and future direction. Heart Fail Rev, 2013, 18(6): 797-813.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Two revascularization strategies in patients with coronary heart disease and left ventricular systolic dysfunction: A systematic review and meta-analysis

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