CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting.
CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting.
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DOI：
10.1016/j.jacc.2015.07.060
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发表时间：
2015-09-29
影响因子：
24
通讯作者：
Tranbaugh RF
中科院分区：
文献类型：
--
作者：
Habib RH;Dimitrova KR;Badour SA;Yammine MB;El-Hage-Sleiman AK;Hoffman DM;Geller CM;Schwann TA;Tranbaugh RF
与使用裸金属支架（BMS）或药物洗脱支架（DES）的经皮冠状动脉介入治疗（PCI）相比，使用传统单动脉冠状动脉旁路移植术（SA-CABG）治疗多支冠状动脉疾病与上级中期生存率和再次介入相关。本研究旨在研究长期结局，包括多动脉冠状动脉旁路移植术（MA-CABG）的潜在附加优势。我们研究了8，402例单机构、初次血运重建、多支冠状动脉疾病患者：2，207例BMS-PCI（年龄66.6 ± 11.9岁）; 2，381例DES-PCI（年龄65.9 ± 11.7岁）; 2，289例SA-CABG（年龄69.3 ± 9.0岁）; 1，525例MA-CABG（年龄58.3 ± 8.7岁）。排除了24小时内发生心肌梗死、休克或左主干支架植入的患者。Kaplan-Meier分析和考克斯回归用于分别比较BMS-PCI和DES-PCI与各自倾向匹配的SA-CABG和MA-CABG队列的9年全因死亡率和计划外再介入。BMS-PCI的生存率低于SA-CABG，尤其是0 - 7年（p = 0.015），并且在更大程度上高于MA-CABG（9年随访：76.3% vs 86.9%; p < 0.001）。手术与BMS-PCI的风险比（HR）如下：对比SA-CABG，HR：0.87;对比MA-CABG，HR：0.38。DES-PCI显示与SA-CABG相似的生存率，除了0 - 3年手术优势（HR：1.06; p = 0.615）。与MA-CABG相比，DES-PCI在5年（86.3% vs. 95.6%）和9年（82.8% vs. 89.8%）时显示出更差的生存率（HR：0.45; p <0.001）。在所有比较中，PCI的再介入显著更差（所有p <0.001）。与BMS-PCI或DES-PCI相比，多动脉手术血运重建导致死亡率和无再介入生存率显著提高。因此，MA-CABG代表了多支冠状动脉疾病的最佳治疗方法，应该被多学科心脏团队作为最佳循证治疗积极采用。
Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES). This study sought to investigate longer-term outcomes including the potential added advantage of multiarterial coronary artery bypass graft (MA-CABG). We studied 8,402 single-institution, primary revascularization, multivessel coronary artery disease patients: 2,207 BMS-PCI (age 66.6 ± 11.9 years); 2,381 DES-PCI (age 65.9 ± 11.7 years); 2,289 SA-CABG (age 69.3 ± 9.0 years); and 1,525 MA-CABG (age 58.3 ± 8.7 years). Patients with myocardial infarction within 24 h, shock, or left main stents were excluded. Kaplan-Meier analysis and Cox regression were used to separately compare 9-year all-cause mortality and unplanned reintervention for BMS-PCI and DES-PCI to respective propensity-matched SA-CABG and MA-CABG cohorts. BMS-PCI was associated with worse survival than SA-CABG, especially from 0 to 7 years (p = 0.015) and to a greater extent than MA-CABG was (9-year follow-up: 76.3% vs. 86.9%; p < 0.001). The surgery-to-BMS-PCI hazard ratios (HR) were as follows: versus SA-CABG, HR: 0.87; and versus MA-CABG, HR: 0.38. DES-PCI showed similar survival to SA-CABG except for a modest 0 to 3 years surgery advantage (HR: 1.06; p = 0.615). Compared with MA-CABG, DES-PCI exhibited worse survival at 5 (86.3% vs. 95.6%) and 9 (82.8% vs. 89.8%) years (HR: 0.45; p <0.001). Reintervention was substantially worse with PCI for all comparisons (all p <0.001). Multiarterial surgical revascularization, compared with either BMS-PCI or DES-PCI, resulted in substantially enhanced death and reintervention-free survival. Accordingly, MA-CABG represents the optimal therapy for multivessel coronary artery disease and should be enthusiastically adopted by multidisciplinary heart teams as the best evidence-based therapy.