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Percutaneous coronary intervention versus repeat bypass surgery for patients with medically refractory myocardial
Douglass A Morrison1, Gulshan Sethi, Jerome Sacks
1Tucson VA Medical Center and the University of Arizona, Tucson, Arizona 85723, USA. douglass.morrisson@med.va.gov
Insights
For patients with prior coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI) showed comparable or better long-term survival than repeat CABG. PCI is a preferred option for many post-CABG individuals.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Repeat coronary artery bypass graft (CABG) surgery carries a higher mortality risk than primary CABG.
- The Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) trial was the first randomized trial to compare CABG with percutaneous coronary intervention (PCI) in post-CABG patients.
Purpose of the Study:
- To compare long-term survival rates between percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in patients with previous CABG.
- To evaluate the efficacy of PCI versus repeat CABG in high-risk patients with medically refractory myocardial ischemia.
Main Methods:
- A cohort of 2,431 high-risk patients with medically refractory myocardial ischemia were screened over five years (1995-2000).
- Survival outcomes were compared between CABG and PCI groups using Kaplan-Meier curves and log-rank tests across a randomized trial and two prospective registries (physician-directed and patient-choice).
Main Results:
- In the randomized trial (142 post-CABG patients), 3-year survival was 73% for CABG vs. 76% for PCI (log-rank, NS).
- In the physician-directed registry, 36-month survival was 71% for reoperation vs. 77% for PCI (log-rank, NS).
- In the patient-choice registry, 36-month survival was significantly higher for PCI (86%) compared to reoperation (65%) (log-rank test, p = 0.01).
Conclusions:
- Percutaneous coronary intervention (PCI) demonstrates comparable or superior long-term survival compared to repeat coronary artery bypass graft (CABG) in post-CABG patients.
- PCI may be a preferable revascularization strategy for select post-CABG patients, particularly when patient choice is involved.
Objectives:
This report compares long-term percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) survival among post-CABG patients included in the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME) randomized trial and prospective registry.
Background:
Repeat CABG surgery is associated with a higher risk of mortality than first-time CABG. The AWESOME is the first randomized trial comparing CABG with PCI to include post-CABG patients.
Methods:
Over a five-year period (1995 to 2000), patients at 16 hospitals were screened to identify a cohort of 2,431 individuals who had medically refractory myocardial ischemia and at least one of five high-risk factors. There were 454 patients in the randomized trial, of whom 142 had prior CABG. In the physician-directed registry of 1,650 patients, 719 had prior CABG. Of the 327 patient-choice registry patients, 119 had at least one prior CABG. The CABG and PCI survivals for the three groups were compared using Kaplan-Meier curves and log-rank tests.
Results:
The CABG and PCI three-year survival rates were 73% and 76% respectively for the 142 randomized patients (75 and 67 patients) (log-rank = NS). In the physician-directed registry, 155 patients were assigned to reoperation and 357 to PCI (207 received medical therapy); 36-month survivals were 71% and 77% respectively (log-rank = NS). In the patient-choice registry, 32 patients chose reoperation and 74 chose PCI (13 received medical therapy); 36-month survivals were 65% and 86% respectively (log-rank test p = 0.01).
Conclusions:
Percutaneous coronary intervention is preferable to CABG for many post-CABG patients.
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