Percutaneous Coronary Revascularization Versus Surgery In Multi-vessel Disease

Ischemic heart disease (IHD) remains the leading cause of mortality in the world. It presents as a spectrum of diseases and syndromes ranging from asymptomatic quiescent states to sudden cardiac death (SCD). When it manifests as obstructive coronary artery disease (CAD), it typically presents as angina pectoris or myocardial infarction (MI). Although mortality has improved over the past several decades, the increasing burdens of obesity, diabetes, and an aging population challenge health care systems and populations. Many treatments have been linked to the improvement of mortality from CAD. These include secondary preventive medical therapy and revascularization; initial treatments for acute coronary syndromes (ACS), including ST-elevation myocardial infarction (STEMI); revascularization for chronic angina; treatment for heart failure (HF); and primary preventive therapies, including treatment of hypertension (HTN) and hyperlipidemia. Multivessel coronary artery disease (MVCAD) is characterized by involvement of greater than 1 epicardial coronary artery (CA) or the unprotected left main (LM). The choice of revascularization strategy in this setting remains a critical issue in cardiology. Although coronary artery bypass grafting (CABG) has traditionally been the revascularization strategy for most patients with MV disease, there has been a gradual shift toward percutaneous revascularization (PCI). Early randomized clinical trials showed CABG to be superior to medical therapy. However, trials comparing CABG to bare metal stenting have not shown a mortality benefit. Advancements in interventional techniques will continue to challenge the notion that CABG is the standard therapy for patients with MVCAD. Several ongoing randomized clinical trials comparing CABG to drug eluting stents (DES) will provide valuable insight into the role of each procedure. Limited data suggests that CABG is superior to MV PCI even when drug-eluting stents are used. Several ongoing randomized trials are evaluating the long-term comparative efficacy of PCI with DES and CABG in patients with DM. Significant LM CAD is characterized as angiographic stenosis of ≥50% of this segment of the coronary tree. It is found in 2.5% to 10% of all patients undergoing diagnostic coronary angiography procedures. Though CABG is currently the gold standard for revascularization of patients with unprotected LMCA stenosis, stent implantation in carefully selected patients appears to be both feasible and safe. Many cardiologists consider it reasonable to assume that PCI using DES thought to be considered equivalent, if not superior to CABG. The argument made is that in previous randomized clinical trials comparing PCI to CABG, restenosis was the determining factor favoring surgery, an event that clinical experience suggests is no longer as frequent. In the absence of a definitive clinical trial to support this view, how should the prudent, cutting edge cardiologist evaluate the data and manage their patients. Aim of the Work: The purpose of this study is to compare the safety and efficacy of PCI using Drug Eluting Stents versus CABG in treatment of MVCAD. Patients and methods 1-Patients: This study was conducted on 50 patients with IHD in the Cardiology departments of National heart Institute from April 2011 to August 2012. 25 of them will undergo PCI using DES while the other 25 will undergo CABG. All patients underwent diagnostic coronary angiography which showed MV lesions with good distal run off that could be treated either by PCI or CABG. The patients were divided into two groups: 1-Group (A) included 25 patients who underwent PCI to accessible lesions. 2-Group (B) included 25 patients who underwent CABG for diseased vessels. Inclusion Criteria: Patients were included if they: Have MV CAD, manifested by -Typical chest pain or angina equivalent -ECG changes suggesting CAD -Wall motion abnormalities by echo if present. Exclusion Criteria: -Patients were excluded if they are: 80 years of age -Severely impaired LV function -Have less than 3vessel disease -Have prior revascularization procedures. -Have experienced an acute MI within 24 h before the procedure. – Multi-organ dysfunction Methods: All patients will be subjected to 1-informed consent 2full history taking 3-Full clinical examination 4-12-lead ECG pre and postintervention. 5Full Conventional transthoracic Echocardiograpgy (TTE) before the intervention with a re assessment after 6 and 12 months. 6Dobutamine stress echo or thallium study before and after the procedure to assessment of ischemic myocardium. 7Coronary angiography A detailed discussion with the patient and his family about benefits of coronary angiography, methods for revascularization, and possible complications was done. Informed consent was signed by the patient after his approval of the procedure. All patients underwent CABG: All these patients provided a written consent; the protocol and the consent were consistent with the national heart institution protocols. Patients were treated with the intention of achieving complete revascularization of all vessels at least 2.5 mm in diameter with stenosis of 70% or more as identified by local interventional cardiologists and cardiac surgeons. The surgical technique for CABG, approaches used for stent implementation and the post procedure Journal of American Science 2018;14(6) http://www.jofamericanscience. org 68 medication regimen were chosen according to local clinical practice. Follow-up Protocol: (A) In hospital follow up: Patients were followed up during hospital stay after revascularization for: i. Mortality: ii. Morbidity. iii. Need for revascularization. Iv. Occurrence of any neurological or vascular events. V. Others. Duration of hospital stay was documented in the medical record of each patient. (B)Outpatient six months follow up: For all patients the following was done: 1-Duration of stay at home and ability to return to work. 2Close observations of all the patients and detailed history taking for early detection of any major adverse cardiac events (MACE) including: 1-All causes of SCD 2Unstable angina or MI, diagnosed by: A. Appearance of any symptoms or signs of acute chest pain. B. New ECG changes (ST-T wave changes and pathological Q wave). C. Elevated cardiac enzymes. iii. Need for revascularization whether surgical or PCI. Echo for detection of any change in LVEDD, LVESD, LVPW, IVS thickness and EF. (C)Outpatient 12months follow up: For all patients the following was done: as done before with six months follow up Statistics: All the data obtained were analyzed statistically using statistical package, Results: Follow up for one year for all the patients showed that MACE positive patients in group (A) were 36% occurred at 9.78±2.1 months. No mortality was found during that period. On the contrary, group (B) showed 24% MACE positive patients, 8% mortality. All our complications occurred during post procedure hospital stay. The difference between the two groups was statistically insignificant. A Combination of semiquantitative stress echo and the clinical history allows us to define the risk of all late cardiac events for patients with MVD undergoing stenting or surgery. This study demonstrates that dobutamine stress echo is a powerful predictor of late cardiac event after coronary revascularization and is superior to simple clinical risk assessment. Regarding group (A), duration of DM was significant predictor of in-stent restenosis (ISR). Mean duration of DM in MACE positive patients was 18.1±7.39 years, versus 10.93±6.38 years in MACE negative patients. Difference between the two groups was statistically significant. In comparison, group (B) showed mean duration of DM in MACE positive patients was 10.17±3.25 years, versus 10.53±4.89 years in MACE negative patients. Difference between the two groups was statistically insignificant. Regarding group (A), Insulin therapy was statistically significant predictor of ISR. Treatment of DM in MACE positive patients was insulin in 6 patients (67%) and insulin with oral hypoglycemic agents in 3 patients (33%). on the other hand treatment of DM in MACE negative patients was insulin in 6 patients (38%) and oral hypoglycemic agents in 10 patients (62%). Difference between the two groups was statistically significant. In comparison, group (B) showed treatment of DM in MACE positive patients was insulin in 2 patients (33%) and oral hypoglycemic agents in 4 patients (67%). on the other hand treatment of DM in MACE negative patients was insulin in 4 patients (21%), oral hypoglycemic agents in 12 patients (63%) and both in 3 patients (16%). Difference between the two groups was statistically insignificant. Regarding group (A), stent length and number was not a predictor of ISR. Also in group (B) type of the graft did not affect the clinical outcome. [Mohamed Mahmoud Osama Osman G.M. Shaaban M.M. Nasr. Percutaneous Coronary Revascularization Versus Surgery In Multi-vessel Disease. J Am Sci 2018;14(6):67-83]. ISSN 1545-1003 (print); ISSN 2375-7264 (online). http://www.jofamericanscience. org. 9. doi:10.7537/marsjas140618.09.