Complete Coronary Artery Bypass Surgery is associated with Superior Survival in Multivessel Disease: A Network Meta-analysis
Jef Van den Eynde1, Dries Noé1, Xander Jacquemin1, Paulien Marchal1, Katrien Bomhals1, Keir McCutcheon1, Johan Bennett1, Johannes Bonatti2, Wouter Oosterlinck1
1University Hospitals of Leuven, Leuven, Belgium, 2Krankenhaus Wien Nord - Vienna North Hospital, Vienna, Austria
BACKGROUND: Although complete revascularization has been an important goal of myocardial revascularisation, incomplete coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) have also been considered as an acceptable strategy in some patients. However, the comparative impact of these strategies on survival in patients with multivessel disease remains unclear.
METHODS: PubMed/MEDLINE, Embase, Cochrane Controlled Trials Register (CENTRAL/CCTR), and reference lists of relevant articles were searched for observational studies and randomized controlled trials (RCTs) published by August 2020. Data about mortality at long-term follow-up (>12 months) was collected. A bayesian network meta-analysis was performed.
RESULTS: Fifteen studies including 66,495 patients (complete CABG: 6,979 patients; incomplete CABG: 6,192 patients; complete PCI: 17,274; incomplete PCI: 36,050 patients) met the eligibility criteria. The network meta-analysis demonstrated that complete CABG was associated with a significant reduction of 13% in mortality compared to incomplete CABG (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.81-0.93), 20% compared to complete PCI (OR 0.80, 95% CI 0.68-0.95), and 22% compared to incomplete PCI (OR 0.78, 95% CI 0.66-0.93). No significant differences were observed between incomplete CABG, complete PCI, and incomplete PCI. Bayesion Markov chain Monte Carlo modelling showed that complete CABG had the highest probability of being ranked first with regard to survival [surface under the cumulative ranking curve (SUCRA) probability: 99.4%], while incomplete CABG was most likely to be ranked as the second most effective strategy (SUCRA probability: 81.8%).
CONCLUSIONS: Complete CABG remains superior to incomplete CABG, complete PCI, and incomplete PCI in terms of improved overall long-term survival. The possibility of complete myocardial revascularization should therefore be a central point of attention in Heart Team discussions.