Minimally Invasive Direct Coronary Artery Bypass 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: Treatment modalities for multivessel coronary artery disease have rapidly expanded in recent years, including on-pump (ONCAB) and off-pump coronary artery bypass (OPCAB), minimally invasive coronary artery bypass (MIDCAB), percutaneous coronary intervention (PCI), and hybrid coronary revascularization (HCR). However, it remains controversial which strategy provides optimal long-term outcomes.
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 up to August 2020. Data on mortality at long-term follow-up (>12 months) were collected. A Bayesian network meta-analysis was performed.
RESULTS: One hundred twenty-three studies including 231,929 patients (ONCAB: 117,516 patients; OPCAB: 15,040 patients; MIDCAB: 262; PCI: 96,951 patients; HCR: 120 patients) met the eligibility criteria. The network meta-analysis demonstrated that MIDCAB was associated with a significant reduction in long-term mortality compared with ONCAB (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.87), OPCAB (OR 0.53, 95% CI 0.34-0.78), and PCI (OR 0.50, 95% CI 0.32-0.74). HCR performed significantly better than OPCAB (OR 0.77, 95% CI 0.64-0.93) and PCI (OR 0.73, 95% CI 0.60-0.88). ONCAB showed significantly lower mortality than OPCAB (OR 0.90, 95% CI 0.87-0.93) and PCI (OR 0.85, 95% CI 0.84-0.87). Lastly, OPCAB showed superior results compared to PCI (OR 0.95, 95% CI 0.92-0.98). Bayesian Markov chain Monte Carlo modelling showed that MIDCAB had the highest probability of being ranked first with regard to survival [surface under the cumulative ranking curve (SUCRA) probability: 95.4%], while HCR was most likely to be ranked as the second most effective strategy (SUCRA probability: 90.8%).
CONCLUSIONS: MIDCAB seems to be superior in terms of improved overall long-term survival and might thus be a promising strategy for the treatment of multivessel coronary artery disease, but RCTs are needed.