Piet W. Boonstra

A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary artery: three-year follow-up

OBJECTIVESnThis study was done to identify the best treatment for an isolated high-grade stenosis of the proximal left anterior descending coronary artery (LAD).nnnBACKGROUNDnPercutaneous transluminal coronary angioplasty with stenting (PCI) and off-pump coronary artery bypass grafting (surgery) are used to treat single-vessel disease of a high-grade stenosis of the proximal LAD. Midterm results of both treatments are compared in this prospective randomized study.nnnMETHODSnIn a single-center prospective trial, we randomly assigned 102 patients with a high-grade stenosis of the proximal LAD (American College of Cardiology/American Heart Association classification type B2 or C) to PCI (n = 51) or surgery (n = 51). Primary composite end point was freedom from Major Adverse Cardiac and Cerebrovascular Events (MACCE) at follow-up, including death, myocardial infarction, cerebrovascular accident, and repeat target vessel revascularization (TVR). Secondary end points were angina pectoris class and need for antianginal medication at follow-up. Analysis was by intention-to-treat (ITT) and received treatment (RT).nnnRESULTSnMean follow-up time was three years (90% midrange, two to four years). Incidence of MACCE was 23.5% after PCI and 9.8% after surgery; p = 0.07 ITT (24.1% vs. 8.3%; p = 0.04 RT). After surgery a significantly lower angina pectoris class (p = 0.02) and need for antianginal medication (p = 0.01) was found compared to PCI. Target vessel revascularization was 15.7% after PCI and 4.1% after surgery (p = 0.09).nnnCONCLUSIONSnAt three-year follow-up (range, two to four years), a trend in favor of surgery is observed in regard to MACCE-free survival with a significantly lower angina pectoris status and significantly lower need for antianginal medication.

Letter Regarding Article by Sawhney et al, “Treatment of Left Anterior Descending Coronary Artery Disease With Sirolimus-Eluting Stents”

To the Editor:nnSawhney et al1 describe a superior adverse cardiac event rate of 9.8% with sirolimus-eluting stents (SES) versus 24.9% with bare metal stents in left anterior descending coronary artery (LAD) disease after 1-year follow-up. Their subgroup analysis of patients with isolated proximal LAD lesions (29.3%) shows similar results because of a reduced in-stent restenosis rate after SES.1 They conclude that long-term SES results might be similar to those of surgically treated LAD lesions.1nnUntil now, the major randomized SES studies (RAVEL and SIRIUS) reported superior results after SES compared with bare metal stents in less complex lesions. Being a SIRIUS substudy, the article by Sawhney et …