Use of Drug-Eluting Stents or Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery Disease




I would like to call your attention to the article by Jiang et al, “Meta-analysis of Effectiveness of First-generation Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Disease.” I have serious concerns regarding the literature search method and classification of studies included in their meta-analysis.


First, although the authors included multiple reports from all over the world, the list is not complete to the date the literature search was completed (i.e., March 2012). The authors did not include in their search the Registry Arm of the Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease trial (PRECOMBAT, a prospective registry including 810 patients) or the long-term follow-up data from the Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization (MAIN-COMPARE) Registry (largest registry of patients with an unprotected left main coronary artery, >2,000 patients followed up for ≥5 years). The MAIN-COMPARE Registry is 1 of the most cited prospective registries from Korea.


Second, the authors mention in their “Methods” section the exclusion of duplicate reports to remove redundancy in the included data. However, in their Table 1, the authors included the following studies, which are redundant and report on the same patients: Cedars Sinai Medical Center, the CUSTOMIZE (Appraise a Customized Strategy for Left Main Revascularization) registry and Chieffo et al.


Although it might be acceptable to list these studies in Table 1 and use their outcomes at different follow-up periods for a landmark analysis, these patients should not be double counted, such as was done by the authors in their report. It creates redundancy in the data and raises questions about the validity of the data search method.


Third, the authors report that all the included studies were prospective cohorts. However, if these studies are reviewed in detail, not all 25 of these studies were prospective.


Fourth, their Figure 5 provides the clinical outcomes for patients after risk adjustment. The authors mention a propensity score-based approach in their study limitations, but I do not see the results of the propensity score matching in their report. The studies included in Figure 5 provide risk adjustment likely by use of multivariate analysis. The studies that reported propensity-adjusted outcomes were not included in this risk-adjusted analysis.


Fifth, as their title indicates, most studies reported the outcomes of first-generation drug-eluting stents compared with those from coronary artery bypass grafting. Three of these reports also used bare metal stents in a significant proportion of patients. Overall, the number of patients who received bare metal stents is not large, but it is an important piece of information that should be reported because it could influence the incidence of repeat revascularization.


Sixth, Figure 2A lists White et al and Lee et al in the analysis, and these studies provide reports from same center, resulting in duplication. These 2 studies combined provided approximately 11% of the total weight for the outcome of mortality at ≤2 years of follow-up. Similar inclusion data are seen in Figure 3(A).


Finally, as of March 2012, the long-term outcomes of patients enrolled in the SYNTAX trial (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) were reported and the 36-month outcomes have also been published. The authors report 2 meta-analyses of randomized clinical trials that included ≤24 months of follow-up from the SYNTAX trial.


References



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  2. 2. Park D.W., Seung K.B., Kim Y.H., Lee J.Y., Kim W.J., Kang S.J., Lee S.W., Lee C.W., Park S.W., Yun S.C., Gwon H.C., Jeong M.H., Jang Y.S., Kim H.S., Kim P.J., Seong I.W., Park H.S., Ahn T., Chae I.H., Tahk S.J., Chung W.S., and Park S.J.: Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol 2010; 56: pp. 117-124

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Dec 7, 2016 | Posted by in CARDIOLOGY | Comments Off on Use of Drug-Eluting Stents or Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery Disease

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