title: What is the optimal revascularization technique for isolated disease of the left anterior descending artery: minimally invasive direct coronary artery bypass or percutaneous coronary intervention?
abstract: A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'What is the optimal revascularization technique for isolated disease of the left anterior descending artery (LAD) in terms of patient survival, morbidity such as myocardial infarction (MI) and need for repeat target vessel revascularization: minimally invasive direct coronary artery bypass graft (MIDCAB) or percutaneous coronary intervention (PCI)?' Altogether 504 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. Outcome parameters that were used in the assessment include the incidence of major adverse cardiovascular or cerebral events (MACCEs), mortality and the rate of repeat target vessel revascularization. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. One meta-analysis showed no significant difference in terms of individual incidences of MI, stroke or mortality, but when considered as a composite MACCE outcome, this was found to be significantly lower in the MIDCAB group. Moreover, further meta-analytical data have revealed a 5-fold increase in the need for repeat revascularization with PCI, with some centres reporting rates of up to 34%. However, retrospective data have shown that average length of hospital stay was longer in the MIDCAB group (7.4 ± 3.2 vs 3.4 ± 3.5 days; P < 0.001). We conclude that there are obvious proven benefits with MIDCAB, namely in terms of a reduced need for repeat target vessel revascularization and incidence of MACCE, and one study has even shown that there is a long-term survival benefit in 'real-world' clinical practice. However, given that there is a lack of well-powered randomized controlled trial and long-term follow-up data to prove a mortality benefit in support of MIDCAB, patients requiring revascularization of isolated proximal LAD stenosis and being considered for percutaneous coronary intervention should be discussed in a multidisciplinary team setting prior to intervention.
authors.affiliation: Department of Cardiac Surgery, St. George's Hospital, London, UK.
authors.forename: Akshay J
authors.initials: AJ
authors.lastname: Patel
authors.affiliation: Department of Cardiac Surgery, St. George's Hospital, London, UK.
authors.forename: Martin T
authors.initials: MT
authors.lastname: Yates
authors.affiliation: Department of Cardiac Surgery, St. George's Hospital, London, UK gopal.soppa@nhs.net.
authors.forename: Gopal K R
authors.initials: GK
authors.lastname: Soppa
mesh_terms: D000368:Aged; D019985:Benchmarking; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Left anterior descending; Minimally invasive direct coronary artery bypass graft; Myocardial infarction; Myocardial revascularization; Percutaneous coronary intervention