Transcript Diapositiva 1 - metcardio.org

AN INTERNATIONAL COLLABORATIVE METAANALYSIS ON 1,274 PATIENTS UNDERGOING
PERCUTANEOUS DRUG-ELUTING STENTING
FOR UNPROTECTED LEFT MAIN CORONARY
ARTERY DISEASE
G. BIONDI-ZOCCAI1, C. MORETTI1, E. MELIGA1, P. AGOSTONI2,
M. VALGIMIGLI3, A. ABBATE4, G. SANGIORGI5, G. TREVI1
AND I. SHEIBAN1
1University of Turin, Turin, Italy ([email protected]); 2AZ Middelheim, Antwerp, Belgium;
3University of Ferrara, Ferrara, Italy; 4Virginia Commonwealth University,
Virginia, USA; 5Emo Centro Cuore Columbus, Milano,Italy
1
BACKGROUND
• Cardiac surgery is the gold standard
revascularization means for unprotected left
main disease (ULM)
• Percutaneous drug-eluting stent (DES)
implantation has been recently reported in
patients with ULM, but with unclear results.
We thus sought to systematically review the
outcomes of DES implantation in patients
with ULM coronary disease
2
OBJECTIVES
• To perform a systematic review of the
outcomes of DES implantation in patients
with ULM coronary disease
• To pool major outcomes with meta-analytic
techniques
3
METHODS
• Several databases (BioMedCentral,
clinicaltrials.gov, Google Scholar, and
PubMed) were systematically searched for
pertinent clinical studies published up to
November 2006
• Major selection criteria were:
– enrolment of at least 20 patients
– follow-up for at least 6 months
– full text publication (thus excluding abstracts)
4
METHODS
• Pre-specified subgroup analyses were performed
according to ostial ULM, and non-high-risk features
(defined by means of Parsonnet or EuroSCORE
systems)
• Generic-inverse-variance random-effect methods were
used to pool incidence rates and adjusted risk
estimates (odds ratios [OR], with 95% confidence
intervals) of death, myocardial infarction (MI), target
vessel revascularization (TVR), or their composite, ie
major adverse cardiovascular events (MACE)
5
REVIEW PROFILE
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RESULTS
• After excluding 806 non-pertinent citations,
we finally included 16 original studies (1274
patients, median follow-up 9 months [range
6-24])
• There were 8 uncontrolled reports on DES, 5
non-randomized comparison between DES
and bare-metal stents (BMS), and 3 between
DES and CABG, with a median follow-up of
10 months
7
INCLUDED STUDIES
8
PATIENT AND PROCEDURAL
CHARACTERISTICS
9
DESIGN AND QUALITY
10
RISK OF IN-HOSPITAL DEATH
11
RISK OF IN-HOSPITAL MI
12
RISK OF MACE AT FOLLOW-UP
13
RISK OF DEATH AT FOLLOW-UP
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RISK OF TVR AT FOLLOW-UP
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NON-RANDOMIZED
COMPARISONS
• Multivariable adjusted estimates for the DES vs BMS comparison
were reported only by a handful of studies, for a total of 206
patients treated with DES vs 190 with bare-metal stents (BMS).
Pooled analysis showed the superiority of DES both in terms of
follow-up MACE and TVR (respectively OR=0.34 [0.16-0.71],
p=0.004, and OR=0.34 [0.12-0.94], p=0.04)
• Adjusted estimates for the DES-based PCI vs CABG were
reported only by Chieffo et al and Lee et al for a total of 157
patients treated with DES and 265 with CABG. Meta-analysis for
the occurrence of MACCE (ie MACE plus stroke) at follow-up,
suggested the superiority of DES vs CABG (OR=0.46 [0.24-0.90],
p=0.02), even if this estimate should be viewed with caution
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CONCLUSIONS
• The largest cohort reported to date of
patients with ULM treated with DES provides
encouraging mid-term follow-up data, at least
in selected patients
• Whether long-term outlook is also favourable
needs to be established by longer clinical
follow-up of currently available registries and
ongoing randomized trials of DES vs CABG
17
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