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Objectives: This study sought to compare the efficacy of coronary artery bypass graft surgery (CABG) to that of percutaneous coronary intervention (PCI) with first-generation drug-eluting stents among patients with multivessel disease (MVD), unprotected left main (LM) disease, and single-vessel proximal left anterior descending (LAD) disease. Background: The efficacy and safety of CABG versus PCI with drug-eluting stents in patient subgroups remains controversial. Methods: We systematically searched Cardiosource, Circulation, Clinicaltrials.gov, the Cochrane Library, EMBASE, and Medline for articles published through June 2013 for randomized controlled trials comparing CABG with PCI. Primary endpoints included mortality, myocardial infarction, revascularization, and stroke. Data were meta-analyzed with random-effects models. Results: We identified 7 randomized controlled trials (N = 5,835): 2 of MVD (n = 2,410, 100% diabetic), 2 of LM disease (n = 1,206, 29.0% diabetic), 1 of 3-vessel or LM disease (n = 1,900, 25.5% diabetic), and 2 of single-vessel proximal LAD disease (n = 319, 36.3% diabetic). In MVD patients, CABG reduced the risk of mortality (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.57 to 0.87), myocardial infarction (RR: 0.47, 95% CI: 0.36 to 0.61), and repeat revascularization (RR: 0.36, 95% CI: 0.24 to 0.52), but increased stroke risk (RR: 1.72, 95% CI: 1.02 to 2.90). In patients with LM disease, CABG reduced revascularization risk (RR: 0.60, 95% CI: 0.46 to 0.78) and increased stroke risk (RR: 2.89, 95% CI: 1.15 to 7.27). Data for patients with single-vessel proximal LAD disease were inconclusive. Conclusions: CABG is more efficacious than is PCI with first-generation drug-eluting stents in patients with LM and MVD, at the cost of increased rates of stroke. No conclusion can be drawn for patients with single-vessel proximal LAD disease. [Copyright &y& Elsevier]

Objectives: This study sought to determine whether computational modeling can be used to predict the functional outcome of coronary stenting by virtual stenting of ischemia-causing stenoses identified on the pre-treatment model. Background: Computed tomography (CT)-derived fractional flow reserve (FFR) is a novel noninvasive technology that can provide computed (FFRct) using standard coronary CT angiography protocols. Methods: We prospectively enrolled 44 patients (48 lesions) who had coronary CT angiography before angiography and stenting, and invasively measured FFR before and after stenting. FFRct was computed in blinded fashion using coronary CT angiography and computational fluid dynamics before and after virtual coronary stenting. Virtual stenting was performed by modification of the computational model to restore the area of the target lesion according to the proximal and distal reference areas. Results: Before intervention, invasive FFR was 0.70 ± 0.14 and noninvasive FFRct was 0.70 ± 0.15. FFR after stenting and FFRct after virtual stenting were 0.90 ± 0.05 and 0.88 ± 0.05, respectively (R = 0.55, p < 0.001). The mean difference between FFRct and FFR was 0.006 for pre-intervention (95% limit of agreement: –0.27 to 0.28) and 0.024 for post-intervention (95% limit of agreement: –0.08 to 0.13). Diagnostic accuracy of FFRct to predict ischemia (FFR ≤0.8) prior to stenting was 77% (sensitivity: 85.3%, specificity: 57.1%, positive predictive value: 83%, and negative predictive value: 62%) and after stenting was 96% (sensitivity: 100%, specificity: 96% positive predictive value: 50%, and negative predictive value: 100%). Conclusions: Virtual coronary stenting of CT-derived computational models is feasible, and this novel noninvasive technology may be useful in predicting functional outcome after coronary stenting. (Virtual Coronary Intervention and Noninvasive Fractional Flow Reserve [FFR]; NCT01478100) [Copyright &y& Elsevier]

Objectives: This study sought to evaluate whether remote ischemic post-conditioning (RIPC) could reduce enzymatic infarct size in patients with anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI). Background: Myocardial reperfusion injury may attenuate the benefit of pPCI. In animal models, RIPC mitigates myocardial reperfusion injury. Methods: One hundred patients with anterior ST-segment elevation myocardial infarction and occluded left anterior descending artery were randomized to pPCI + RIPC (n = 50) or conventional pPCI (n = 50). RIPC consisted of 3 cycles of 5 min/5 min ischemia/reperfusion by cuff inflation/deflation of the lower limb. The primary endpoint was infarct size assessed by the area under the curve of creatinine kinase-myocardial band release (CK-MB). Secondary endpoints included the following: infarct size assessed by cardiac magnetic resonance delayed enhancement volume; T2-weighted edema volume; ST-segment resolution >50%; TIMI (Thrombolysis In Myocardial Infarction) frame count; and myocardial blush grading. Results: Four patients (2 RIPC, 2 controls) were excluded due to missing samples of CK-MB. A total of 96 patients were analyzed; median area under the curve CK-MB was 8,814 (interquartile range [IQR]: 5,567 to 11,325) arbitrary units in the RIPC group and 10,065 (IQR: 7,465 to 14,004) arbitrary units in control subjects (relative reduction: 20%, 95% confidence interval: 0.2% to 28.7%; p = 0.043). Seventy-seven patients underwent a cardiac magnetic resonance scan 3 to 5 days after randomization, and 66 patients repeated a second scan after 4 months. T2-weighted edema volume was 37 ± 16 cc in RIPC patients and 47 ± 22 cc in control subjects (p = 0.049). ST-segment resolution >50% was 66% in RIPC and 37% in control subjects (p = 0.015). We observed no significant differences in TIMI frame count, myocardial blush grading, and delayed enhancement volume. Conclusions: In patients with anterior ST-segment elevation myocardial infarction, RIPC at the time of pPCI reduced enzymatic infarct size and was also associated with an improvement of T2-weighted edema volume and ST-segment resolution >50%. (Remote Postconditioning in Patients With Acute Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention [PCI] [RemPostCon]; NCT00865722) [Copyright &y& Elsevier]

Objectives: This study sought to investigate whether the everolimus-eluting stent (EES) is superior to the paclitaxel-eluting stent (PES) with respect to long-term individual clinical outcomes. Background: Individual studies have indicated a clinical advantage of coronary EES compared with PES with respect to restenosis and the composite endpoint of major adverse cardiac events. However, these trials were not powered for superiority in low-frequency event rates and have reported limited data beyond 1-year follow-up. Methods: We conducted a meta-analysis of the final 3-year results from the international SPIRIT (Clinical Evaluation of the Xience V Everolimus Eluting Coronary Stent System in the Treatment of Patients With De Novo Native Coronary Artery Lesions) II, III, and IV clinical trials. Individual patient data from 4,989 patients who were prospectively randomized to treatment with EES (n = 3,350) or PES (n = 1,639) were pooled for analysis. Results: At 3-year follow-up, EES was superior to PES in reducing the following event rates: target lesion failure (8.9% vs. 12.5%, hazard ratio [HR]: 0.71, 95% confidence interval [CI]: 0.59 to 0.85; p = 0.0002), all-cause mortality (3.2% vs 5.1%, HR: 0.65, 95% CI: 0.49 to 0.86; p = 0.003), myocardial infarction (3.2% vs. 5.1%, HR: 0.64, 95% CI: 0.48 to 0.85; p = 0.002), cardiac death or myocardial infarction (4.4% vs. 6.3%, HR: 0.70, 95% CI: 0.54 to 0.90; p = 0.005), ischemia-driven target lesion revascularization (6.0% vs. 8.2%, HR: 0.72, 95% CI: 0.58 to 0.90; p = 0.004), stent thrombosis (0.7% vs. 1.7%, HR: 0.45, 95% CI: 0.26 to 0.78; p = 0.003), and major adverse cardiac events (9.4% vs. 13.0%, HR: 0.71, 95% CI: 0.60 to 0.85; p = 0.0002). No interaction was present between stent type and the 3-year relative rates of target lesion failure across a broad range of subgroups, with the exception of diabetes and vessel (left anterior descending vs. other). Conclusions: In this large dataset with 3-year follow-up, coronary implantation of EES compared with PES resulted in reduced rates of all-cause mortality, myocardial infarction, ischemia-driven target lesion revascularization, stent thrombosis, and target lesion failure. Further research is warranted to characterize possible interactions between stent type, diabetes, and vessel. [Copyright &y& Elsevier]