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A Prospective Randomized Trial Comparing Stenting to Internal Mammary Artery Grafting for Proximal, Isolated De Novo Left Anterior Coronary Artery Stenosis: The SIMA Trial

      OBJECTIVE

      To compare coronary artery bypass grafting (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in patients with proximal, isolated de novo left anterior descending coronary artery disease and left ventricular ejection fraction of 45%.

      PATIENTS AND METHODS

      In the multicenter Stenting vs Internal Mammary Artery (SIMA) study, patients were randomly assigned to PTCA and stent implantation or to CABG (using the internal mammary artery). The primary clinical composite end point was event-free survival, including death, myocardial infarction, and the need for additional revascularization. Secondary end points were functional class, antianginal treatment, and quality of life. Analyses were by intention to treat.

      RESULTS

      Of 123 patients who accepted randomization, 59 underwent CABG, and 62 were treated with stent implantation (2 patients were excluded because of protocol violation). At a mean ± SD follow-up of 2.4±o.9 years, a primary end point had occurred in 19 patients (31%) in the stent group and in 4 (7%) in the CABG group (P<.OOI). This significant difference in clinical outcome is due to a higher incidence of additional revascularization in the stent group, the incidence of death and myocardial infarction being similar (7% vs 7%, respectively; P=.90). The functional class, need for antianginal drug, and quality-of-life assessment showed no significant differences.

      CONCLUSIONS

      Both stent implantation and CABG are safe and highly effective treatments to relieve symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. Both are associated with a low and comparable incidence of death and myocardial infarction. However, similar to PTCA alone, a percutaneous approach using elective stent placement remains hampered by a higher need for repeated intervention because of restenosis.
      CABG (coronary artery bypass grafting), CCS (Canadian Cardiovascular Society), CK (creatine kinase), IMA (internal mammary artery), LAD (left anterior descending), PTCA (percutaneous trans luminal coronary angioplasty), SF -36 (Medical Outcomes Study 36-Item Short-Form Health Survey)
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      Linked Article

      • Left Anterior Descending Artery Stenosis: The Widow Maker Revisited
        Mayo Clinic ProceedingsVol. 75Issue 11
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          Stenosis of the proximal left anterior descending artery is regarded with considerable anxiety by patients, physicians, and surgeons alike. The appellation widow maker, which has been applied to this lesion (in part because of the large amount of myocardium that the left anterior descending artery supplies and its proximity to the distal left main coronary artery), has done nothing to allay this anxiety.
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