Routine versus selective coronary artery bypass for left main coronary artery revascularization: the Appraise a
Corrado Tamburino1, Davide Capodanno, Maria Elena Di Salvo
1Cardiovascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy. tambucor@unict.it
Insights
A non-guideline-driven approach using percutaneous coronary intervention (PCI) by default for unprotected left main coronary artery (ULMCA) disease showed similar safety to the traditional guideline-driven approach. This study compared PCI-default versus coronary artery bypass grafting (CABG)-default strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Current guidelines recommend coronary artery bypass grafting (CABG) for unprotected left main coronary artery (ULMCA) disease.
- A non-guideline-driven approach (NGD) using percutaneous coronary intervention (PCI) as default was compared to a guideline-driven (GD) approach.
Purpose of the Study:
- To test if a non-guideline-driven approach using PCI by default is as safe as the traditional guideline-driven approach for ULMCA revascularization.
Main Methods:
- PCI was the default strategy in Center 1 (NGD group) from 2002-2008.
- CABG was the default strategy in Center 2 (GD group) during the same period.
- 838 patients with ULMCA disease were included in the comparison.
Main Results:
- The NGD group had a higher risk of major adverse cardiac events (MACE) and target vessel revascularization at 24 months.
- Propensity score adjustment did not significantly alter safety and efficacy endpoints.
- The composite of MACE was no longer significant after statistical adjustments.
Conclusions:
- An approach using PCI by default and selective CABG for ULMCA disease is not inferior to the traditional guideline-driven approach.
- This finding is based on a large registry of patients in current clinical practice.
Background:
Current guidelines recommend coronary artery bypass grafting (CABG) as the first choice of revascularization in patients with unprotected left main coronary artery (ULMCA) disease. We tested the hypothesis that a non guideline-driven approach to ULMCA revascularization which uses percutaneous coronary intervention (PCI) by default and CABG in selected patients may be as safe as the traditional guideline-driven approach.
Methods:
Between March 2002 and December 2008, PCI has been used as a default strategy for ULMCA revascularization in Center 1 (non guideline-driven [NGD] group), whereas CABG has been used as a default strategy in Center 2 (guideline-driven [GD] group).
Results:
A total of 838 patients with ULMCA disease were included. Of these 67.1% and 32.9% were treated in the NGD and GD groups, respectively. A significant higher risk of major adverse cardiac events (MACE) (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.10-2.33, p=0.014) and target vessel revascularization (HR 2.44, 95% CI 1.26-4.72, p=0.008) occurred at 24 months in the NGD group as compared with GD Group. Adjustment by means of propensity score did not result in substantial changes with regard to the subcomponent safety and efficacy endpoints. Conversely, the composite of MACE was no longer significant according to all types of statistical adjustment.
Conclusions:
In a large registry of patients with ULMCA disease undergoing revascularization in current clinical practice, an approach based on PCI and the selective use of CABG gives results which are not inferior to those of a traditional approach guided by the current guidelines.
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