Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Interventions in Patients With Unprotected Left Main
Zhe Zheng1, Bo Xu2, Heng Zhang1
1National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Insights
Coronary artery bypass graft (CABG) surgery demonstrated better long-term survival than percutaneous coronary intervention (PCI) for unprotected left main disease. CABG is particularly beneficial for patients with complex coronary artery disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Unprotected left main disease (ULMD) poses significant risks.
- Percutaneous coronary intervention (PCI) is an alternative to Coronary Artery Bypass Graft (CABG) surgery for ULMD.
- Limited comparative data exist for long-term outcomes between PCI and CABG in ULMD patients.
Purpose of the Study:
- To compare long-term clinical outcomes of CABG versus PCI in patients with ULMD.
- To evaluate the safety and efficacy of revascularization strategies for ULMD.
Main Methods:
- A single-center observational study included 4,046 patients with ULMD from 2004-2010.
- Patients underwent either CABG (n=2,604) or PCI with drug-eluting stents (n=1,442).
- Primary endpoint was 3-year all-cause mortality; secondary was a composite of death, myocardial infarction, or stroke.
Main Results:
- Unadjusted 3-year mortality was higher with PCI (3.8%) vs. CABG (2.5%).
- Adjusted analysis showed PCI significantly increased all-cause mortality risk (HR 1.71) but not the composite outcome.
- PCI was associated with increased mortality and composite outcomes in patients with high SYNTAX scores (>32).
Conclusions:
- CABG is associated with improved long-term outcomes compared to PCI in ULMD patients.
- The benefit of CABG is more pronounced in patients with complex coronary artery disease (high SYNTAX score).
- CABG also showed a lower risk of repeat revascularization.
Objectives:
This study sought to investigate long-term clinical outcomes following coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in patients with unprotected left main disease (ULMD).
Background:
PCI has been increasingly used as an alternative mode of revascularization for ULMD. However, there are limited data comparing clinical outcomes between CABG surgery and PCI.
Methods:
Between 2004 and 2010, 4,046 consecutive patients with ULMD were treated with either CABG surgery (n = 2,604) or PCI (n = 1,442) with drug-eluting stents. The primary outcome was 3-year all-cause mortality and the secondary outcome was the composite of death, nonfatal myocardial infarction, or nonfatal stroke.
Results:
The unadjusted 3-year all-cause mortality was higher in the PCI group as compared with the CABG group (3.8% vs. 2.5%; log-rank p = 0.03), although there was no significant difference in the composite outcome (7.5% vs. 9.4%; log-rank p = 0.07). After adjustment for differences in baseline risk factors, PCI was associated with significantly higher risk of all-cause mortality (hazard ratio [HR]: 1.71; 95% confidence interval [CI]: 1.32 to 2.21; p < 0.001) but similar risk of the composite outcome (HR: 0.94; 95% CI: 0.82 to 1.09; p = 0.43). These differences were not statistically significant among patients with low or intermediate SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score (≤32) or diabetes; however, PCI was associated with an increased risk among those with high SYNTAX score (>32), with HRs of 3.10 (95% CI: 1.84 to 5.22; p < 0.001) for all-cause mortality and 1.82 (95% CI: 1.36 to 2.45; p < 0.001) for the composite outcome. CABG was associated with lower risk of repeat revascularization but higher risk of stroke in each clinically relevant subgroup.
Conclusions:
In this single-center observational study among patients with ULMD, CABG was associated with improved long-term outcomes, especially in patients with more complex disease.
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