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Published on: March 27, 2018
Comparison of the survival between coronary artery bypass graft surgery versus percutaneous coronary intervention in
Shaneel Shah1, Umberto Benedetto2, Massimo Caputo2
1University of Bristol Academy, Bristol Royal Infirmary, Bristol, UK.
Insights
Coronary artery bypass graft (CABG) surgery offers superior long-term survival benefits compared to percutaneous coronary intervention (PCI) for patients with poor left ventricular function (LVF). Despite a longer hospital stay, CABG significantly reduces mortality risk in this vulnerable patient group.
Area of Science:
- Cardiology
- Cardiac Surgery
- Interventional Cardiology
Background:
- Limited evidence exists comparing coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) for patients with poor left ventricular function (LVF).
- Previous studies often excluded patients with poor LVF or did not account for modern PCI techniques like drug-eluting stents.
Purpose of the Study:
- To compare the long-term outcomes of CABG versus PCI in patients with severely impaired left ventricular function (ejection fraction <30%).
- To evaluate the comparative effectiveness of revascularization strategies in a high-risk cardiac population.
Main Methods:
- A propensity score analysis was used to match 67 patients who underwent CABG with 67 patients who underwent PCI.
- Data from 717 patients with LVF (ejection fraction <30%) treated between 2002 and 2015 were analyzed.
- Outcomes were assessed using national registry data, with a focus on 8-year mortality rates.
Main Results:
- CABG patients had a significantly longer hospital stay (7 days vs. 2 days) compared to PCI patients.
- PCI was associated with a higher adjusted 8-year mortality rate (hazard ratio 3.291, P < 0.001).
- Both on-pump and off-pump CABG demonstrated superior survival outcomes compared to PCI in patients with poor LVF.
Conclusions:
- Coronary artery bypass graft (CABG) surgery is a superior revascularization strategy to percutaneous coronary intervention (PCI) for patients with poor left ventricular function.
- Despite increased initial hospitalization, CABG provides significant long-term survival benefits for this high-risk group.
- The findings support CABG as the preferred treatment modality for coronary artery disease in patients with impaired LVF.
Objectives:
Existing evidence comparing the outcomes of coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in patients with poor left ventricular function (LVF) is sparse and flawed. This is largely due to patients with poor LVF being underrepresented in major research trials and the outdated nature of some studies that do not consider drug-eluting stent PCI.
Methods:
Following strict inclusion criteria, 717 patients who underwent revascularization by CABG or PCI between 2002 and 2015 were enrolled. All patients had poor LVF (defined by ejection fraction <30%). By employing a propensity score analysis, 134 suitable matches (67 CABG and 67 PCI) were identified. Several outcomes were evaluated, in the matched population, using data extracted from national registry databases.
Results:
CABG patients required a longer length of hospital stay post-revascularization compared to PCI in the propensity-matched population, 7 days (lower-upper quartile; 6-12) and 2 days (lower-upper quartile; 1-6), respectively (Mood's median test, P = 0.001). Stratified Cox-regression proportional-hazards analysis of the propensity-matched population found that PCI patients experienced a higher adjusted 8-year mortality rate (hazard ratio 3.291, 95% confidence interval 1.776-6.101; P < 0.001). This trend was consistent amongst urgent cases of revascularization: patients with 3 or more vessels with coronary artery disease and patients where complete revascularization was achieved. Although sub-analyses found no difference between survival distributions of on-pump versus off-pump CABG (log-rank P = 0.726), both modes of CABG were superior to PCI (stratified log-rank P = 0.002).
Conclusions:
Despite a longer length of hospital stay, patients with impaired LVF requiring intervention for coronary artery disease experienced a greater post-procedural survival benefit if they received CABG compared to PCI. We have demonstrated this at 30 days, 90 days, 1 year, 3 years, 5 years and 8 years following revascularization. At present, CABG remains a superior revascularization modality to PCI in patients with poor LVF.
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