Mortality after multivessel revascularisation involving the proximal left anterior descending artery
Masafumi Ono1,2, Hironori Hara1,2, Chao Gao2,3
1Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands.
Insights
For patients with three-vessel disease (3VD), the location of lesions in the proximal left anterior descending artery (P-LAD) did not impact long-term outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Both PCI and CABG showed similar long-term results regardless of P-LAD involvement.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Three-vessel disease (3VD) poses significant therapeutic challenges.
- The impact of proximal left anterior descending artery (P-LAD) lesions on treatment choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remains debated.
- Long-term outcomes comparing PCI and CABG in 3VD patients with and without P-LAD lesions require further investigation.
Purpose of the Study:
- To compare long-term clinical outcomes of PCI versus CABG in patients with 3VD.
- To evaluate the influence of proximal left anterior descending artery (P-LAD) lesions on treatment outcomes.
- To assess 10-year all-cause mortality and 5-year major adverse cardiac or cerebrovascular events (MACCE).
Main Methods:
- Post-hoc analysis of the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) Extended Survival study.
- Inclusion of 1088 patients with 3VD, stratified by the presence or absence of P-LAD lesions.
- Assessment of 10-year all-cause death and 5-year MACCE.
Main Results:
- No significant interaction between P-LAD lesion presence and treatment effect on 10-year mortality (pinteraction=0.837).
- PCI was associated with numerically higher 10-year mortality in patients with P-LAD lesions (28.9% vs 21.9%).
- Higher 5-year MACCE rates were observed with PCI compared to CABG, irrespective of P-LAD involvement (pinteraction=0.408).
Conclusions:
- The presence or absence of a P-LAD lesion did not influence the treatment effect on long-term outcomes between PCI and CABG in 3VD patients.
- Long-term outcomes appear comparable between PCI and CABG for 3VD, regardless of P-LAD lesion location.
- Individualized risk assessment may be necessary for optimal treatment selection in specific patient subgroups.
Objective:
We sought to investigate whether long-term clinical outcomes differ following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with three-vessel disease (3VD) and lesions in the proximal left anterior descending artery (P-LAD).
Methods:
This post-hoc analysis of the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) Extended Survival study included patients with 3VD who were classified according to the presence or absence of lesions located in the P-LAD. Ten-year all-cause death and 5-year major adverse cardiac or cerebrovascular events (MACCE) were assessed.
Results:
Among 1088 patients with 3VD, 559 (51.4%) had involvement of P-LAD and their 10-year mortality was numerically higher following PCI versus CABG (28.9% vs 21.9%; HR: 1.39, 95% CI 0.99 to 1.95). Although patients without P-LAD lesions had significantly higher 10-year mortality following PCI compared with CABG, there was no evidence of a treatment-by-subgroup interaction (28.8% vs 20.2%; HR: 1.47, 95% CI 1.03 to 2.09, pinteraction=0.837). The incidence of MACCE at 5 years was significantly higher with PCI than CABG, irrespective of involvement of P-LAD (with P-LAD: HR: 1.86, 95% CI 1.36 to 2.55; without P-LAD: HR: 1.54, 95% CI 1.11 to 2.12; pinteraction=0.408). Individualised assessment using the SYNTAX Score II 2020 established that a quarter of patients with P-LAD lesions had significantly higher mortality with PCI than CABG, whereas in the remaining three-quarters CABG had similar mortality.
Conclusions:
Among patients with 3VD, the presence or absence of a P-LAD lesion was not associated with any treatment effect on long-term outcomes following PCI or CABG.
Trial Registration Number:
SYNTAXES: NCT03417050; SYNTAX: NCT00114972.
