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Revascularisation in Left Ventricular Systolic Dysfunction: A Meta-analysis of Kaplan-Meier Reconstructed Individual
Grace Lee1, Abdullah Malik1, Dominique Vervoort2
1Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada.
Insights
Coronary artery disease patients with reduced ejection fraction benefit from coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI). CABG improves survival and reduces repeat procedures compared to PCI in ischemic left ventricular systolic dysfunction.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Coronary artery disease frequently causes ischemic left ventricular systolic dysfunction (LVSD).
- The optimal revascularization strategy for LVSD remains debated.
- This study compares percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in LVSD patients.
Purpose of the Study:
- To determine the survival advantage of PCI versus CABG in patients with LVSD.
- To compare mortality, myocardial infarction, stroke, and revascularization rates between PCI and CABG.
Main Methods:
- Study-level (SLMA) and reconstructed individual patient data (rIPDMA) meta-analyses were conducted.
- Systematic search of Medline, Embase, and Cochrane Library for studies published after 2010.
- Included studies compared PCI and CABG in patients with left ventricular ejection fraction ≤ 40%.
Main Results:
- PCI was associated with increased all-cause mortality, myocardial infarction, and repeat revascularization compared to CABG in SLMA.
- rIPDMA confirmed higher all-cause mortality and repeat revascularization with PCI.
- PCI showed a lower risk of stroke in the rIPDMA, attributed to fewer early events.
Conclusions:
- Percutaneous coronary intervention (PCI) is linked to higher mortality and revascularization rates than coronary artery bypass grafting (CABG) in ischemic LVSD.
- CABG may offer a survival advantage in this patient group.
- PCI demonstrated a reduced risk of short-term stroke.
Background:
Coronary artery disease is a common cause of ischemic left ventricular systolic dysfunction (LVSD), for which the optimal revascularisation strategy remains unclear. We aimed to determine whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) results in greater survival advantage in patients with LVSD.
Methods:
Study-level (SLMA) and reconstructed individual patient data (rIPDMA) meta-analyses from Kaplan-Meier (KM) survival curves were performed. A systematic search of Medline, Embase, and Cochrane Library was conducted for observational and randomised studies published after 2010 that compared PCI and CABG in patients with left ventricular ejection fraction ≤ 40%. The primary outcome was all-cause mortality at longest follow-up. The secondary outcomes were myocardial infarction (MI), stroke, repeated revascularisation, cardiovascular mortality, and major adverse cardiovascular and cerebrovascular events (MACCE) at longest follow-up.
Results:
Fourteen studies (11 observational, 3 randomised, 13,063 patients) were eligible for the SLMA. Seven contained digitisable KM curves from which individual patient data could be reconstructed. Study-level analysis found PCI to be associated with increased all-cause mortality (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.18-1.69), MI (HR 2.10, 95% CI 1.62-2.72), repeated revascularisation (HR 2.39, 95% CI 1.37-4.17), and MACCE (HR 1.58, 95% CI 1.23-2.03), without significant differences in stroke (HR 0.86, 95% CI 0.39-1.92) or cardiovascular mortality (HR 1.42, 95% CI 0.78-2.59). In the rIPDMA, PCI resulted in increased all-cause mortality (HR 1.57, 95% CI 1.34-1.87) and repeated revascularisation (HR 3.63, 95% CI 3.12-4.21) but overall lower risk of stroke (HR 0.62, 95% CI 0.39-0.99) owing to fewer events during initial follow-up.
Conclusions:
In patients with ischemic LVSD, PCI was associated with higher risk of all-cause mortality and repeated revascularisation than CABG, but lower risk of short-term stroke. (PROSPERO: CRD42021291408).
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