Revascularization strategy for left main coronary artery disease comparing percutaneous coronary intervention versus
Ryaan El-Andari1, Jimmy Kang2, Nicholas Fialka2
1Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada. elandari@ualberta.ca.
Insights
Coronary artery bypass grafting (CABG) shows better long-term survival and fewer complications than percutaneous coronary intervention (PCI) for left main coronary artery disease (LMCAD). CABG remains the preferred treatment for LMCAD patients with acceptable surgical risk.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Left main coronary artery disease (LMCAD) is a critical condition often treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).
- Previous studies on LMCAD revascularization strategies have been limited by sample size and follow-up duration.
- This study provides a long-term comparison of CABG versus PCI for LMCAD outcomes up to 14 years.
Purpose of the Study:
- To compare the long-term efficacy and safety of CABG versus PCI in patients with LMCAD.
- To evaluate differences in all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization rates.
- To inform clinical decision-making regarding the optimal revascularization strategy for LMCAD.
Main Methods:
- Retrospective analysis of a provincial database including patients aged 18+ with LMCAD undergoing CABG or PCI.
- Primary outcome: all-cause mortality. Secondary outcomes: rehospitalization, MI, stroke, repeat revascularization.
- Outcomes were adjusted for age, sex, and comorbidities, with follow-up extending up to 14 years.
Main Results:
- In a cohort of 1706 patients (1180 CABG, 526 PCI), CABG demonstrated significantly lower 14-year all-cause mortality (40.0% vs. 58.4%; aHR 0.58).
- CABG also showed significantly lower rates of myocardial infarction (MI) (10.7% vs. 22.3%; aHR 0.40) and repeat revascularization (5.4% vs. 16.3%; aHR 0.25) compared to PCI.
- All comparisons favored CABG, with p-values < 0.001.
Conclusions:
- Coronary artery bypass grafting (CABG) offers significant long-term survival benefits over percutaneous coronary intervention (PCI) for patients with left main coronary artery disease (LMCAD).
- CABG is associated with reduced risks of myocardial infarction and repeat revascularization.
- These findings support CABG as the preferred revascularization strategy for LMCAD patients with acceptable surgical risk.
Background:
Coronary artery bypass grafting(CABG) has long been the preferred treatment for left main coronary artery disease(LMCAD), although percutaneous coronary intervention(PCI) has been increasingly utilized. Despite numerous investigations seeking to identify the optimal revascularization strategy for LMCAD, limitations in sample size or follow-up duration have hindered definitive conclusions. Herein, we compare the long-term outcomes up to 14 years after CABG or PCI for patients with LMCAD.
Methods:
Data was retrospectively collected from a provincial database. The inclusion criteria is patients ≥18 years old, with LMCAD, and revascularization with CABG or PCI. The primary outcome is all-cause mortality. Secondary outcomes are any rehospitalization, myocardial infarction (MI), stroke, or repeat revascularization. Outcomes are adjusted for age, sex, and clinical comorbidities. The average age of the patients was 67 ± 9 years for the CABG patients and 71 ± 11 years for the PCI patients. 84.7% of the CABG patients and 71.5% of the PCI patients were male.
Results:
5580 patients are identified with LMCAD between 2009 and 2018. 1706 patients (1180 CABG; 526 PCI) are included in the final analysis and followed until March 31, 2023. Rates of mortality at longest follow-up of 14 years are 40.0% for CABG and 58.4% for PCI (adjusted hazard ratio(aHR) 0.58, 95% confidence interval(CI) 0.48-0.70, p < 0.001). Rates of MI (10.7% vs 22.3%, aHR 0.40, 95% CI 0.29-0.55, p < 0.001) and repeat revascularization (5.4%vs16.3%, aHR 0.25, 95% CI 0.18-0.36, p < 0.001) favor CABG over PCI.
Conclusions:
Patients with LMCAD undergoing CABG experience significant benefit over PCI in terms of long-term mortality, MI, and required repeat revascularization. These finding suggest CABG should remain the preferred revascularization strategy for patients with LMCAD and acceptable surgical risk. Future studies should explore evolving PCI techniques and their impact on long-term outcomes.
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