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Angioplasty versus bypass surgery for multivessel coronary artery disease with left ventricular ejection fraction <
J H O'Keefe1, J J Allan, B D McCallister
1Mid America Heart Institute, St. Luke's Hospital, Kansas City, Missouri.
Insights
For high-risk patients with multivessel coronary artery disease and left ventricular dysfunction, angioplasty offers better early outcomes, while bypass surgery provides superior long-term benefits, including reduced angina and improved survival, especially with complete revascularization.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Patients with multivessel coronary artery disease (CAD) and left ventricular dysfunction (LVD) are a high-risk group.
- Coronary artery bypass grafting (CABG) improves survival in this subgroup compared to medical therapy.
- Comparative data on angioplasty versus CABG in this specific patient population are limited.
Purpose of the Study:
- To compare the early and late outcomes of multivessel angioplasty versus CABG in patients with multivessel CAD and LVD.
- To evaluate the risks and benefits associated with each revascularization strategy in this high-risk cohort.
Main Methods:
- Retrospective analysis of 100 consecutive patients treated with CABG versus 100 matched patients treated with multivessel angioplasty.
- Comparison of in-hospital outcomes, including mortality and stroke rates.
- Assessment of late follow-up outcomes over 5 years, including repeat revascularization, myocardial infarction, angina relief, and survival.
Main Results:
- Angioplasty group had shorter hospital stays (4.3 days vs. 12.8 days) and similar in-hospital mortality (3% vs. 5%).
- Stroke occurred more frequently in the CABG group (7% vs. 0%).
- Late follow-up favored CABG with superior angina relief (99% vs. 89%) and a trend toward improved survival (76% vs. 67%). Repeat revascularization and myocardial infarction were higher after angioplasty.
Conclusions:
- Early outcomes favor angioplasty, while late outcomes favor CABG in patients with multivessel CAD and LVD.
- Complete revascularization was associated with similar late survival rates regardless of the revascularization method.
- The choice of revascularization strategy should consider both early risks and long-term benefits for this high-risk patient group.
Abstract:
Patients with multivessel coronary artery disease and left ventricular dysfunction represent a high-risk subgroup in whom coronary artery bypass grafting has been shown to improve survival compared with that of medically treated patients. The comparative benefits and risks of coronary angioplasty and bypass surgery in this subgroup of patients are unclear. This study retrospectively analyzes 100 consecutive patients treated with bypass surgery compared with a matched, concurrent cohort of 100 treated with multivessel angioplasty. Early results favored angioplasty; a hospital stay of 12.8 days was noted in the bypass group compared with 4.3 days in the angioplasty group (p < 0.001). In-hospital mortality rates were similar in the bypass (5%) and angioplasty (3%) groups (p = NS). Stroke was observed significantly more often in the bypass group (7 vs 0%). However, late follow-up favored bypass patients; repeat revascularization procedures and late myocardial infarction occurred more frequently during follow-up in the angioplasty group. During 5-year follow-up, superior relief from disabling angina (99 vs 89%; p = 0.01) and a trend toward improved survival (76 vs 67%; p = 0.09) were observed in the bypass group as compared with the angioplasty group. Multivariate correlates of late mortality included age and incomplete revascularization, but not mode of revascularization. Thus, in patients with multivessel coronary artery disease and left ventricular dysfunction, early results favor angioplasty, whereas late follow-up favors bypass surgery. However, late survival was similar in both groups of patients who were completely revascularized.