Long-Term Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Bifurcation Disease in the Drug-Eluting Stent Era

Study Questions:

What is the long-term comparative effectiveness of treating unprotected left main coronary bifurcation disease with surgery versus drug-eluting stents (DES)?

Methods:

The authors reported the outcome of 865 patients with unprotected left main bifurcation disease treated with either percutaneous coronary intervention (PCI) using DES (n = 556) or coronary artery bypass grafting (CABG) (n = 309) between May 2003 and December 2009 at 18 major Korean centers. PCI-treated patients were further categorized into simple stenting (n = 360) or complex stenting (n = 196). Simple stenting was defined as stenting the left main bifurcation across the left circumflex ostium with the final kissing balloon at the discretion of the operator.

Results:

Over a median follow-up of 4.2 years, 102 patients died (57 patients [10.2%] in the PCI group and 45 patients [14.6%] in the CABG group), and 115 patients had a primary clinical event including death, Q-wave myocardial infarction, or stroke (11.5% in the PCI group and 16.5% in the CABG group). After adjusting for baseline difference using multivariate Cox hazard regression model and inverse probability of treatment weighting, there was no difference in the long-term cumulative rates of death (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.62-1.45) or composite of death, Q-wave myocardial infarction, or stroke (HR, 0.97; 95% CI, 0.64-1.48). Patients treated with PCI were significantly more likely to require target vessel revascularization (TVR) (HR, 4.42; 95% CI, 2.39-8.18). The complex stenting group had similar long-term clinical outcomes compared with the simple stenting group except for TVR (HR, 1.94; 95% CI, 1.22-3.10).

Conclusions:

Compared with patients undergoing CABG, patients treated with PCI for left main bifurcation disease had a similar survival, but were more likely to undergo TVR.

Perspective:

The best revascularization strategy for treatment of severe left main coronary disease continues to be debated. While most patients with left main coronary artery disease in the United States are treated with CABG, PCI is a viable alternative, but is usually reserved for patients with ostial or body disease. The small but evolving body of randomized data suggest that PCI may be a reasonable alternative to CABG in patients with a low SYNTAX score, whereas CABG should be the preferred treatment for patients with more complex disease.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Interventions and Coronary Artery Disease

Keywords: Coronary Artery Disease, Myocardial Infarction, Stroke, Drug-Eluting Stents, Cardiology, Coronary Disease, Confidence Intervals, Coronary Artery Bypass, Angioplasty, Balloon, Coronary, United States, Stents, Percutaneous Coronary Intervention


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