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10-Year Outcomes of PCI vs. CABG for Left Main Disease
Study Questions:
What are the 10-year outcomes after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease?
Methods:
The investigators evaluated 2,240 patients with unprotected LMCA disease who underwent PCI (n = 1,102) or CABG (n = 1,138) between January 2000 and June 2006, in the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. Adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction [MI], or stroke; and target-vessel revascularization) were compared with the use of propensity scores and inverse-probability-weighting adjustment. The follow-up was extended to ≥10 years for all patients (median, 12.0 years).
Results:
In the overall cohort, there was no significant difference in adjusted risks of death and the composite outcome between the groups up to 10 years. The risk of target-vessel revascularization was significantly higher in the PCI group. In the cohort comparing drug-eluting stents (DES) and concurrent CABG, the two study groups did not differ significantly in the risks of death and the composite outcome at 5 years. However, after 5 years, DES were associated with higher risks of death (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.00-1.81) and the composite outcome (HR, 1.46; 95% CI, 1.10-1.94) compared to CABG.
Conclusions:
The authors concluded that patients with significant LMCA disease, as compared with CABG, PCI showed similar rates of death and serious composite outcome, but a higher rate of target-vessel revascularization at 10 years.
Perspective:
This multicenter registry study of patients with LMCA disease reports no significant difference in the rates of death and a composite endpoint of death, Q-wave MI, or stroke between the PCI and the CABG groups up to 10 years. However, in the groups comparing DES and CABG, PCI with DES was associated with higher risks of death and serious composite outcomes compared with CABG after 5 years. The rate of target-vessel failure also was consistently higher in the PCI group. Overall, study results suggest that clinical equipoise may be present for either PCI or CABG in patients with less complex clinical and anatomic characteristics, but CABG remains the preferred modality in those with high clinical and anatomical complexity. Additional studies are needed to better understand the mechanisms underlying differences in long-term vascular outcomes after PCI and CABG for LMCA disease and potential ways to mitigate residual risk.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Coronary Stenosis, Drug-Eluting Stents, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention, Stroke, Vascular Diseases
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