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PCI or CABG for Left Main Disease
Quick Takes
- PCI for distal bifurcation left main (LM) disease is associated with worse long-term outcomes compared to CABG.
- PCI and CABG have comparable long-term outcomes among patients with ostial/shaft LM disease.
- PCI is associated with higher rates of target vessel revascularization regardless of LM lesion location.
Study Questions:
Does lesion location (ostial or shaft vs. distal bifurcation) impact long-term outcomes among patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main disease?
Methods:
Patients from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry were analyzed, comparing adverse outcomes (all-cause mortality, a composite outcome of death, Q-wave myocardial infarction [MI], or stroke and target vessel revascularization) between PCI and CABG according to left main coronary artery (LMCA) lesion location during a median follow-up period of 12.0 years.
Results:
In the overall population, the adjusted risks for death and serious composite outcome were higher after PCI than after CABG for distal bifurcation disease, which was mainly separated beyond 5 years. These outcomes were not different for ostial or shaft disease. When comparing drug-eluting stents (DES) and CABG, the adjusted risks for death and serious composite outcome progressively diverged beyond 5 years after DES compared with CABG for distal bifurcation disease (death: hazard ratio, 1.78; 95% confidence interval, 1.22-2.59; composite outcome: hazard ratio, 1.94; 95% confidence interval, 1.35-2.79). This difference was driven mainly by PCI with a two-stent technique for distal bifurcation. In contrast, the adjusted risks for these outcomes were similar between DES and CABG for ostial or shaft disease.
Conclusions:
Among patients with distal LMCA bifurcation disease, CABG showed lower mortality and serious composite outcome rates compared with DES beyond 5 years. However, there were no between-group differences in these outcomes among patients with ostial or shaft LMCA disease.
Perspective:
This report on Korean patients with stable, unprotected LM disease undergoing PCI or CABG from 2000-2006 evaluated the impact of lesion location on long-term outcomes. Barring the limitations of a prospective registry, the current analysis of over 2,000 patients showed no difference in all-cause death, Q-wave MI, or stroke between PCI or CABG among patients with ostial/shaft left main disease. On the other hand, among patients with distal LM disease, PCI was associated with increased hazard of death, MI, and stroke, especially when a two-stent approach was used. Need for repeat revascularization was higher among patients undergoing PCI regardless of lesion location. A one-size-fits-all approach for LM disease remains elusive and many variables including lesion location need to be considered to ultimately tailor the treatment for each individual patient.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Coronary Artery Disease
Keywords: Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Coronary Stenosis, Drug-Eluting Stents, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Stroke
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