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PCI vs. CABG in Left Main Coronary Artery Disease
Quick Takes
- CABG was the most common revascularization strategy for left main coronary disease.
- Although there was no difference in early mortality, improved late survival and freedom from major adverse cardiac and cerebrovascular events with CABG was noted.
- CABG should be the preferred revascularization approach for left main coronary disease in those who are good surgical candidates.
Study Questions:
What are the long-term clinical outcomes of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with left main coronary disease?
Methods:
The investigators linked clinical and administrative databases for Ontario, Canada to obtain records of all patients with angiographic evidence of left main coronary artery disease (≥50% stenosis) treated with either isolated CABG or PCI from 2008–2020. Emergent, cardiogenic shock, and ST-segment elevation myocardial infarction patients were excluded. Baseline characteristics of patients were compared and 1:1 propensity-score matching was performed. Late mortality and major adverse cardiac and cerebrovascular events were compared between the matched groups using a Cox proportional hazards model.
Results:
After exclusions, 1,299 and 21,287 patients underwent PCI and CABG, respectively. Prior to matching, PCI patients were older (75.2 vs. 68.0 years) and more likely to be women (34.6% vs. 20.1%), although they had less coronary artery disease burden. Propensity-score matching on 25 baseline covariates yielded 1,128 well-matched pairs. There was no difference in early mortality between PCI and CABG (5.5% vs. 3.9%; p = 0.075). Over 7-year follow-up, all-cause mortality (53.6% vs. 35.2%; hazard ratio [HR], 1.63; 95% confidence interval [CI], 1.42-1.87; p < 0.001) and major adverse cardiac and cerebrovascular events (66.8% vs. 48.6%; HR, 1.77; 95% CI, 1.57-2.00) were significantly higher with PCI than CABG.
Conclusions:
The authors report that after matching, there was no difference in early mortality but improved late survival and freedom from major adverse cardiac and cerebrovascular events with CABG.
Perspective:
This real-world study reports that CABG was the most common revascularization strategy for left main coronary disease. Of note, patients undergoing PCI were much older and of higher risk at baseline. After matching, although there was no difference in early mortality, improved late survival and freedom from major adverse cardiac and cerebrovascular events with CABG was noted. Superimposed on existing published data, these findings suggest that CABG should be the preferred revascularization approach for left main disease in those who are good surgical candidates. Since, recent clinical trials provided outcomes to 5 years only, longer-term follow-up of clinical trials is indicated to validate findings from observational studies.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine
Keywords: Cardiac Surgical Procedures, Cerebrovascular Disorders, Coronary Artery Bypass, Coronary Artery Disease, Coronary Stenosis, Geriatrics, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention
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