Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Interventions in Patients With Unprotected Left Main Coronary Artery Disease

Abstract

Objectives: This study sought to investigate long-term clinical outcomes following coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in patients with unprotected left main disease (ULMD).

Background: PCI has been increasingly used as an alternative mode of revascularization for ULMD. However, there are limited data comparing clinical outcomes between CABG surgery and PCI.

Methods: Between 2004 and 2010, 4,046 consecutive patients with ULMD were treated with either CABG surgery (n = 2,604) or PCI (n = 1,442) with drug-eluting stents. The primary outcome was 3-year all-cause mortality and the secondary outcome was the composite of death, nonfatal myocardial infarction, or nonfatal stroke.

Results: The unadjusted 3-year all-cause mortality was higher in the PCI group as compared with the CABG group (3.8% vs. 2.5%; log-rank p = 0.03), although there was no significant difference in the composite outcome (7.5% vs. 9.4%; log-rank p = 0.07). After adjustment for differences in baseline risk factors, PCI was associated with significantly higher risk of all-cause mortality (hazard ratio [HR]: 1.71; 95% confidence interval [CI]: 1.32 to 2.21; p < 0.001) but similar risk of the composite outcome (HR: 0.94; 95% CI: 0.82 to 1.09; p = 0.43). These differences were not statistically significant among patients with low or intermediate SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score (≤32) or diabetes; however, PCI was associated with an increased risk among those with high SYNTAX score (>32), with HRs of 3.10 (95% CI: 1.84 to 5.22; p < 0.001) for all-cause mortality and 1.82 (95% CI: 1.36 to 2.45; p < 0.001) for the composite outcome. CABG was associated with lower risk of repeat revascularization but higher risk of stroke in each clinically relevant subgroup.

Conclusions: In this single-center observational study among patients with ULMD, CABG was associated with improved long-term outcomes, especially in patients with more complex disease.

Keywords: coronary artery bypass surgery; coronary artery disease; percutaneous coronary intervention; unprotected left main disease.