The current indication for severe left main lesion continues to be coronary artery bypass graft surgery (CABG) but percutaneous coronary intervention (PCI) has come far in this territory thanks to increasing operator experienced and the use of IVUS during procedures.
At present, left main disease have a Class IIa indication in the American guidelines when revascularization will be comparable to surgery, and the European guidelines indicate Class I with low complexity coronary anatomy and Class II with intermediate complexity.
Even though there is good information from important randomized studies with 3 to 5 year followup, it seldom reflects real world data, but we find different registries comparing both strategies.
This is a retrospective analyzis carried out in Ontario, Canada, between October 2008 and 2020 from patients presenting severe left main lesion receiving revascularization within 90 days.
It included 2526 patients undergoing PCI and 21287 receiving CABG. Over time, the number of PCI patients increased, while CABG decreased.
The populations were different: PCI patients were older, were more often women, had more acute coronary syndrome and more comorbidities.
Populations were therefore matched with propensity score, leaving 1128 patients in each group.
There were no differences in hospital or early mortality, (3.7% vs 3.8% y 5.5% vs 3.9%) when comparing PCI against CABG. Neither were there differences in stroke, but there was higher MI rate among PCI patients. (2.7% vs 1.2% P =0.007).
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At 7 year followup, all-cause mortality (53.6% vs 35.2%; HR: 1.63; 95% CI: 1.42-1.87; P < 0.001) and MACCE (66.8% vs 48.6%; HR: 1.77; 95% CI: 1.57-2.00), were higher among PCI patients vs. CABG. Also, PCI saw higher MI rate (10.6% vs. 19.3% 95% CI: 1.77-2.91P>0.0001) and need for repeat revascularization (18.4% vs 6.4% HR: 3.09; 95% CI: 2.31-4.16; P < 0.0001), it was also associated to higher stroke rate (5.3% vs 7.6% HR of 0.61 (95% CI: 0.42-0.89; P < 0.001).
Conclusion
CABG was the most common revascularization procedure in this “real world” registry. Those undergoing PCI were older and had higher risk. After propensity score matching, there were no differences in early mortality but survival and freedom from cardiac and cerebrovascular events were better with CABG.
Dr. Carlos Fava.
Member of the editorial board of SOLACI.org.
Original Title: Real-World Examination of Revascularization Strategies for Left Main Coronary Disease in Ontario, Canada.
Reference: Derrick Y. Tam, et al J Am Coll Cardiol Intv 2023;16:277–288.
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