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Comparison of Coronary Artery Bypass Surgery and Percutaneous Drug-Eluting Stent Implantation for Treatment of Left Main Coronary Artery Stenosis

Anthony J. White, MBBS, PhD^_*, Gautam Kedia, MD^_*, James M. Mirocha, MS^_*, Michael S. Lee, MD, James S. Forrester, MD^_*, Walter C. Morales, BS^_*, Suhail Dohad, MD^_*, Saibal Kar, MD^_*, Lawrence S. Czer, MD^_*, Gregory P. Fontana, MD^_*, Alfredo Trento, MD^_*, Prediman K. Shah, MD^_*, Raj R. Makkar, MD^_*,_*

^_* Cedars-Sinai Medical Center, University of California, Los Angeles School of Medicine, Los Angeles, California
UCLA Division of Cardiology, Los Angeles, California.

^_* Reprint requests and correspondence: Dr. Raj Makkar, Director, Interventional cardiology & Cardiac Catheterization Laboratory, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048. (Email: Raj.Makkar{at}cshs.org).

Objectives: The purpose of this study was to compare outcomes for drug-eluting stents (DES) and coronary artery bypass graft (CABG) surgery in patients with unprotected left main coronary artery (ULMCA) stenosis.

Background: Expert guidelines recommend coronary artery bypass graft (CABG) surgery for the treatment of significant stenosis of the unprotected left main coronary artery (ULMCA) if the patient is eligible for CABG; however, treatment by percutaneous coronary intervention (PCI) is common.

Methods: Details of patients (n = 343, ages 69.9 ± 11.9 years) undergoing coronary revascularization for ULMCA stenosis (April 2003 to January 2007) were recorded. A total of 223 patients were treated with CABG (mean [interquartile range]: follow-up 600 [226 to 977) days) and 120 by PCI (follow-up 362 [192 to 586) days). The hazard ratios (HRs) for death and major adverse cardiovascular and cerebrovascular events (MACCE) were calculated incorporating propensity score adjustment. Survival comparisons were conducted in propensity-matched subjects (n = 134), and in low- and high-risk subjects for CABG.

Results: Patients treated by PCI were more likely to be 75 years of age (49% vs. 33%; p = 0.005), and of greater surgical risk (Parsonnet score 17.2 ± 11.2 vs. 13.0 ± 9.3; p < 0.001) than patients treated by CABG. Overall, the propensity-adjusted HR for death was not statistically different (HR 1.93, 95% confidence interval [CI] 0.89 to 4.19, p = 0.10), but MACCE was greater in the PCI group (HR 1.83, 95% CI 1.01 to 3.32, p = 0.05). In propensity-matched individuals, neither survival nor MACCE-free survival were different. Survival was equivalent among low-risk candidates, but PCI had a tendency to inferior survival in high-risk candidates (Ellis category IV, log-rank p = 0.05). Interaction testing, however, failed to demonstrate a difference in outcomes of the 2 revascularization techniques as a function of baseline risk assessment.

Conclusions: Overall, the propensity-adjusted risk of mortality for treatment of ULMCA disease does not differ between PCI- and CABG-treated groups. There appears to be sufficient equipoise that a randomized clinical trial to compare the techniques would not be ethically contraindicated.

Abbreviations and Acronyms   CABG = coronary artery bypass graft (surgery)   CI = confidence interval   DES = drug-eluting stent(s)   HR = hazard ratio   IABP = intra-aortic balloon pump   LAD = left anterior descending (coronary artery)   MACCE = major adverse cardiovascular and cerebrovascular event   PCI = percutaneous coronary intervention   ULMCA = unprotected left main coronary artery

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