52 Percutaneous coronary intervention vs. coronary artery bypass graft surgery in left main coronary artery disease – clinical outcomes in the mid-west region

Abstract

<h3>Importance</h3> Ischaemic heart disease is the leading cause of death worldwide. Percutaneous coronary Intervention (PCI) and coronary artery bypass graft surgery (CABG) represent the primary treatment options for coronary revascularisation in patients with significant coronary artery disease. Significant left main coronary artery disease is increasingly being treated with PCI. This is despite the CABG remaining the gold standard of treatment in left main disease – and holding class 1A indication from both US and European Societies. However, as interventional techniques have become more refined coupled with the advent of drug eluting stents and – the outcomes of patients with left main disease treated with PCI have improved. This serves to threaten the long-standing position of CABG as the primary treatment of left main disease. <h3>Objective</h3> Since July 2013 PCI for unprotected LMCA stenosis has been performed in the cardiology department of the University Hospital Limerick (UHL). The primary aim of this study is to assess the outcomes of patients with unprotected significant LMCA stenosis (&gt; 50%) who underwent PCI in the cardiology department of UHL in 2013 and 2014. The performance of this cohort will then be compared to those underwent CABG for unprotected left main disease within the same time frame. <h3>Methods</h3> Patients with significant ULMCA disease who attended UHL between January 2013 and July 2014, and subsequently underwent PCI or CABG, were identified from the clinical registry. Baseline demographic and cardiac risk factor data was collected for each patient. The SYNTAX 5 and the European System for Cardiac Operative Risk Evaluation (euroSCORE) were calculated for each subject. This determined their severity of coronary artery disease and surgical risk. The primary end points of this study were in-hospital major adverse cardiac and cerebrovascular events (MACCE) and length of hospital stay. MACCE were defined as death, Q wave myocardial infarction, CVA, the requirement for repeat revascularisation, and re-admission within 30 days. Finally, in October 2014, 50 of 57 participants were followed up by telephone questionnaire where; angina severity (CCS score), heart failure status (NYHA classification), and quality of life (EQD5L) were also determined. Analysis was performed using SPSS for Windows Version 22. Categorical variables were compared across both groups using Fischer’s exact test or the Chi-Square test where appropriate. Continuous variables were compared using the Independent Samples Median Testing. A p value of &lt; 0.05 was considered statistically significant. <h3>Results</h3> 57 patients with significant LMCAD attending UHL were identified from the clinical registry. 27 patients underwent PCI (median age 67.71) and 30 CABG (median age 68.59). A high volume of emergency index admissions was common to both the PCI and CABG arms of the study (PCI 70.4 vs CABG 75.9, p = 0.765). Male patients dominated both the PCI and CABG groups, at 85.2% and 82.8% respectively. Diabetes was present in under 20% of both groups (PCI 18.5 vs. 17.2, p = 1). A history of myocardial infarction (inclusive of the index admission) was also common to both cohorts (PCI 51.9 vs 41.4), p = 0.592. Angina was seen in 81.5% of the PCI-treated patients and 75.9% of the CABG grip, p = 0.748. Renal impairment as determined by creatinine clearance was significantly associated with allocation to CABG surgery (PCI 80.8 vs CABG 56.3, p = 0.004). While the PCI patients had a higher surgical risk as measured by the euroSCORE, this difference was not of statistical significance (PCI 19.2 vs, 6.9, p = 0.236). The PCI group had a shorter length of stay (6.6 vs. 37.6 days, p = 0.06). What is more, those who were treated with CABG had to wait significantly longer for their revascularisation (PCI 3.4 vs CABG 8 days, p = 0.04). PCI is the treatment of choice in 90.5% of patients presenting to UHL with mild to intermediate left main disease. On the contrary however, when disease burden is severe the Heart team in UHL refer 77% of patients for CABG. Both of these differences were of statistical significance (p &lt; 0.001). <h3>Conclusions</h3> This study has provided baseline and outcome data on patients at UHL with left main disease and subsequently treated with PCI or CABG. At UHL, patients with mild to moderate coronary artery disease (SYNTAX 0–32) are most often treated with PCI. However, in the presence of severe disease (SYNTAX &gt; 33) tend to be referred to a tertiary centre for CABG. The average follow up for all patients was 293 days. At the time, there was no significant differences in the occurrence of all MACCE, death, myocardial infarction, stroke or target vessel revascularisation. Patients treated with CABG had a longer hospital stay but this was not of statistical significance. The EuroQoL questionnaire provides an interesting insight into the subjective experience of the patient after PCI or CABG. Both PCI and CABG can be viewed as reasonable options for treating left main coronary artery disease, as they share similiar short term outcome. More data is need on the durability of PCI in the long term.