Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction

Abstract

Decades have passed since studies comparing coronary artery bypass grafting (CABG) with medical therapy for multivessel coronary disease indicated a survival advantage of surgery in the subset of patients with significant left ventricular impairment.1–3 These investigations changed the prevailing clinical impression such that severe left ventricular (LV) dysfunction might be an indication for revascularization as opposed to a relative contraindication. Although the studies might currently be deemed obsolete by many measures, they continue to inform societal guidelines with regard to CABG and LV dysfunction.4,5 Recently, the long-term outcomes after the Surgical Treatment for Ischemic Heart Failure (STICH) trial have reinforced the potential benefits of surgical revascularization in patients with congestive heart failure and an ejection fraction of <35%.6 Over the intervening period, numerous trials have compared percutaneous coronary intervention (PCI) with CABG in patients with stable angina and multivessel disease. Aside from diabetes mellitus, the trials by and large have demonstrated equivalence in the end points of death and myocardial infarction. So can one extrapolate equivalence for PCI with CABG in patients with LV dysfunction? The short answer is no. There is scant direct evidence from randomized trials comparing the 2 methods of revascularization because patients with congestive heart failure or severe LV dysfunction have typically been underrepresented or excluded.7–9 Article, see p 2132 Acknowledging the lack of a large randomized evidence base, there are theoretical reasons why PCI might perform less well than CABG in patients with LV dysfunction. PCI, by its nature, addresses short segments of severe stenosis. However surgery will also address the intervening disease that might progress to become culprit lesions in the future.10 This disadvantage of PCI is likely to be particularly important in patients with limited LV reserve who over the longer term …