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CABG vs. PCI in Severe Ischemic Cardiomyopathy
Quick Takes
- In patients undergoing coronary revascularization for ischemic cardiomyopathy, isolated CABG is associated with better long-term survival compared to PCI.
- CABG is associated with higher risk of periprocedural stroke and increased length of hospital stay compared to PCI.
Study Questions:
In patients with ischemic cardiomyopathy (ICM), what is the long-term survival of revascularization associated with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI)?
Methods:
This study was conducted using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group prospective registries. Adult patients with severe ICM (left ventricular ejection fraction [LVEF] <35%) undergoing isolated CABG or PCI from January 2005 to 2018 were included. Patients with ST-segment elevation myocardial infarction (MI), cardiac arrest, cardiogenic shock, and prior cardiac surgeries were excluded. The primary outcome was all-cause mortality up to 10 years post-revascularization. Mortality data were obtained from the National Death Index. Secondary outcomes included 30-day all-cause mortality, length of hospital stay, periprocedural stroke, kidney injury, and MI.
Results:
Of the 2,042 patients included in the study, 1,451 (71.1%) underwent isolated CABG and 591 (28.9%) underwent PCI. At baseline, patients receiving CABG compared to PCI were more likely to be younger and male, and more likely to have comorbid conditions (except for chronic kidney disease), lower LVEF, higher New York Heart Association class, non–acute coronary syndrome indication for revascularization, and multivessel/left main disease. The median follow-up was 4.0 years (interquartile range, 2.2-6.8).
For the primary outcome, CABG compared to PCI was associated with better unadjusted 10-year survival (51.8% [47.1-56.3] vs. 45.7% [39.9-51.4]; hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.68-0.97; p = 0.025). Similar findings were seen on multivariable regression analysis (HR, 0.73; 95% CI, 0.58-0.93; p = 0.010). Risk adjustment using a propensity score analysis with inverse probability of treatment weighting was performed to estimate the average treatment effect. With this analysis, CABG compared to PCI was associated with reductions in long-term mortality (adjusted HR, 0.59; 95% CI, 0.45-0.79; p = 0.001).
For the secondary outcomes, no differences were noted for 30-day mortality, in-hospital mortality, periprocedural MI, and periprocedural kidney injury. CABG compared to PCI was associated with a higher risk of periprocedural stroke (adjusted odds ratio, 19.6; 95% CI, 4.21-91.6; p < 0.001) and increased length of hospital stay (exponentiated coefficient, 3.58; 95% CI, 3.00-4.28; p < 0.001).
Conclusions:
In patients with ICM undergoing revascularization, isolated CABG is associated with better long-term survival compared to PCI. CABG compared to PCI was associated with higher risk of periprocedural stroke and increased length of hospital stay.
Perspective:
The optimal treatment strategy for patients with ICM is not clear. Based on randomized trials, CABG versus medical therapy has similar outcomes in the short-/medium-term but potentially favors CABG in the long-term. Trial data also show that PCI versus medical therapy has similar outcomes in the short-/medium-term, with long-term data not yet available. Dedicated clinical trials comparing CABG versus PCI in ICM are lacking, though are underway. Given these evidence gaps, studies like this one are valuable for guiding clinician–patient discussions on the advantages and trade-offs of each treatment option. Despite certain limitations, this study offers important insights into the potential benefits of CABG over PCI in cases where revascularization is deemed necessary, while also highlighting associated risks, such as increased stroke risk and extended hospital stays.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure
Keywords: Cardiomyopathies, Coronary Artery Bypass, Myocardial Revascularization, Percutaneous Coronary Intervention
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