Revascularization in Patients With Multivessel Coronary Artery Disease and Severe Left Ventricular Systolic Dysfunction

The 2014 European Society of Cardiology and the European Association of Cardio-Thoracic Surgery guidelines on myocardial revascularization give a class I recommendation for coronary artery bypass graft surgery (CABG) but a class IIb recommendation for percutaneous coronary intervention (PCI) for revascularization in patients with chronic heart failure and systolic left ventricular (LV) dysfunction (ejection fraction ≤35%). However, the American College of Cardiology Foundation/American Heart Association stable ischemic heart disease guidelines give a class IIb recommendation for CABG for improving survival in patients with severe LV systolic dysfunction (ejection fraction <35%) with no recommendations for PCI. The American College of Cardiology Foundation/ American Heart Association guidelines state “the choice of revascularization in patients with CAD and LV systolic dysfunction is best based on clinical variables (eg, coronary anatomy, presence of diabetes mellitus, presence of CKD), magnitude of LV systolic dysfunction, patient preferences, clinical judgment, and consultation between the interventional cardiologist and the cardiac surgeon.” In addition, the 2009 American College of Cardiology Foundation/American Heart Association appropriate use criteria for coronary revascularization considered patients with 3-vessel CAD and depressed LV Background—Guidelines recommend coronary artery bypass graft surgery (CABG) over percutaneous coronary intervention (PCI) for multivessel disease and severe left ventricular systolic dysfunction. However, CABG has not been compared with PCI in such patients in randomized trials. Methods and Results—Patients with multivessel disease and severe left ventricular systolic dysfunction (ejection fraction ≤35%) who underwent either PCI with everolimus-eluting stent or CABG were selected from the New York State registries. The primary outcome was long-term all-cause death. Secondary outcomes were individual outcomes of myocardial infarction, stroke, and repeat revascularization. Among the 4616 patients who fulfilled our inclusion criteria (1351 everolimus-eluting stent and 3265 CABG), propensity score matching identified 2126 patients with similar propensity scores. In the short term, PCI was associated with a lower risk of stroke (hazard ratio [HR], 0.05; 95% confidence interval [CI], 0.01–0.39; P=0.004) in comparison with CABG. At long-term follow-up (median, 2.9 years), PCI was associated with a similar risk of death (HR, 1.01; 95% CI, 0.81–1.28; P=0.91), a higher risk of myocardial infarction (HR, 2.16; 95% CI, 1.42–3.28; P=0.0003), a lower risk of stroke (HR, 0.57; 95% CI, 0.33–0.97; P=0.04), and a higher risk of repeat revascularization (HR, 2.54; 95% CI, 1.88–3.44; P<0.0001). The test for interaction was significant (P=0.002) for completeness of revascularization, such that, in patients in whom complete revascularization was achieved with PCI, there was no difference in myocardial infarction between PCI and CABG. Conclusions—Among patients with multivessel disease and severe left ventricular systolic dysfunction, PCI with everolimuseluting stent had comparable long-term survival in comparison with CABG. PCI was associated with higher risk of myocardial infarction (in those with incomplete revascularization) and repeat revascularization, and CABG was associated with higher risk of stroke. (Circulation. 2016;133:2132-2140. DOI: 10.1161/CIRCULATIONAHA.115.021168.)