Coronary artery bypass grafting is still the best treatment for multivessel and left main disease, but patients need to know

1PCI, used appropriately (including some subsets of multivessel disease and left main stem stenosis) can be a very effective and worthwhile intervention. My criticisms, however, are aimed at its increasing, inappropriate, and non-evidence-based use in the wider population of patients with multivessel disease and, increasingly, left main stem stenosis, despite strong evidence from randomized trials and large real-world registries that CABG is a more effective treatment in terms of survival and freedom from recurrent angina and reintervention.2Although randomized trials, registries, and guidelines all strongly favor CABG for most patients with left main stem disease, are randomized trials against PCI ethical or justifiable?3Why will PCI never match the results of CABG in multivessel or left main disease? As explained earlier, CABG deals with the initial coronary lesion of any complexity, is also prophylactic against future culprit lesions, and offers more complete and more durable revascularization.4Patients undergoing PCI for multivessel or left main disease should be informed that PCI as an initial strategy, rather than CABG, significantly reduces survival, even at 3 years, and increases the risk of reintervention fourfold to sevenfold. With PCI, there is a 10% risk of significant myocardial infarction and no benefit in short-term or long-term cognitive outcome when compared with CABG. Finally, even with drug-eluting stents, the risk of restenosis is 10% to 30%, and there is a real risk of late thrombosis if antiplatelet medication is stopped. So why is PCI replacing CABG against best evidence? There are three reasons:1the cardiologist is the gatekeeper, and this may produce a conflict of interest in terms of self-referral;2the disingenuous presentation and inappropriate application of results of randomized trials in highly select and atypical groups to the whole population; and3the result of what happens when evidence-based medicine is challenged by a multibillion dollar industry. © 2006 The Society of Thoracic Surgeons.