Coronary Revascularization for Patients With Severe Left Ventricular Dysfunction

Background. The efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with coronary artery disease has been well defined by randomized controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction <35%) were underrepresented in these trials, and management of these complex patients remains unclear. The purpose of this study was to compare the outcomes of patients with coronary artery disease and left ventricular dysfunction undergoing CABG versus PCI. Methods. The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and outcome monitoring initiative for the province of Alberta, Canada, was used to identify 2925 patients with coronary artery disease and left ventricular dysfunction undergoing CABG (n = 1,326)or PCI (n = 1,599) between 1995 and 2008. Patients were propensity matched to obtain comparable subgroups among left ventricular dysfunction patients. Results. Cox proportional hazard analysis of the propensity-matched subgroups identified that CABG was significantly associated with lower rates of repeat revascularization and better survival compared with PCI at 1, 5, 10, and 15 years. Other significant independent predictors of poor long-term survival included age, renal failure, heart failure, diabetes mellitus, peripheral vascular disease, prior myocardial infarction, left main coronary artery disease, and prior CABG. Conclusions. For patients with coronary artery disease and left ventricular dysfunction, CABG was associated with lower rates of repeat revascularization and improved survival over PCI, after adjustment for baseline risk profile differences. Further research exploring the factors leading to use of a particular revascularization modality in this patient population is required. (C) 2013 by The Society of Thoracic Surgeons