Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graftinge Among Patients with Unprotected Left Main Coronary Artery Disease in the New-Generation Drug-Eluting Stents Era (From the CREDO-Kyoto PCI/CABG Registry Cohort-3)

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Long-term safety of percutaneous coronary intervention (PCI) as compared with coronary artery bypass grafting (CABG) is still controversial in patients with unprotected left main coronary artery disease (ULMCAD), and there is a scarcity of real-world data on the comparative long-term clinical outcomes between PCI and CABG for ULMCAD in new-generation drug-eluting stents era. The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013, and we identified 855 patients with ULMCAD (PCI: N = 383 [45%], and CABG: N = 472 [55%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.5 (interquartile range: 3.9 to 6.6) years. The cumulative 5-year incidence of all-cause death was not significantly different between the PCI and CABG groups (21.9% vs 17.6%, Log-rank p = 0.13). After adjusting confounders, the excess risk of PCI relative to CABG remained insignificant for all-cause death (HR, 1.00; 95% CI, 0.68 to 1.47; p = 0.99). There were significant excess risks of PCI relative to CABG for myocardial infarction and any coronary revascularization (HR, 2.07; 95% CI, 1.30 to 3.37; p = 0.002, and HR, 2.96; 95% CI, 1.96 to 4.46; p < 0.001), whereas there was no significant excess risk of PCI relative to CABG for stroke (HR, 0.85; 95% CI, 0.50 to 1.41; p = 0.52). In conclusion, there was no excess long-term mortality risk of PCI relative to CABG, while the excess risks of PCI relative to CABG were significant for myocardial infarction and any coronary revascularization in the present study population reflecting real-world clinical practice in Japan.

Section snippets

Methods

The Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) PCI/CABG registry Cohort-3 is a physician-initiated, noncompany-sponsored, multicenter registry enrolling consecutive patients who underwent first coronary revascularization with PCI or isolated CABG without combined non-coronary surgery among 22 Japanese centers between January 2011 and December 2013 (Supplemental Appendix). The relevant ethics committees in all the participating centers approved the study

Results

Among the 855 current study patients, 383 patients (45%) underwent PCI, while 472 patients (55%) underwent CABG (Figure 1). Patients in the PCI group were significantly older and more often had severe frailty and peripheral vascular disease than those in the CABG group, whereas patients in the CABG group had higher prevalence of chronic obstructive pulmonary disease than those in the PCI group (Table 1). Regarding angiographic and procedural characteristics, patients with isolated LMCA or

Discussion

The main findings of this study comparing PCI with CABG in patients with ULMCAD in the new-generation DES era were as follows; (1) In the present study population reflecting real-world clinical practice in Japan between 2011 and 2013, 45% of patients with ULMCAD underwent PCI as the first coronary revascularization, and selection of coronary revascularization modalities appeared to be mainly based on the extent of coronary artery disease with isolated LMCA or LMCA+1-VD almost exclusively

Author contribution

Ko Yamamoto: Methodology, Formal analysis, Investigation, Data curation, Writing - Original Draft. Hiroki Shiomi: Methodology, Investigation, Data curation, Writing-Review and Editing, Supervision, Project administration. Takeshi Morimoto: Methodology, Formal analysis, Writing-Review and Editing, Supervision. Kazushige Kadota: Investigation, Resources. Tomohisa Tada: Investigation, Resources. Yasuaki Takeji: Investigation, Data curation. Yukiko Matsumura-Nakano: Investigation, Data curation.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

We appreciate the support and collaboration of the co-investigators participating in the CREDO-Kyoto PCI/CABG Registry Cohort-3. We are indebted to the clinical research coordinators for data collection.

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    Disclosures: Dr. Shiomi reports honoraria from Abbott Vascular, and Boston Scientific. Dr. Morimoto reports honoraria from Bayer and Kowa, and expert witness from Boston Scientific and Sanofi. Dr. Ehara reports honoraria from Abbott Vascular, Bayer, Boston Scientific, Medtronic, and Terumo. Dr. Furukawa reports honoraria from Bayer, Kowa, and Sanofi. Dr. Nakagawa reports research grant from Abbott Vascular and Boston Scientific, and honoraria from Abbott Vascular, Bayer, and Boston Scientific. Dr. Kimura reports honoraria from Abbott Vascular, Astellas, AstraZeneca, Bayer, Boston Scientific, Kowa, and Sanofi. The remaining authors have nothing to disclose.

    Funding: This work was supported by an educational grant from the Research Institute for Production Development (Kyoto, Japan).

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