Methods

The present study was an analysis of a 2-center registry of unprotected LMCA disease from the Seoul National University Hospital and Seoul National University Bundang Hospital (Seoul, Korea). From January 2003 to December 2006, 462 patients underwent revascularization treatment. Of these 462 patients, 257 underwent CABG and 205 underwent PCI with a drug-eluting stent for de novo lesions in unprotected LMCA or LMCA-equivalent disease. LMCA disease was defined as >50% LMCA stenosis and LMCA-equivalent disease as severe (≥70%) proximal left anterior descending and proximal left circumflex stenoses. It was an “all-comer analysis” that included patients who presented with acute myocardial infarction or cardiogenic shock and those who underwent emergency procedures. Before determining the revascularization modality, the treatment strategies were carefully discussed with the patient, interventional cardiologist, cardiac surgeon, and attending physician. The local institutional review board approved the study protocol, which was in accordance with the Declaration of Helsinki.

The interventional and operational procedures were performed according to current standard techniques. CABG was performed either “on pump” using cardioplegics or “off pump.” When possible, the internal thoracic arteries were harvested, and the left anterior descending artery was revascularized. If the use of bilateral internal thoracic arteries as in situ or Y grafts did not achieve complete revascularization, the right gastroepiploic artery, radial artery, or saphenous vein was used for additional revascularization. All patients undergoing PCI were premedicated with a loading dose of aspirin (300 mg) and clopidogrel (300 to 600 mg). Unfractionated heparin was administered either before or during PCI to achieve an activated clotting time of ≥300 seconds. The type of drug-eluting stent to be implanted was decided by the operator. Either the radial or femoral artery was used for vascular access; and the use of glycoprotein IIb/IIIa inhibitors, predilation devices, stenting techniques, and intravascular ultrasound guidance was at the operators’ discretions. After PCI, lifelong aspirin and dual antiplatelet therapy for ≥6 months were recommended to all patients.

Clinical follow-up examinations after PCI or CABG was recommended at 1, 3, 6, and 12 months and then every 6 months thereafter. The clinical data were collected for ≤3 years after the index procedure. Although routine angiographic follow-up was recommended at 6 months after PCI, it was left to the surgeon’s discretion after CABG. The clinical, angiographic, procedural, and outcome data were collected by independent nurses and researchers who had not participated in the treatment of the study patients. The subjects who had not adhered to the recommended follow-up processes were interviewed by telephone at regular 6-month intervals. To validate complete follow-up data, vital status information was obtained from the Korea National Statistical Office using a unique personal identification number.

The study population was followed for the occurrence of clinical events, including death, myocardial infarction, cerebrovascular accident, and target vessel revascularization (TVR). Death was classified as from either cardiac or noncardiac causes, according to the Academic Research Consortium definition. All deaths were considered cardiac in origin unless a noncardiac origin had definitely been documented. Myocardial infarction was defined according to the recommendations of the European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation Task Force. TVR was defined as the repeat intervention (surgical or percutaneous) of any segment of the treated vessel, including the left main, left anterior descending, and left circumflex arteries. cerebrovascular accident, including both ischemic and hemorrhagic stroke, was confirmed by a neurologist from the imaging study findings. Major adverse cardiac and cerebrovascular events were defined as a composite of death, myocardial infarction, cerebrovascular accident, or TVR. The occurrence of “definite” and “probable” stent thrombosis (ST), according to the Academic Research Consortium definition, or of symptomatic graft occlusion after CABG was recorded. ST was stratified relative to the timing of the events as acute (0 to 24 hours), subacute (>24 hours to 30 days), late (31 days to 1 year), and very late (>1 year).

The baseline data are presented as the frequency or mean ± SD. Continuous variables were compared using the Student t tests, and categorical variables were compared using the chi-square tests. Because of the nonrandomized observational nature of the study, propensity score analyses were performed to minimize any selection bias. In brief, propensity to each treatment strategy was scored using multivariate logistic regression analysis for every patient with 27 variables, including demographic characteristics, co-existing medical conditions, and laboratory and angiographic findings. The individual propensity score was incorporated into the Cox regression model as a covariate to calculate the propensity-adjusted hazard ratio. In addition, after patients were matched according to the propensity score in a 1:1 ratio, the risk of each outcome was compared to the matched cohort. A 2-sided p value of <0.05 was considered significant for all tests. All statistical analyses were performed using Stata/MP, version 10.0 for Windows (StataCorp, College Station, Texas).

Results

Table 1 lists a comparison of the baseline characteristics of the 2 treatment groups. The patients treated with CABG were more likely to have peripheral artery disease and a familial history of coronary artery disease and had a greater mean EuroSCORE. Angiographically, coronary artery disease was more extensive and right coronary artery and distal bifurcation involvement were more common in the CABG group. Most of the CABG cases used internal thoracic arteries and anastomosized the left anterior descending artery ( Table 2 ). CABG was performed off pump in 71.6% of patients. Most PCIs were performed with a first-generation drug-eluting stent (sirolimus-eluting or paclitaxel-eluting stent); however, zotarolimus-eluting stents were used in 7 patients. Ostial or shaft lesions were generally treated with a single stent. In lesions involving the distal bifurcation, a variety of techniques were applied after consideration of angiographic factors such as the presence of left circumflex ostial disease and reference vessel size. Of the lesions involving distal bifurcation, “final kissing ballooning” was performed in 38.5% of the cases.

Figure 1 shows the clinical outcomes of the crude study population. After a median follow-up of 33.5 months (interquartile range 22.8 to 36.0), the mortality rate was 12.1% in the CABG group and 14.1% in the PCI group, and the overall incidence of the composite of death, myocardial infarction, and cerebrovascular accident was 17.5% and 20.0%, respectively. The rate of TVR in the CABG group was significantly lower than that in the PCI group (5.1% vs 22.4%; p <0.001; Table 3 ), resulting in a significantly lower rate of major adverse cardiac and cerebrovascular events in the CABG group (21.8% vs 35.1%; p = 0.001). Moreover, the rate of target lesion revascularization (i.e., excluding non-target lesion TVR) after PCI was 13.7%, and was still greater than the TVR rate after CABG (5.1%, p = 0.001). The data for each clinical outcome event at each follow-up time point are listed in Table 3 . Although the mortality rate in the PCI group was significantly greater at the initial 30 days, the difference was no longer present at 6 months. Although statistically insignificant, the cerebrovascular accident rates in all follow-up periods were consistently greater in the CABG group. The rate of TVR in the 2 groups started to diverge at 6 months of follow-up.

Clinical outcomes of crude study population. Kaplan-Meier curves in CABG and PCI patient groups for (A) death from any cause, (B) a composite of death, myocardial infarction, or cerebrovascular accident, (C) TVR, and (D) major adverse cardiovascular and cerebrovascular events (MACCE). Hazard ratios indicate calculated hazard ratios and their 95% confidence intervals.

Table 3

Outcomes at 30 days, 6 months, 1 year, 2 years, and final follow-up

Variable	CABG (n = 257)	PCI (n = 205)	OR (95% CI)	p Value
30-Day outcomes
Death from any cause	3 (1.2%)	9 (4.4%)	0.26 (0.07–0.96)	0.044
Cardiac death	3 (1.2%)	9 (4.4%)	0.26 (0.07–0.96)	0.044
Myocardial infarction	1 (0.4%)	3 (1.5%)	0.26 (0.03–2.55)	0.249
Cerebrovascular accident	5 (1.9%)	2 (1.0%)	2.01 (0.39–10.49)	0.406
Composite hard endpoint ⁎	8 (3.1%)	13 (6.3%)	0.48 (0.19–1.17)	0.105
Target vessel revascularization	3 (1.2%)	3 (1.5%)	0.80 (0.16–3.98)	0.780
Major adverse cardiac and cerebrovascular events	10 (3.9%)	13 (6.3%)	0.60 (0.26–1.39)	0.233
6-Month outcomes
Death from any cause	13 (5.1%)	11 (5.4%)	0.94 (0.41–2.14)	0.882
Cardiac death	8 (3.1%)	10 (4.9%)	0.63 (0.24–1.62)	0.334
Myocardial infarction	1 (0.4%)	3 (1.5%)	0.26 (0.03–2.55)	0.249
Cerebrovascular accident	8 (3.1%)	2 (1.0%)	3.26 (0.69–15.53)	0.138
Composite hard endpoint ⁎	18 (7.0%)	15 (7.3%)	0.95 (0.47–1.94)	0.897
Target vessel revascularization	6 (2.3%)	9 (4.4%)	0.52 (0.18–1.49)	0.223
Major adverse cardiac and cerebrovascular events	23 (8.9%)	21 (10.2%)	0.86 (0.46–1.61)	0.638
1-Year outcomes
Death from any cause	16 (6.2%)	14 (6.8%)	0.91 (0.43–1.90)	0.794
Cardiac death	10 (3.9%)	12 (5.9%)	0.65 (0.28–1.54)	0.328
Myocardial infarction	3 (1.2%)	5 (2.4%)	0.49 (0.16–1.52)	0.215
Cerebrovascular accident	8 (3.1%)	2 (1.0%)	3.26 (0.69–15.53)	0.138
Composite hard endpoint ⁎	23 (8.9%)	20 (9.8%)	0.74 (0.44–1.25)	0.264
Target vessel revascularization	10 (3.9%)	35 (17.1%)	0.20 (0.11–0.39)	<0.001
Major adverse cardiac and cerebrovascular events	32 (12.5%)	49 (23.9%)	0.45 (0.28–0.74)	0.002
2-Year outcomes
Death from any cause	23 (8.9%)	24 (11.7%)	0.74 (0.41–1.36)	0.331
Cardiac death	15 (5.8%)	17 (8.3%)	0.69 (0.33–1.41)	0.304
Myocardial infarction	5 (1.9%)	8 (3.9%)	0.49 (0.16–1.51)	0.211
Cerebrovascular accident	8 (3.1%)	2 (1.0%)	3.24 (0.68–15.42)	0.140
Composite hard endpoint ⁎	32 (12.5%)	33 (16.1%)	0.79 (0.47–1.32)	0.369
Target vessel revascularization	13 (5.1%)	43 (21.0%)	0.20 (0.10–0.38)	<0.001
Major adverse cardiac and cerebrovascular events	43 (16.7%)	65 (31.7%)	0.43 (0.28–0.67)	<0.001
3-Year outcomes
Death from any cause	31 (12.1%)	29 (14.1%)	0.83 (0.48–1.43)	0.508
Cardiac death	18 (7.0%)	21 (10.2%)	0.66 (0.34–1.28)	0.216
Myocardial infarction	7 (2.7%)	10 (4.9%)	0.55 (0.20–1.46)	0.228
Cerebrovascular accident	16 (6.2%)	6 (2.9%)	2.20 (0.85–5.73)	0.106
Composite hard endpoint ⁎	45 (17.5%)	41 (20.0%)	0.85 (0.53–1.36)	0.495
Target vessel revascularization	13 (5.1%)	46 (22.4%)	0.18 (0.10–0.35)	<0.001
Major adverse cardiac and cerebrovascular events	56 (21.8%)	72 (35.1%)	0.52 (0.34–0.78)	0.002

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