Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Eur J Cardiothorac Surg. 2013 Oct;44(4):718-24. doi: 10.1093/ejcts/ezt054. Epub 2013 Feb 19.
There is no evidence for the increasing use of percutaneous coronary intervention (PCI) compared with surgery in patients with left main coronary artery (LMCA) disease. We compared the clinical outcomes of patients with LMCA disease who had undergone PCI with those of patients who had off-pump coronary artery bypass (OPCAB) grafting.
From January 2001 to December 2009, 899 patients with LMCA disease were treated with OPCAB (n = 553) or PCI (n = 346). Analyses using propensity-score matching were performed to minimize the selection bias. We compared major adverse cardiac and cerebrovascular events (MACCE) including death, stroke, acute myocardial infarction and target-vessel revascularization. The median follow-up was 55.9 months.
For the 159 propensity-matched pairs, the early mortality in the OPCAB group was lower than in the PCI group (0 vs 5%, the PCI group; P < 0.001). Overall survival at 8 years was similar between groups (88.6 ± 3.5%, the OPCAB group vs 85.8 ± 5.3%, the PCI group; P = 0.394). Freedom from MACCE at 8 years was significantly higher in the OPCAB than in the PCI group (83.9 ± 5.1 vs 60.2 ± 6.9%, P < 0.001). Although there was no intergroup difference in the risk of death [hazard ratio (HR) for the PCI group, 1.435; 95% confidence interval (CI), 0.62-3.31; P = 0.396], a significant difference was found in the risk of MACCE (HR for the PCI group, 4.193; 95% CI, 2.165-8.121; P < 0.001). This difference was primarily due to a higher risk of acute myocardial infarction (HR for the PCI group, 4.730; 95% CI, 0.99-22.63; P = 0.049) and higher rates of target-vessel revascularization (HR for the PCI group, 5.508; 95% CI, 1.87-16.22; P = 0.002).
Compared with PCI, OPCAB is associated with a lower incidence of MACCE in patients with LMCA disease, determined mainly by the lower incidences of acute myocardial infarction and target-vessel revascularization. The incidence of stroke in the OPCAB group was similar to the PCI group.
目前尚无证据表明左主干冠状动脉（LMCA）疾病患者中经皮冠状动脉介入治疗（PCI）的应用较手术治疗有所增加。我们比较了 LMCA 疾病患者接受 PCI 治疗与接受非体外循环冠状动脉旁路移植术（OPCAB）搭桥术治疗的临床结局。
2001 年 1 月至 2009 年 12 月，899 例 LMCA 疾病患者接受 OPCAB（n=553）或 PCI（n=346）治疗。采用倾向评分匹配分析以尽量减少选择偏倚。我们比较了主要不良心脑血管事件（MACCE），包括死亡、卒中和急性心肌梗死和靶血管血运重建。中位随访时间为 55.9 个月。
在 159 对倾向评分匹配的患者中，OPCAB 组的早期死亡率低于 PCI 组（0%对 5%，PCI 组；P<0.001）。两组 8 年总生存率相似（OPCAB 组 88.6±3.5%，PCI 组 85.8±5.3%；P=0.394）。8 年时 OPCAB 组 MACCE 无事件生存率显著高于 PCI 组（83.9±5.1%对 60.2±6.9%，P<0.001）。尽管两组间死亡率无差异[PCI 组的风险比（HR）为 1.435；95%置信区间（CI）为 0.62-3.31；P=0.396]，但 MACCE 的风险差异显著（PCI 组的 HR 为 4.193；95%CI 为 2.165-8.121；P<0.001）。这种差异主要归因于急性心肌梗死风险较高（PCI 组的 HR 为 4.730；95%CI 为 0.99-22.63；P=0.049）和靶血管血运重建发生率较高（PCI 组的 HR 为 5.508；95%CI 为 1.87-16.22；P=0.002）。
与 PCI 相比，LMCA 疾病患者接受 OPCAB 治疗与 MACCE 发生率较低相关，这主要取决于急性心肌梗死和靶血管血运重建发生率较低。OPCAB 组的卒中发生率与 PCI 组相似。
