University of Bristol Academy, Bristol Royal Infirmary, Bristol, UK.
Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK.
Eur J Cardiothorac Surg. 2019 Feb 1;55(2):238-246. doi: 10.1093/ejcts/ezy236.
Existing evidence comparing the outcomes of coronary artery bypass graft (CABG) surgery versus percutaneous coronary intervention (PCI) in patients with poor left ventricular function (LVF) is sparse and flawed. This is largely due to patients with poor LVF being underrepresented in major research trials and the outdated nature of some studies that do not consider drug-eluting stent PCI.
Following strict inclusion criteria, 717 patients who underwent revascularization by CABG or PCI between 2002 and 2015 were enrolled. All patients had poor LVF (defined by ejection fraction <30%). By employing a propensity score analysis, 134 suitable matches (67 CABG and 67 PCI) were identified. Several outcomes were evaluated, in the matched population, using data extracted from national registry databases.
CABG patients required a longer length of hospital stay post-revascularization compared to PCI in the propensity-matched population, 7 days (lower-upper quartile; 6-12) and 2 days (lower-upper quartile; 1-6), respectively (Mood's median test, P = 0.001). Stratified Cox-regression proportional-hazards analysis of the propensity-matched population found that PCI patients experienced a higher adjusted 8-year mortality rate (hazard ratio 3.291, 95% confidence interval 1.776-6.101; P < 0.001). This trend was consistent amongst urgent cases of revascularization: patients with 3 or more vessels with coronary artery disease and patients where complete revascularization was achieved. Although sub-analyses found no difference between survival distributions of on-pump versus off-pump CABG (log-rank P = 0.726), both modes of CABG were superior to PCI (stratified log-rank P = 0.002).
Despite a longer length of hospital stay, patients with impaired LVF requiring intervention for coronary artery disease experienced a greater post-procedural survival benefit if they received CABG compared to PCI. We have demonstrated this at 30 days, 90 days, 1 year, 3 years, 5 years and 8 years following revascularization. At present, CABG remains a superior revascularization modality to PCI in patients with poor LVF.
比较左心室功能不良（LVF）患者行冠状动脉旁路移植术（CABG）与经皮冠状动脉介入治疗（PCI）的结果，目前相关证据有限且存在缺陷。这主要是因为左心室功能不良患者在大型研究试验中代表性不足，以及一些未考虑药物洗脱支架 PCI 的研究已经过时。
严格遵循纳入标准，共纳入 2002 年至 2015 年间接受 CABG 或 PCI 血运重建的 717 例患者。所有患者均存在左心室功能不良（射血分数<30%）。通过采用倾向评分分析，确定了 134 例合适的匹配（CABG 67 例，PCI 67 例）。使用从全国登记数据库中提取的数据，评估匹配人群中的多项结局。
与 PCI 相比，CABG 患者在血运重建后的住院时间更长，匹配人群中分别为 7 天（下四分位数-上四分位数；6-12）和 2 天（下四分位数-上四分位数；1-6）（Mood 中位数检验，P=0.001）。对匹配人群进行分层 Cox 比例风险回归分析发现，PCI 患者调整后 8 年死亡率更高（风险比 3.291，95%置信区间 1.776-6.101；P<0.001）。这种趋势在紧急血运重建的情况下仍然存在：3 支及以上冠状动脉病变的患者和实现完全血运重建的患者。尽管亚组分析发现体外循环与非体外循环 CABG 的生存分布无差异（对数秩检验 P=0.726），但两种 CABG 模式均优于 PCI（分层对数秩检验 P=0.002）。
尽管住院时间较长，但与 PCI 相比，需要接受冠状动脉疾病介入治疗的左心室功能不良患者接受 CABG 治疗后具有更大的术后生存获益。我们在血运重建后 30 天、90 天、1 年、3 年、5 年和 8 年时均观察到了这一结果。目前，在左心室功能不良患者中，CABG 仍然是一种优于 PCI 的血运重建方式。
