Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
J Am Coll Cardiol. 2020 Sep 22;76(12):1395-1406. doi: 10.1016/j.jacc.2020.07.047.
Left main coronary artery (LMCA) disease is associated with high mortality and morbidity due to a large area of jeopardized myocardium. However, the optimal revascularization strategy for patients with LMCA disease and left ventricular dysfunction is still unclear.
This study sought to examine long-term comparative outcomes after percutaneous coronary intervention (PCI) or a coronary artery bypass grafting (CABG) according to the severity of left ventricular dysfunction.
The authors evaluated a total of 3,488 patients with LMCA disease who underwent CABG (n = 1,355) or PCI (n = 2,133) from the IRIS-MAIN (Interventional Research Incorporation Society-Left MAIN Revascularization) registry. Left ventricular function was categorized according to left ventricular ejection fraction (LVEF) as normal function (LVEF ≥55%), mild dysfunction (LVEF ≥45% to <55%), moderate dysfunction (LVEF ≥35% to <45%), or severe dysfunction (LVEF <35%). The primary outcome was a composite of death, myocardial infarction, or stroke.
Among the overall patient population, 2,641 (75.7%) patients had normal LVEF and 403 (11.6%), 260 (7.5%), and 184 (5.3%) had mild, moderate, and severe left ventricular dysfunction at baseline, respectively. Compared with CABG, PCI was associated with a higher adjusted risk of primary outcomes in patients with moderate (hazard ratio [HR]: 2.23; 95% confidence interval [CI]: 1.17 to 4.28) or severe (HR: 2.45; 95% CI: 1.27 to 4.73) dysfunction. In contrast, PCI and CABG had similar risks of the primary outcomes in patients with normal (HR: 0.80; 95% CI: 0.59 to 1.07) or mild (HR: 1.17; 95% CI: 0.63 to 2.17) dysfunction (p for interaction = 0.004).
In the revascularization of LMCA disease, PCI was associated with an inferior primary composite outcome of death, MI, or stroke compared with CABG in patients with moderate or severe left ventricular dysfunction. However, the risk for the primary outcome was comparable between PCI and CABG in those with normal or mild left ventricular dysfunction. (Observational Study for Left Main Disease Treatment; NCT01341327).
左主干冠状动脉（LMCA）疾病与大面积心肌受损相关，死亡率和发病率较高。然而，对于左主干疾病和左心室功能障碍患者，最佳的血运重建策略仍不清楚。
本研究旨在根据左心室功能障碍的严重程度，比较经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）后的长期比较结果。
作者从 IRIS-MAIN（介入研究协会-左主干血运重建）注册中心评估了 3488 例接受 CABG（n=1355）或 PCI（n=2133）的 LMCA 疾病患者。根据左心室射血分数（LVEF）将左心室功能分为正常功能（LVEF≥55%）、轻度功能障碍（LVEF≥45%至<55%）、中度功能障碍（LVEF≥35%至<45%）或严重功能障碍（LVEF<35%）。主要结局是死亡、心肌梗死或卒中的复合结局。
在整个患者人群中，2641 例（75.7%）患者具有正常的 LVEF，分别有 403 例（11.6%）、260 例（7.5%）和 184 例（5.3%）患者在基线时存在轻度、中度和重度左心室功能障碍。与 CABG 相比，PCI 与中度（风险比 [HR]：2.23；95%置信区间 [CI]：1.17 至 4.28）或重度（HR：2.45；95%CI：1.27 至 4.73）功能障碍患者的主要结局调整后风险增加相关。相比之下，在正常（HR：0.80；95%CI：0.59 至 1.07）或轻度（HR：1.17；95%CI：0.63 至 2.17）功能障碍患者中，PCI 和 CABG 的主要结局风险相似（交互检验 P=0.004）。
在左主干疾病的血运重建中，与 CABG 相比，PCI 与中度或重度左心室功能障碍患者的死亡、心肌梗死或卒中的主要复合结局不良相关。然而，在正常或轻度左心室功能障碍患者中，PCI 和 CABG 的主要结局风险相当。（左主干疾病治疗观察性研究；NCT01341327）
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