Bloom Jason E, Vogrin Sara, Reid Christopher M, Ajani Andrew E, Clark David J, Freeman Melanie, Hiew Chin, Brennan Angela, Dinh Diem, Williams-Spence Jenni, Dawson Luke P, Noaman Samer, Chew Derek P, Oqueli Ernesto, Cox Nicholas, McGiffin David, Marasco Silvana, Skillington Peter, Royse Alistair, Stub Dion, Kaye David M, Chan William
Cardiology Division, Columbia University Medical Center, 161 Fort Washington Ave, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA.
Department of Cardiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004, Australia.
Eur Heart J. 2025 Jan 3;46(1):72-80. doi: 10.1093/eurheartj/ehae672.
The optimal revascularization strategy in patients with ischaemic cardiomyopathy remains unclear with no contemporary randomized trial data to guide clinical practice. This study aims to assess long-term survival in patients with severe ischaemic cardiomyopathy revascularized by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).
Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group registries (from January 2005 to 2018), patients with severe ischaemic cardiomyopathy [left ventricular ejection fraction (LVEF) <35%] undergoing PCI or isolated CABG were included in the analysis. Those with ST-elevation myocardial infarction and cardiogenic shock were excluded. The primary outcome was long-term National Death Index-linked mortality up to 10 years following revascularization. Risk adjustment was performed to estimate the average treatment effect using propensity score analysis with inverse probability of treatment weighting (IPTW).
A total of 2042 patients were included, of whom 1451 patients were treated by CABG and 591 by PCI. Inverse probability of treatment weighting-adjusted demographics, procedural indication, coronary artery disease extent, and LVEF were well balanced between the two patient groups. After risk adjustment, patients treated by CABG compared with those treated by PCI experienced reduced long-term mortality [adjusted hazard ratio 0.59, 95% confidence interval (CI) 0.45-0.79, P = .001] over a median follow-up period of 4.0 (inter-quartile range 2.2-6.8) years. There was no difference between the groups in terms of in-hospital mortality [adjusted odds ratio (aOR) 1.42, 95% CI 0.41-4.96, P = .58], but there was an increased risk of peri-procedural stroke (aOR 19.6, 95% CI 4.21-91.6, P < .001) and increased length of hospital stay (exponentiated coefficient 3.58, 95% CI 3.00-4.28, P < .001) in patients treated with CABG.
In this multi-centre IPTW analysis, patients with severe ischaemic cardiomyopathy undergoing revascularization by CABG rather than PCI showed improved long-term survival. However, future randomized controlled trials are needed to confirm the effect of any such benefits.
缺血性心肌病患者的最佳血运重建策略仍不明确，缺乏当代随机试验数据来指导临床实践。本研究旨在评估通过冠状动脉旁路移植术（CABG）或经皮冠状动脉介入治疗（PCI）进行血运重建的重度缺血性心肌病患者的长期生存率。
利用澳大利亚和新西兰心脏与胸外科医师协会以及墨尔本介入治疗组登记处（2005年1月至2018年）的数据，纳入接受PCI或单纯CABG治疗的重度缺血性心肌病患者[左心室射血分数（LVEF）<35%]。排除ST段抬高型心肌梗死和心源性休克患者。主要结局是血运重建后长达10年的与国家死亡指数相关的长期死亡率。采用倾向评分分析和治疗权重逆概率（IPTW）进行风险调整，以估计平均治疗效果。
共纳入2042例患者，其中1451例接受CABG治疗，591例接受PCI治疗。两组患者在治疗权重逆概率调整后的人口统计学特征、手术指征、冠状动脉疾病范围和LVEF方面均衡良好。风险调整后，与接受PCI治疗的患者相比，接受CABG治疗的患者在中位随访期4.0年（四分位间距2.2 - 6.8年）内长期死亡率降低[调整后风险比0.59，95%置信区间（CI）0.45 - 0.79，P = 0.001]。两组患者的院内死亡率无差异[调整后优势比（aOR）1.42，95% CI 0.41 - 4.96，P = 0.58]，但接受CABG治疗的患者围手术期卒中风险增加（aOR 19.6，95% CI 4.21 - 91.6，P < 0.001），住院时间延长（指数系数3.58，95% CI 3.00 - 4.28，P < 0.001）。
在这项多中心IPTW分析中，接受CABG而非PCI进行血运重建的重度缺血性心肌病患者长期生存率提高。然而，需要未来的随机对照试验来证实任何此类益处的效果。
